Horner’s syndrome caused by the first rib fracture sustained during coronary artery bypass grafting: a case report and literature review

Abstract

Background
Horner’s syndrome is a rare complication of cardiovascular surgery. A bone fragment and hematoma due to rib fracture after cardiac surgery may cause injury to the brachial nerve plexus and sympathetic nerve trunk, leading to neurologic disorders and Horner’s syndrome. However, few reports have revealed the etiology of Horner’s syndrome after cardiovascular surgery based on imaging. Herein we present a case in which a plain CT scan confirmed the etiology of Horner’s syndrome after coronary artery bypass grafting (CABG), reviewing 139 CABG cases retrospectively in our hospital and 6 case reports of Horner’s syndrome associated with cardiovascular surgery.

Case presentation
A 69-year-old woman with a history of percutaneous coronary intervention and total abdominal hysterectomy with bilateral salpingo-oophorectomy had chest pain on exertion. Coronary angiography showed severe triple vessel disease. She underwent off-pump coronary artery bypass grafting (CABG). A median sternotomy was performed, and the split sternums were widened using a sternal retractor. The bilateral internal thoracic arteries were harvested. A triple CABG was performed. She had left shoulder pain after surgery. She complained of anhidrosis involving the left face and hyperhidrosis involving the right face from postoperative day (POD) 6. Left ptosis and blurry vision appeared after discharge from the hospital, for which she saw a neurologist in our hospital on POD 48. Miosis could not be clearly confirmed. She was diagnosed with Horner’s syndrome. A plain CT scan revealed displaced fractures of the bilateral first ribs and left second rib. The bone fragment of the left first rib head was displaced 3 mm anteriorly compared to the left first rib head before surgery, which suggested that the fragment affected the stellate ganglion in the sympathetic trunk. The patient had regular follow-up evaluations. The anhidrosis persisted, but the ptosis improved, and the miosis was not confirmed at the 6-month follow-up evaluation.

Conclusions
We should recognize that Horner’s syndrome is one of the complications of cardiovascular surgery, especially CABG. Fracture of the first rib head with a displaced bone fracture was shown to be a contributor to ipsilateral Horner’s syndrome. When symptoms of Horner’s syndrome and other neurologic symptoms are noted after open heart surgery, a plain CT examination should be obtained.

Full text

Yasumuraetal.
General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
https://doi.org/10.1186/s44215-024-00166-2
CASE REPORT
Horner’s syndrome caused bytherst rib
fracture sustained duringcoronary artery
bypass grafting: acase report andliterature
review
Hiroto Yasumura1* , Koji Tao1, Ryo Imada1, Yushi Yamashita1, Naoki Tateishi1 and Tamahiro Kinjo1
Abstract
Background Horner’s syndrome is a rare complication of cardiovascular surgery. A bone fragment and hematoma
due to rib fracture after cardiac surgery may cause injury to the brachial nerve plexus and sympathetic nerve trunk,
leading to neurologic disorders and Horner’s syndrome. However, few reports have revealed the etiology of Horner’s
syndrome after cardiovascular surgery based on imaging. Herein we present a case in which a plain CT scan con-
firmed the etiology of Horner’s syndrome after coronary artery bypass grafting (CABG), reviewing 139 CABG cases
retrospectively in our hospital and 6 case reports of Horner’s syndrome associated with cardiovascular surgery.
Case presentation A 69-year-old woman with a history of percutaneous coronary intervention and total abdomi-
nal hysterectomy with bilateral salpingo-oophorectomy had chest pain on exertion. Coronary angiography showed
severe triple vessel disease. She underwent off-pump coronary artery bypass grafting (CABG). A median sternotomy
was performed, and the split sternums were widened using a sternal retractor. The bilateral internal thoracic arter-
ies were harvested. A triple CABG was performed. She had left shoulder pain after surgery. She complained of anhi-
drosis involving the left face and hyperhidrosis involving the right face from postoperative day (POD) 6. Left ptosis
and blurry vision appeared after discharge from the hospital, for which she saw a neurologist in our hospital on POD
48. Miosis could not be clearly confirmed. She was diagnosed with Horner’s syndrome. A plain CT scan revealed
displaced fractures of the bilateral first ribs and left second rib. The bone fragment of the left first rib head was dis-
placed 3 mm anteriorly compared to the left first rib head before surgery, which suggested that the fragment affected
the stellate ganglion in the sympathetic trunk. The patient had regular follow-up evaluations. The anhidrosis persisted,
but the ptosis improved, and the miosis was not confirmed at the 6-month follow-up evaluation.
Conclusions We should recognize that Horner’s syndrome is one of the complications of cardiovascular surgery,
especially CABG. Fracture of the first rib head with a displaced bone fracture was shown to be a contributor to ipsilat-
eral Horner’s syndrome. When symptoms of Horner’s syndrome and other neurologic symptoms are noted after open
heart surgery, a plain CT examination should be obtained.
Keywords Horner’s syndrome, Rib fracture, Open heart surgery, Coronary artery bypass grafting
Background
Horner’s syndrome is a rare complication of cardiovas-
cular surgery. e triad of Horner’s syndrome is ptosis,
miosis, and anhidrosis, which leads to a lower aesthetic,
visual, and hygienic quality of life [1]. e mean force of
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General Thoracic and
Cardiovascular Surgery Cases
*Correspondence:
Hiroto Yasumura
hiroto1331255@yahoo.co.jp
1 Department of Cardiovascular Surgery, Kagoshima Medical Center, 8-1,
Shiroyamacho, Kagoshima, Kagoshima 892-0853, Japan

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Yasumuraetal. General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
median sternotomy is a remarkably forceful procedure,
requiring forces from 150 to 300 N (kg・m/s2) in corpses
[2] and leading to rib fracture. A bone fragment and
hematoma due to rib fracture may cause injury to the
sympathetic nerve trunk and brachial nerve plexus [3, 4],
leading to Horner’s syndrome and other neurologic dis-
orders. However, few reports have revealed the etiology
based on imaging. Herein we present a case in which a
plain CT scan confirmed the etiology of Horner’s syn-
drome after coronary artery bypass grafting (CABG),
reviewing 139 CABG cases retrospectively in our hospi-
tal and 6 case reports of Horner’s syndrome associated
with cardiovascular surgery.
Case presentation
A 69-year-old woman with a history of percutaneous cor-
onary intervention and a total abdominal hysterectomy
with bilateral salpingo-oophorectomy had chest pain on
exertion. Coronary angiography showed severe triple
vessel disease. e SYNTAX score was 30, which favored
CABG over percutaneous coronary intervention. She
underwent off-pump CABG without anti-platelet respite.
A pillow was placed under the back adjacent to the shoul-
der bones. A median sternotomy was performed, and
the split sternums were widened using a sternal retractor
(IMR15-710-J; Getinge, Gothenburg, Sweden) (Fig.1A,
B). Bilateral internal thoracic arteries (ITAs) were har-
vested with a Harmonic® scalpel (Johnson and Johnson,
NJ, USA). A saphenous vein graft was also harvested. A
triple CABG was performed. e respirator was with-
drawn on postoperative day (POD) 1. Her recovery was
uneventful, but she complained of left shoulder pain
after the surgery. She also had anhidrosis involving the
left face and hyperhidrosis involving the right face from
POD 6. e pain persisted and was treated with acetami-
nophen. e patient had such a severe allergy to a con-
trast agent that myocardial scintigraphy was substituted
for a postoperative coronary CT. A plain CT and MRI
were not performed. e patient was discharged on POD
16. After discharge, in addition to anhidrosis involving
the left face, left ptosis and blurry vision appeared, for
which she saw a neurologist in our hospital on POD 48
(Fig.2A). Miosis could not be clearly confirmed. She was
diagnosed with Horner’s syndrome. A head MRI revealed
no lesions around the medulla oblongata. e symptoms
persisted and a plain CT scan on POD 76 revealed dis-
placed fractures of the bilateral first ribs and left second
rib (Fig. 2B), which were thought to be caused by rib
retraction during the CABG. e bone fragment of the
left first rib head was displaced 3 mm anteriorly com-
pared to the left first rib head before surgery (Fig. 2C),
which suggested that the fragment affected the stellate
ganglion in the sympathetic trunk. e patient had regu-
lar follow-up evaluations. At the 6-month follow-up eval-
uation, the anhidrosis persisted, but the ptosis and blurry
vision improved, and the miosis was not confirmed.
To elucidate the relationship between Horner’s syn-
drome and the first rib fracture due to CABG using
ITA in our hospital, we retrospectively researched 139
patients who underwent CABG using an ITA from Janu-
ary 2022 to February 2024 who were followed by coro-
nary or plain CT scans within 2 months after CABG
(Table1). In all cases, the same sternal retractor (IMR15-
710-J) was used. e bilateral ITAs, LITA, and RITA
were used in 91, 44, and 4 patients, respectively. e
types of rib fractures were categorized as displaced or
non-displaced (infraction fracture), and the sites of rib
fractures were divided into the head, neck, tubercle, and
body. Among all patients who sustained rib fractures, no
patient sustained more than one fracture per rib. Among
95 patients in whom the RITA was used, 31 (32.6%)
patients sustained a right first rib fracture, and among
135 patients in whom the LITA was used, 37 (27.4%)
patients sustained a left first rib fracture. Of both ribs, a
Fig. 1 Finding of LITA harvesting (These are pictures of reference and irrelevant to the patient described herein). A A median sternotomy
was performed and the split sternums were widened using a sternal retractor (IMR15-710-J; Getinge, Gothenburg, Sweden). The maximum chest
opening width of this retractor is 130 mm. This is a picture of reference and irrelevant to the patient described herein. B Rib retraction can be
adjusted by a screw. The maximum movement range of the screw is 70 mm

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Yasumuraetal. General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
fracture of rib body was most frequent (right, 54.8%; left,
56.8%). Although 8 (5.8%) of 139 patients sustained the
first rib head fracture, only the patient described herein
(0.72%) developed Horner’s syndrome.
Discussion
Horner’s syndrome results from damage to the ipsilat-
eral oculosympathetic pathway. Lung, breast, and medi-
astinum tumors, as well as neck injuries may cause the
syndrome due to direct compression of the oculosym-
pathetic pathway [5]. However, cardiovascular surgery
can also cause Horner’s syndrome. Only six case reports
[1, 6–10] of Horner’s syndrome due to cardiovascu-
lar surgery were identified on a search of the literature
(Table2), which may in part be because the symptoms
of Horner’s syndrome do not always appear simultane-
ously and are sometimes too mild to be noticed. Left-
sided Horner’s syndrome was attributed to CABG in
three cases [1, 6, 10] and the current case, and left lat-
eral thoracotomy operation in two case [7, 8]. In most
cases, the firstly recognized Horner’s symptom was pto-
sis and the onset day was within 2 days after the opera-
tion. Generally speaking, Horner’s syndrome caused by
trauma is immediately diagnosed after a traumatic event,
but the symptoms can be shown in a delayed manner
[11], as in the current case. In some cases, the symptoms
resolved spontaneously or with medication.
A sternal retractor, especially one for harvesting the
ITAs, can cause rib fractures. Kimura [12] reported up to
five fractures of the left upper rib after CABG using the
left ITA (LITA). Rib retraction for harvesting ITAs after
a median sternotomy exerts leverage on ribs like a nail
puller. Specifically, the rib tubercle, split sternum, and rib
head are the fulcrum, point of force, and point of action,
respectively (Fig.3). e rib head and neck are fixed by
the costovertebral joint and costotransverse ligament,
respectively. A sternal retractor for ITA harvesting is
often placed at an upper position across the sternal angle.
Forceful retraction during harvesting an ITA can exert
excessive work according to the principle of leverage,
Fig. 2 Findings before and after CABG. A Left ptosis appeared after discharge and she was diagnosed with Horner’s syndrome on postoperative
day (POD) 48. B Plain CT scan on POD 76 revealed displaced fractures of the right first rib neck (blue arrow) and the left first rib head (red arrow).
C Plain CT scan before CABG. Compared to this image, the bone fragment of the left first rib head (B, red arrow) was shown to be displaced 3 mm
anteriorly, which suggested that the fragment affected the stellate ganglion in the sympathetic trunk
Table 1 The first rib fracture after CABG using the ITA in our hospital (2022.1∼2024.2)
ITA Internal thoracic artery
Right Left
Harvested ITA 95 135
Site Head Neck Tubercle Body Head Neck Tubercle Body
First rib fracture Type Displaced 0 0 1 1 1 (this case) 0 0 8
Non-displaced (infraction) 3 10 0 16 4 5 6 13
Total 31 37

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Yasumuraetal. General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
Table 2 Case reports of Horner’s syndrome caused by cardiovascular surgery
CABG Coronary artery bypass grafting, MAP Mitral annuloplasty, PA Pulmonary arter y, PDA Patent ductus arteriosus, ITA I nternal thoracic artery, BITAs Bilateral internal thoracic arteries
Author and year of
publication Age (years) Sex (M/F) Aected side Surgery Incision Used ITA The rst symptom
and the onset day Findings on
radiology Treatment and course
Imamaki et al. in 2006
[1]70 F Left Off-pump CABG Median sternotomy BITA Ptosis on POD2 No data Spontaneous remission
1 month after the sur-
gery
Murakami et al.
in 2007 [6]77 F Left MAP + CABG Median sternotomy LITA Ptosis, miosis,
and enophthalmos
on POD2
Fracture of left 1st rib
on chest X-ray Spontaneous remission
6 months after the sur-
gery
Tsuchiya et al. in 2013
[7]0 (1 month) F Left PA banding + PDA
closure Left lateral thora-
cotomy No use Ptosis just
after the operation No data Transconjunctival
resection of Mul-
ler muscle 1.5 years
after the surgery
Nasser et al. in 2015
[8]0 (9 months) F Left Division of vascular
ring Left lateral thora-
cotomy No use Ptosis, miosis,
and enophthalmos
on POD2
No data No remission 7 days
after the surgery
Aslankurt et al. in 2021
[9]9 M Right VSD, aortic and mitral
valve repair Median sternotomy No use Ptosis on unknown
day No data No remission 4 months
after the surgery
Gopinath et al.
in 2021 [10]56 M Left CABG Median sternotomy No data Unknown symptom
on POD1 Infraction fracture
of left 1st rib head
on CT
Remission with Anti-
immflammatories
and steroids
This case in 2024 69 F Left Off-pump CABG Median sternotomy BITA Anhidrosis on POD6 Displaced fracture
of 1st rib and left 2nd
rib on plain CT
Anhidrosis remained,
but ptosis improved
6 months after the sur-
gery

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Yasumuraetal. General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
leading to fracture of the point of action (head of the first
rib). If the rib is fragile, the power of excessive retraction
may focus on the point of action, resulting in disruption
of the principle of leverage and a fracture between the
fulcrum (rib tubercle) and the point of force (split ster-
num). e rib fracture on CABG will incur more bleed-
ing because perioperative anti-platelet drug therapy is
a cornerstone of CABG. A displaced fracture and the
ensuing bleeding could lead to injury of the surrounding
organs and a hemothorax.
A dislocation fracture of the costovertebral joint has
been reported to cause injury to the intercostal artery
and azygos vein, leading to a hematoma [13]. In the same
way, a bone fragment of the first rib and subsequent
hematoma is considered to directly or indirectly com-
press brachial nerve plexus and stellate ganglion [3, 4,
12] (Fig.4). e stellate ganglion, which is a second-order
neuron of the oculosympathetic pathway, is located on
the ventral surface of the first rib head [14] (Fig.3). e
left stellate ganglion is more densely surrounded than the
right ganglion by the vertebral artery, esophagus, lon-
gus colli muscle, vertebral body, and left rib head, which
might explain why Horner’s syndrome occurs more often
on the left side after open heart surgery. In addition, the
LITA is used more frequently than the right ITA (RITA)
during CABG for its good patency.
Horner’s syndrome complicates all open heart surgery
in 0.6–1.7% of cases [3, 16–18] and 0.2–7.7% of CABG
cases [19–21]. We retrospectively reviewed 139 CABG
cases, among which 8 patients (5.8%) sustained the first
rib head fracture (Table 1). Among those 8 patients,
only the patient with displaced fracture described herein
(0.72%) developed Horner’s syndrome, and the other 7
patients with non-displaced fracture (infraction fracture)
did not develop Horner’s syndrome. is can not only
graphically but also statistically prove that the displaced
bone fracture of the first rib head and the ensuing inflam-
mation and hematoma directly compress or injure the
left stellate ganglion and lead to Horner’s syndrome.
Horner syndrome after cardiovascular surgery may be
a self-limiting complication based on the outcomes of 7
patients (Table2), including the patient described herein.
is finding can be in part because the inflammation
and hematoma surrounding the fracture improved over
time and the injured neuron recovered spontaneously.
However, we should take Horner syndrome into account
as a preventable complication. Minimum sternal widen-
ing and careful manipulation of a sternal retractor may
prevent iatrogenic Horner’s syndrome [6]. e incidence
of first rib fractures due to median sternotomy has been
reported to decrease when the sternal retractor is placed
at a lower position [3].
Fig. 3 Schema for the mechanism underlying rib fracture. Forceful retraction (blue arrow) can exert excessive work according to the principle
of leverage (red arrow), leading to a fracture at the point of action (rib head). If the rib is fragile, the power of excessive retraction may be conducted
to the point of action, resulting in disruption of the leverage principle and fracture between the fulcrum (rib tubercle) and point of force (split
sternum)

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Yasumuraetal. General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
From the viewpoints of the retraction blade, a sternal
retractor for harvesting the ITAs is mainly divided into
two types: Takedown pattern retractor and French pat-
tern retractor (Fig.5). ere are no reports comparing
the two retractors in the literature. A sternal retractor
can be equipped with foil load sensors to measure the
force distribution over the retractor blades [2]. ere-
fore, further research for the relation among retraction
force, chest opening width, harvesting time, and ortho-
pedic and neurological complications for each retractor
is expected, which may lead to a decrease in the com-
plications by retractors.
Conclusion
We should recognize that Horner’s syndrome is one of
the complications of cardiovascular surgery, especially
CABG. Fracture of the first rib head with a displaced
bone fracture is a contributor to ipsilateral Horner’s syn-
drome. When symptoms of Horner’s syndrome and other
neurologic symptoms are noted after cardiovascular sur-
gery, a plain CT examination should be obtained.
Fig. 4 Schema involving the mechanism underlying Horner’s syndrome due to fracture of the first rib head. A bone fragment of the first rib head
and subsequent hematoma can compress or injure the stellate ganglion (orange arrow), which is a second-order neuron of the oculosympathetic
pathway, leading to Horner’s syndrome. Copyright© 2011, Medic Media. Reproduced with permission from Institute for Health Care Information
Sciences ed. Medical Disease: An Illustrated Reference Guide. vol. 7 Neurology and Neurosurgery. 1st ed. Tokyo, Japan: Medic Media; 2011 [15]
Fig. 5 Two types of sternal retractor for harvesting the ITAs. A Takedown pattern retractor (IMR15-710-J; Getinge, Gothenburg, Sweden). B French
pattern retractor (SCT70026 Sternal-IMA Retractor, M A Corporation, Chiba, Japan)

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Yasumuraetal. General Thoracic and Cardiovascular Surgery Cases (2024) 3:41
Abbreviations
CABG Coronary artery bypass grafting
PCI Percutaneous coronary intervention
ITA Internal thoracic artery
POD Postoperative day
LITA Left internal thoracic artery
RITAs Right internal thoracic arteries
Acknowledgements
We would like to thank cardiologist Kento Tagata for the perioperative
examination and treatment, and orthopedist Hisashi Sameshima for image
diagnosis.
Authors’ contributions
T.K., K.T., and H.Y. performed the cardiac surgery. H.Y. drafted the manuscript.
K.T. and T.K. supervised manuscript preparation. All authors contributed to
patient treatment. All the authors read and approved the final manuscript.
Funding
There are no sources of funding.
Availability of data and materials
There are no additional data to disclose.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Informed consent was obtained from the patient for publication of this case
report and accompanying images.
Competing interests
The authors declare that they have no competing interests.
Received: 20 April 2024 Accepted: 30 August 2024
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