case_images: PMC6309030_01
case_images: (A) Postero-anterior and (B) lateral radiographs of the spine at initial clinical presentation show a mild right upper thoracic kyphoscoliosis with pencilling of the 2 apical ribs on the convexity of the curve but no other dystrophic changes.
case_images: 10.1177_1179573518819484-fig1.jpg
case_images: PMC6309030_01_10.1177_1179573518819484-fig1.jpg
case_images: fig1-1179573518819484
case_images: The scoliosis was measuring 14  from T1-T6 and the kyphosis 40  from T1-T12 (Figure 1).
case_images: PMC6309030_02
case_images: (A) Postero-anterior and (B) lateral radiographs at age 16.8 years show progressing of the deformity in both coronal and sagittal planes and dystrophic changes including rib pencilling, lateral vertebral scalloping, vertebral wedging, and a short-segmented angular curve but no vertebral displacement in the upper thoracic spine.
case_images: 10.1177_1179573518819484-fig2.jpg
case_images: PMC6309030_02_10.1177_1179573518819484-fig2.jpg
case_images: fig2-1179573518819484
case_images: At age 16.8 years, the patient had completed his spinal growth as the iliac apophysis had fully formed and fused (Figure 2).
case_images: PMC6309030_03
case_images: (A) Postero-anterior and (B) lateral radiographs at age 18.8 years show significant deterioration of the kyphoscoliosis associated with rotatory displacement of T2 on T3 (arrow). (C-D) This is better illustrated on the CT scans obtained as part of the preoperative assessment. (E) CT angiography performed before the anterior spinal fusion demonstrates the relationship of the aortic arch and major vascular structures with the apex of the deformity which made the anterior approach to the upper thoracic spine very challenging. CT indicates computed tomography.
case_images: 10.1177_1179573518819484-fig3.jpg
case_images: PMC6309030_04_10.1177_1179573518819484-fig3.jpg
case_images: fig3-1179573518819484
case_images: A contrast CT angiogram determined the anatomy of the adjacent vessels in front of the apex of the deformity to allow surgical planning (Figure 3).
case_images: PMC6309030_04
case_images: (A) Postero-anterior and (B) lateral radiographs at age 18.8 years show significant deterioration of the kyphoscoliosis associated with rotatory displacement of T2 on T3 (arrow). (C-D) This is better illustrated on the CT scans obtained as part of the preoperative assessment. (E) CT angiography performed before the anterior spinal fusion demonstrates the relationship of the aortic arch and major vascular structures with the apex of the deformity which made the anterior approach to the upper thoracic spine very challenging. CT indicates computed tomography.
case_images: 10.1177_1179573518819484-fig3.jpg
case_images: PMC6309030_04_10.1177_1179573518819484-fig3.jpg
case_images: fig3-1179573518819484
case_images: A contrast CT angiogram determined the anatomy of the adjacent vessels in front of the apex of the deformity to allow surgical planning (Figure 3).
case_images: PMC6309030_05
case_images: (A) Postero-anterior and (B) lateral radiographs at age 22.3 years show a stable spine with the posterior instrumentation in adequate position and no progression of the deformity. (C-D) Repeat computed tomographic scans show good consolidation of the rib struts across the area of the rotatory T2/T3 displacement providing anterior vertebral column support.
case_images: 10.1177_1179573518819484-fig4.jpg
case_images: PMC6309030_05_10.1177_1179573518819484-fig4.jpg
case_images: fig4-1179573518819484
case_images: A repeat CT of the spine confirmed good consolidation of the anterior rib strut grafts and a circumferential fusion (Figure 4).