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Sternum Tomographic Sagittal Evaluation in Pectus Patients: New Radiological Angles and Index, and Subjective Analysis of Sternal Patterns

Davi Haje¹², Kelsen Texixeira², Moacir Neto², Paulo Mendlovitz³, Paulo Dolabela*

¹Centro Clínico Orthopectus and ²Hospital de Base do Distrito Federal in Brasília, DF, Brazil

³Department of Radiology, Hospital Universitário (HUB) and Hospital Anchieta, Brazil

*Department of Radiology, Clinica Vilas Boas, Brazil


Background: Physician may have difficulties to interpret sagittal computer tomography (CT) or X-ray of pectus patients. The objective of this study is to evaluate the sagittal reconstruction of sternal region objectively, through unpublished radiographic parameters (RP-indexes and angles), in different types of pectus, comparing them with each other and controls. Another objective is to evaluate the type of the sternum body curvature (TSBC) subjectively assessing whether there are pre-defined patterns in each type of pectus in sagital CT, and making a correlation with objective analysis.

Methods: 274 pectus patients underwent CT of the sternal region and undergone a subjective analysis, being analysed the following TSBC: vertical gradual curved; posterior gradual curved; anterior gradual curved; curved proximal third; curved middle third; curved distal third; anterior rectilinear; vertical rectilinear; and posterior rectilinear.  56 were subjected to objective analysis of RP, being created: manubrium-sternum-spine index(MSS); sternum-spine index(SS); evaluation of degree of anterior curvature of the sternum(ACS); superior sternum angle(SSA); inferior sternum angle(ISA). The types of pectus were classified as pectus carinatum (PC) inferior (PCI), PC superior (PCS), PC lateral (PCL), pectus excavatum (PE) wide (PEW) and PE localized (PEL).

Results: There was a significant difference (p<0,05) between PC and PE when analyzed MSS, SS, SSA and ISA. For the analysis of each RP separately between pectus groups and controls, there were significant differences on the MSS (PELxcontrol) and ISA (PELxcontrol). Comparing RP between the different types of pectus, there was significance: MSS (PCLxPEL; PCLxPEA); SS (PEWxPCL); ISA (PCIxPEL; PCIxPEA); SSA (PCSxPEL; PCSxPEW). The TSBC had significant difference between controls and the PEL, PEW and PCI.   MSS, SS and ISA showed significant differences in the comparison to some TSBC. We observed patients with different pectus but with similar TSBC.  Some TSBC and RP correlate with some types of pectus. In cases with completely straight sternal body, independent of the degree of severity, the degree of agreement among examiners in the matter of sternal standard definition was high. In cases of curved sternum, there was disagreement between the examiners about the principal place of curvature. In the subjective analysis in cases of mild severity and with some degree of curvature in the sternal body there was disagreement between the examiners. Knowledge of the patterns and parameters studied may help in better understanding of the pathogenesis of pectus, search of better classifications and better understanding by the radiologist. TSBC and RP showed significance in specific situations and may have clinical applicability.

Keywords: sagittal, computer tomography, pectus, radiographic parameters, radiographic index, angles, sternum