AJR 2004; 183:1487-1488
© American Roentgen Ray Society
Chronic Scapulothoracic Bursitis Associated with Thoracoplasty
Akira Fujikawa1,
Yoshiro Oshika2,
Taiji Tamura1 and
Yutaka Naoi1
1 Department of Radiology, Japan Self-Defense Forces Central Hospital, 1-2-24,
Ikejiri, Setagaya, Tokyo 154-8532, Japan.
2 Department of Thoracic Surgery, Japan Self-Defense Forces Central Hospital,
Tokyo 154-8532, Japan.
Received November 22, 2003;
accepted after revision December 28, 2003.
Address correspondence to A. Fujikawa.
Introduction
The scapulothoracic bursa is known to cause snapping scapular syndrome,
characterized by shoulder pain and bony crepitus accompanying shoulder motion.
Although a significant clinical overlap exists between scapulothoracic
bursitis and snapping scapular syndrome, scapulothoracic bursitis can be an
isolated entity causing shoulder discomfort
[1]. The pathogenesis of
scapulothoracic bursa formation is thought to be related to chronic repetitive
mechanical stress on the periscapular tissue, usually resulting from a bone
abnormality such as a protrusion of the scapula or rib cage.
We report a case of chronic scapulothoracic bursitis associated with
thoracoplasty in a woman having left inferior periscapular pain. CT and MRI
revealed a cystic mass located between the inferior tip of the scapula and the
deformed chest wall, due to thoracoplasty performed 50 years earlier. The
patient's status after thoracoplasty was thought to have caused
scapulothoracic bursitis or bursa formation.
Case Report
A 74-year-old woman was referred to our institution because of a
periscapular mass found during a CT study performed at another hospital as
part of a workup for left upper-back pain. She had a history of pulmonary
tuberculosis that had been treated with thoracoplasty at 24 years old; during
the thoracoplasty, her left upper ribs had been resected
(Fig. 1A). Since then, she had
experienced a limited range of motion in her left shoulder. CT revealed a
mass, measuring 5 x 4.5 x 2 cm, between the inferior tip of the
scapula and the chest wall (Figs.
1B and
1C). MRI revealed the cystic
nature and thin wall of the mass (Fig.
1D). Aspiration of the lesion produced serosanguineous fluid with
no evidence of microorganisms. Surgical tumor excision was performed because
of a persistent pain at the site of the mass, although a presurgical diagnosis
of chronic bursitis had been made on the basis of the MRI findings. At the
time of surgery, a partial rib resection was also performed because of a firm,
fibrous adhesion between the mass and the adjacent rib. Histologically, the
inner surface of the cystic mass was covered by a synovial lining, with no
evidence of malignancy; these findings were consistent with a diagnosis of
bursa formation with inflammatory change. The patient's periscapular pain
resolved after surgery.
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Fig. 1A. —74-year-old woman with scapulothoracic bursitis associated
with thoracoplasty. Anteroposterior chest radiograph shows deformity of left
upper thorax and malpositioned left scapula as result of thoracoplasty.
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Fig. 1B. —74-year-old woman with scapulothoracic bursitis associated
with thoracoplasty. Axial CT image shows mass adjacent to deformed rib at
level of inferior tip of left scapula and evidence of abnormal articulation
between rib and scapula with flattening and sclerosis indicating chronic
change.
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Discussion
Few reports on the imaging findings for scapulothoracic bursitis or bursa
formation have been found in the literature
[2–6].
Most of the previously reported cases of scapulothoracic bursitis or bursa
formation are related to scapular osteochondroma and, rarely, to exostosis of
the rib or a partial scapulectomy
[7,
8]. To our knowledge,
scapulothoracic bursitis or bursa formation secondary to thoracoplasty has not
been previously reported.
Thoracoplasty was the treatment of choice for pulmonary tuberculosis in the
preantibiotic era and is still sometimes indicated for the treatment of
thoracic empyema. During thoracoplasty, the ribs and periscapular muscles over
the empyema space are removed to collapse the affected pulmonary cavity and to
obliterate the pleural space. During this procedure, a native major
scapulothoracic bursa is likely to be resected. We think that the lesion in
the present case was the result of secondary bursa formation.
Bursa formation probably occurred as a result of a chronic irritation
between the scapula and the deformed thoracic wall— that is, secondary
to the alteration in the alignment of the scapulothoracic joint after
thoracoplasty. A muscular imbalance may also have been involved
[1]. Therefore, the present
case indicates that a mere incongruence in the articulation can cause
scapulothoracic bursa formation.
Cold abscess is important in the differential diagnosis of a cystic mass
lesion adjacent to the tip of the scapula in patients who have undergone
thoracoplasty. Although this particular site and situation are unusual,
abnormal bursae throughout the body may, in a similar fashion, produce
symptomatic masses and should be considered more frequently in differential
diagnoses.
In conclusion, thoracoplasty was implicated as the source of a
scapulothoracic bursa formation or bursitis in this case. Recognition of this
association may lead to a correct diagnosis and may help clinicians to make
decisions regarding proper clinical management.
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Introduction
Case Report
