Assessment of Thoracic Kyphosis Using Flexicurve Ruler after Open Heart Surgery: A Cross-Sectional Study

Ali M. Hassan, Mohamed Abdel Bary, Sara M. Mohamed Kamel, Fatma A. Hegazy, Emad A. Aboelnasr, Amany M. Helmy, Ahmed S. Abdelhamid


In literature, the development of spinal deformities was reported after surgical intervention for congenital heart disease using thoracotomy and sternotomy incisions in children; however, there are not enough data regarding the incidence of spinal kyphosis after open-heart surgery in adults. This study aimed to determine the impact of open-heart surgery using median sternotomy incision on the sagittal plane thoracic spine curve and pulmonary functions after open-heart surgery. A cross- sectional study was conducted on 100 participants (53 ± 9.43 years), who underwent open heart surgery using median sternotomy. The spinal kyphotic curve was evaluated using a Flexicurve ruler and spirometry parameters [forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and ratio of forced expiratory volume in the first second to forced vital capacity (FEV1/FVC)] were evaluated before and one week after open-heart surgery. The comparison between the preoperative and postoperative measurements of the variables under study was performed using the paired t-test. Statistical significance was set at (P ˂ 0.05). The results revealed a significant increase in the dorsal kyphotic curve (9.75 ± 2.32) and a significant decrease in all spirometry parameters under study [(FVC: 2.12 ± .77); (FEV1:1.55 ± .64) and (FEV1/FVC: 0.72 ± .13)] with an alpha level of (P < 0.05). There is a high incidence of exaggerating the sagittal plane thoracic spine curvature (thoracic kyphosis), and reduction in the pulmonary functions after open-heart surgery using median sternotomy incision.


Keywords: open heart surgery, spinal kyphosis, assessment, pulmonary functions.

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HERRERA-SOTO J A, VANDER HAVE K L, BARRY-LANE P, & WOO A. Spinal Deformity after Combined Thoracotomy and Sternotomy for Congenital Heart Disease. Journal of Pediatric Orthopaedics, 2006, 26(2): 211-215.

MANJI R A, et al. Seizures following cardiac surgery: the impact of tranexamic acid and other risk factors. Canadian Journal of Anesthesia, 2012, 59(1): 6-13.

TUSMAN G, BÖHM S H, WARNER D O, & SPRUNG J. Atelectasis and perioperative pulmonary complications in high-risk patients. Current Opinion in Anaesthesiology, 2012, 25(1): 1-10.

PATANÈ F, VERZINI A, ZINGARELLI E, and DI SUMMA M. Simultaneous operation for cardiac disease and lung cancer. Interactive Cardiovascular and Thoracic Surgery, 2002, 1(2): 69-71.

WOODS LS, FROELICHER E S, MOTZER S. Cardiac Nursing. 4th ed. Philadelphia Pa: JB Lippincott, 2000.

CHETTA, A., TZANI, P., MARANGIO, E., et al. Respiratory effects of surgery and pulmonary function testing in the preoperative evaluation. Acta bio-medica: Atenei Parmensis, 2006, 77(2): 69-74.

RAGNARSDOTTIR, M., KRISTJANSDOTTIR, A., INGVARSDOTTIR, I., et al. Short term changes on pulmonary function and respiratory movement after cardiac surgery via median sternotomy. Scandinavian Cardiovascular Journal 2004, 38(1): 46-52.

BRASILIENSE, L. B., LAZARO, B. C., REYES, P. M., et al. Biomechanical contribution of the rib cage to thoracic stability. Spine, 201136(26), E1686–E1693.

RONCADA, G., DENDALE, P., LINSEN, L., et al. Reduction in pulmonary function after CABG surgery is related to postoperative inflammation and hypercortisolemia. International Journal of Clinical and Experimental Medicine, 2015, 8(7): 10938–10946.

LYDICK, E., ZIMMERMAN, S. I., YAWN, B., et al. Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL). Journal of Bone and Mineral Research, 1997;12(3): 456-63.

RYAN, S. D., & FRIED, L. P. The impact of kyphosis on daily functioning. Journal of the American Geriatrics Society, 1997, 45(12), 1479–1486.

LUNDON K, LI A, & BIBERSHTEIN S. Interrater and intrarater reliability in the measurement of kyphosis in post-menopausal women with osteoporosis. Spine, 1998, 23(18): 1978-1985.

SPENCER, L., FARY, R., MCKENNA, L., et al. Thoracic kyphosis assessment in postmenopausal women: an examination of the Flexicurve method in comparison to radiological methods. Osteoporosis International, 2019, 30(10), 2009–2018.

BARRETT, E., LENEHAN, B., O’SULLIVAN, K., et al. Validation of the manual inclinometer and flexicurve for the measurement of thoracic kyphosis. Physiotherapy Theory and Practice, 2017, 34(4): 1-9.

MANDAL A, & GANGULY S. Non-invasive Measurement of Thoracic Kyphosis and Lumber lordosis among Agricultural workers and Corporate Professionals (IT) using Flexicurve Ruler. International Journal of Occupational Safety and Health, 2019, 9(2): 37-44

GALLUCCI, M., CARBONARA, P., PACILLI, A., et al. Use of Symptoms Scores, Spirometry, and Other Pulmonary Function Testing for Asthma Monitoring. Frontiers in Pediatric Journal, 2019, 7(54): 1-12.

KALSO E, MENNANDER S, TASMUTH T, & NILSSON E. Chronic post-sternotomy pain. Acta Anaesthesiologica Scandinavica, 2001, 45(8): 935-939.

VAN GULIK L, JANSSEN LI, AHLERS SJ, et al. Risk factors for chronic thoracic pain after cardiac surgery via sternotomy. European Journal of Cardio-Thoracic Surgery, 2011, 40(6): 1309–1313.

LIEBSCH C, GRAF N, & WILKE H J. Wire cerclage can restore the stability of the thoracic spine after median sternotomy: an in vitro study with entire rib cage specimens. European Spine Journal, 2017, 26(5), 1401-1407.

JOHARI, J., SHARIFUDIN, M. A., AB RAHMAN, A., et al. Relationship between pulmonary function and degree of spinal deformity, location of apical vertebrae and age among adolescent idiopathic scoliosis patients. Singapore Medical Journal, 2016, 57(1), 33–38.

MCMASTER MJ, GLASBY MA, SINGH H, & CUNNINGHAM S. Lung function in congenital kyphosis and kyphoscoliosis. Journal of Spinal Disorders & Techniques, 2007; 20(3):203 8.

HUFFMYER, J. L., & GROVES, D. S. Pulmonary complications of cardiopulmonary bypass. Best Practice & Research. Clinical Anaesthesiology, 2015, 29(2): 163-175.

RONCADA, G., DENDALE, P., LINSEN, L., et al. Reduction in pulmonary function after CABG surgery is related to postoperative inflammation and hypercortisolemia. International Journal of Clinical and Experimental Medicine, 2015, 8(7): 10938–10946.

HEGAZY FA, MOHAMED KAMEL SM, ABDELHAMID AS, et al. Effect of postoperative high load long duration inspiratory muscle training on pulmonary function and functional capacity after mitral valve replacement surgery: A randomized controlled trial with follow-up. PloS One, 2021, 16(8): e0256609.

HASSAN AM, KAMEL SM, ABDELHAMID AS, et al. Short-term effect of inspiratory muscle training on pulmonary function after mitral valve replacement: Quasi-experimental study. Physiotherapy Practice and Research, 2022, 43(1): 55-61

BAUMGARTEN, M. C., GARCIA, G. K., FRANTZESKI, M. H., et al. Pain and pulmonary function in patients submitted to heart surgery via sternotomy. Brazilian Journal of Cardiovascular Surgery, 2009, 24(4), 497-505.

RENAULT JA, COSTA-VAL R, ROSSETTI MB, HOURI NETO M. Comparison between deep breathing exercises and incentive spirometry after CABG surgery. Brazilian Journal of Cardiovascular Surgery, 2009; 24(2): 165-72


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