胸廓出口综合征的新认识——解剖学与临床观察

目的探讨胸廓出口综合征的病因。方法对３０具６０侧经福尔马林固定的成人尸体小斜角肌及前中斜角肌的起始部进行解剖研究;对５３例胸廓出口综合征手术患者（１９６６～１９９４年４５例,１９９６～１９９７年８例）随访情况进行总结分析。结果解剖研究发现小斜角肌的出现率为８８３％,Ｔ１神经根或其下干在小斜角肌近段起源的腱性组织上跨过;前中斜角肌在颈椎横突的前后结节均有起点,Ｃ５、Ｃ６神经根从前中斜角肌的交叉腱性起点中穿过。４５例１９６６～１９９６年手术者中,有颈肩痛症状者３４例,术后１７例颈肩痛症状仍存在,其中７例加重;８例１９９６～１９９７年手术者中,７例有颈肩痛,术中切断前中斜角肌在Ｃ５～６神经根旁的腱性纤维组织,术后仅有１例仍有颈肩部不适。结论小斜角肌的腱性纤维是臂丛神经下干或Ｔ１神经根受压的原因;前中斜角肌在Ｃ４～５横突前后结节的交叉腱性起点是压迫Ｃ５～６,有时包括Ｃ７神经根或臂丛神经上（中）干的原因     

胸廓出口综合征的诊疗体会

目的探讨胸廓出口综合征(TOS)的诊断和手术治疗。方法我院自1997-2003年诊断和手术治疗胸廓出口综合征23例24侧，诊断为臂丛上千型TOS2例，下千型17例18侧，全臂丛型1例，血管型2例，混合型1例。手术切除颈肋及过长的横突，同时作臂丛神经外膜松解术。术中发现23例有纤维束带压迫臂丛神经，均切断前斜角肌，松解臂丛神经及受压的锁骨下血管，如果发现中、小斜角肌压迫臂丛神经血管，则予切断。术后当天行颈肩部活动。结果按Ross的疗效评定标准评定疗效，本组优10例11例，良9例，可2例，差2例，优良率83.33％。结论胸廓出口综合征应早期手术探查，彻底松解臂丛神经血管。     

胸廓出口综合征26例术后远期疗效分析

目的 报道胸廓出口综合征（thoracic outlet syndrome，TOS）手术治疗后的远期疗效。方法 对26例胸廓出口综合征患者．切断前、中、小斜角肌及臂丛神经松解术后进行5年3个月-10年7个月的长期随访，并分析其疗效。结果 14例颈肩部疼痛、手麻症状消失，6例症状明显好转，6例自觉效果不佳或无效，优良率为76．93％。结论 胸廓出口综合征是常见病，一旦确诊，保守治疗效果不佳或反复发作者，应及早手术。但必需注意术后大约有23．07％的患者效果不佳甚至无效。     

颈肋综合征13例分析

目的探讨颈肋综合征的特点和治疗方法。方法回顾分析13例颈肋综合征的临床表现、手术探查所见和手术方法。本组臂丛下干受压型8例,臂丛中、下干受压型3例,全臂丛受压型2例。13例均有下颈部肿块,全部采用手术治疗。术中见不完整颈肋4例,完整颈肋7例,颈肋由两个节段组成2例;同时合并前、中、小斜角肌异常和纤维索带,共同构成对臂丛特别是下干的卡压。结果随访6个月～5年3个月,手术疗效优6例,良5例,可2例。结论颈肋综合征和颈肋两者内涵不同。颈肋可分为横突增长、不完整颈肋、完整颈肋和特殊形态等4种。而臂丛下干支配区的运动和感觉障碍以及下颈部肿块是颈肋综合征的重要特点,臂丛下干受压型是其主要临床类型。手术是主要的治疗措施,应将颈肋等卡压组织逐一切除或切断。建议将颈肋综合征作为胸廓出口综合征的特殊类型加以研究。     

颈3,4神经根卡压与前、中斜角肌的解剖关系及其临床研究

颈肩痛在临床上比较常见，引起此症状的原因很多，包括颈椎病、软组织损伤、肩周炎、颈项肌劳损、颈筋膜炎，肩胛背神经卡压等犤１－３犦。此外，我们在临床实践中发现，部分颈肩痛是由C３，４神经根卡压所致，常表现为下枕部、面部、颈部的疼痛不适，有时可合并胸廓出口综合征     

切断前中小斜角肌治疗胸廓出口综合征的远期疗效

目的 远期随访切断前中斜角肌治疗胸廓出口综合征（thoracic outlet syndrome，TOS）的疗效。方法对31例32侧胸廓出口综合征患者术后的疗效作远期随访。其中上干型4例，下干型26例27侧，全臂丛型1例。X线片示颈肋1例。第七颈椎横突过长2例。均行手术治疗。术中发现31例均有纤维束带压迫臂丛神经，作前、中、小前斜角肌切断术；3例骨异常者同时切除增长的骨组织和颈肋。术后随访4年8个月-8年3个月．平均为5年4个月。以症状、体征有无复发以及是否恢复原工作为随访主要观察项目。疗效按胸廓出口综合征评定标准评定。结果 术后症状明显改善15例16侧，部分改善6例，无效10例。优良率为68．7％。结论 该组病例远期疗效的优良率为68．7％，因此，胸廓出口综合征的治疗方法仍是个有待于进一步研究的临床课题。     

胸廓出口综合征手术治疗中对前中小斜角肌的处理

目的随访35例胸廓出口综合征手术治疗的疗效。方法手术治疗35例37侧胸廓出口综合征患者,其中上干型5例,下干型28例30侧,全臂丛型2例。X线片示颈肋1例,第七颈椎横突过长3例。手术切除增长的骨组织和颈肋,术中发现35例均有纤维束带压迫臂丛神经,均作前、中、小前斜角肌切断术。术后随访1年～3年6个月。结果术后症状明显改善26例27侧,部分改善5例6侧,无效4例。结论斜角肌是引起臂丛神经血管受压征的主要因素,手术探查时应常规切断前、中斜角肌及小斜角肌。     

椎孔外颈神经根卡压松解术

目的探讨用神经松解术治疗颈神经根椎孔外卡压综合征。方法对符合手术指征的24例患者经系统的保守治疗无效后行颈神经根探查松解术。对术中发现的相应神经根卡压进行彻底松解。结果除2例术前有明显肌萎缩者未见恢复外,其余22例术后症状均得到明显改善。结论颈神经根椎管外卡压是导致颈肩痛的重要原因之一,手术治疗效果明显。     

颈神经根受压伴远端神经卡压的诊治

目的 探讨近端颈神经根受压合并远端神经卡压(双卡综合征)的诊断和治疗。方法 1997年以来共收治双卡综合征29例。5例神经根无明确受压者采用颈椎手法调整及颈椎硬膜外神经阻滞术。24例作受压节段髓核摘除、椎间植骨融合术及远端受压神经松解术。结果 术后平均随访12个月。根据症状、体征的恢复程度评定疗效，分为优、良、可、差4级。评定结果25例为优良占86％。结论 双卡综合征并非罕见，正确的诊断和合理的治疗方案，对预后有重要的意义。     

对颈神经卡压认识的进展

颈神经卡压的文献已累有报道。《中华手外科杂志》在本期又刊出了“颈神经卡压引起的肘外侧顽固性疼痛”“胸廓出口综合征的神经－肌电图检测”和“臂丛神经血管受压征的临床分析”等文章，以加深读者对颈神经卡压的认识和理解。颈部受卡压的神经包括颈神经根及其分支，臂...     

近端肌萎缩型颈椎病11例的诊治分析

目的:探讨近端肌萎缩型颈椎病的临床特点、治疗方法及临床效果。方法:回顾性分析2016年9月至2020年12月治疗的11例近端肌萎缩型颈椎病患者,其中男7例,女4例,年龄38~68岁。分析其临床症状特点、MRI及神经电生理表现,分别采用保守治疗或颈椎前路减压融合手术进行治疗,治疗前后采用徒手肌力评定方法(manual muscle test,MMT)对患者进行疗效评价,同时随访患者满意度。结果:所有患者获得随访,时间6~19个月。11例均为单侧发病,主要表现以三角肌、冈上肌、冈下肌萎缩为主,早期可以伴有同侧颈肩痛;MRI显示以C_4,5、C_5,6节段病变多见,神经电生理检查表现为受累肌肉失神经支配,患侧支配神经复合肌肉动作电位(compound muscle action potential,CMAP)波幅较健侧降低。所有手术患者获得骨性融合,1例行颈椎体次切减压融合术(anterior cervical corpectomy and fusion,ACCF)术后出现对侧C₅神经根麻痹,经对症治疗10周后完全恢复。治疗后12个月时根据MMT疗效评估:保守治疗3例,优2例,良1例;手术治疗8例,优3例,良4例,可1例。结论:近端肌萎缩型颈椎病发病率低,表现为单侧近端肌肉萎缩,早期可以伴有同侧颈肩痛,结合MRI、神经电生理检查可以减少误诊。在发病早期尤其是髓核脱出导致神经压迫的可以采取保守治疗,当保守治疗无效或疼痛不能耐受时建议行前路减压手术,整体疗效满意。     

Surgical treatment of thoracic outlet syndrome in pediatrics

AimThoracic outlet syndrome (TOS) is a condition that occurs when the cervical neuro-vascular bundle becomes compressed at one of the three narrow areas of the thoraco-cervico-axillary region. Conservative management is the first line of treatment. Patients who do not respond to conservative management should be treated surgically. The aim of this review is to present our experience with the surgical management of TOS in pediatric patients.MethodsWe retrospectively reviewed the outcomes of all patients with TOS operated at our Hospital between 2001 and 2020. We collected all demographic data, clinical features, imaging data, type of operation performed, intraoperative findings, complications and recurrence.ResultsWe operated 9 patients within the study period. The median age at surgery was 14 (7 to 17) years. A transaxillary approach was used in 7 patients and a supraclavicular approach in 2. There was only one minor intraoperative complication (violation of the pleural space). There were no postoperative complications. The median length of stay was 3 (2 to 4) days. All patients were extubated in the operating room. Two patients developed symptoms on the contralateral side. One of these underwent a successful contralateral transaxillary Roos operation. The follow-up was 4 months to 20 years. All patients are asymptomatic.ConclusionWe believe that the Roos operation is a safe and effective treatment with excellent long-term outcomes for children with TOS that fail conservative management.     

神经根型颈椎病伴有周围神经卡压的诊断和治疗

目的：研究29例双卡综合征的诊断和治疗。方法：从1997年以来同时诊断为神经根型颈椎病与周围神经卡压的病例中选出29例患者，诊断标准为：(1)影像学上存在神经根在椎管内受压的证据；(2)有临床和(或)电生理的证据表明存在周围神经受到卡压；(3)周围神经的Tine1征阳性。对其中5例行保守治疗，24例行手术治疗，即神经松解术。平均随访12个月，根据术后症状、体征改善的程度分优、良、可和无效4级。结果：25例治疗后疗效优良，占86％。结论：神经根型颈椎病伴有周围神经卡压的双卡综合征并不罕见，正确认识双卡综合征，对诜择正确的治疗方案和估计愈后有重要意义．一旦确诊．应采取手术或非手术相结合的方法，可以达到满意的效果。     

颈椎后凸畸形的临床特征和外科治疗策略

目的 分析颈椎后凸畸形的临床特征和治疗策略.方法 自2006年3月至2009年10月治疗颈椎后凸畸形31例.根据患者的临床特点和影像学表现对其采用不同的治疗方法.手术组9例:男性4例,女性5例,年龄17～72岁,平均35岁;其中继发性后凸畸形4例,特发性颈椎后凸畸形5例.保守治疗组22例:男性11例,女性11例,年龄14～40岁,平均29岁,均为特发性颈椎后凸畸形.手术组:术前及术后1周,按美国脊髓损伤协会的脊髓损伤神经分级标准(AISA)对患者进行评估,术后定期复查颈椎正侧位X线片,并在手术后1周及之后每6个月复查1次颈椎MRI,以评估患者矫形、融合效果及脊髓减压情况.保守治疗组:每个月拍摄颈椎正侧位X线片评估治疗效果.分析此类患者的临床特征及治疗策略.结果 手术组:术后3 d颈椎侧位片示:Cobb角平均-1.3°(术前54.2°),AISA评分神经功能明显改善,随访时间6～18个月,未见内固定和融合失败.保守组:治疗后4个月Cobb角平均-5.4°(治疗前11.2°),颈项肩背痛症状基本消失,随访3～24个月未见症状复发.结论 早期采用体位疗法、石膏支具纠正颈椎生物力学的失衡可以阻止颈椎后凸畸形的发展.根据患者的临床特征,采用个性化的治疗方案,能够充分矫正严重的颈椎后凸畸形.     

Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach.

OBJECTIVES: Although the transaxillary route appears to be the optimal approach in patients with thoracic outlet syndrome (TOS), the effect of clinical features on surgical outcome remains unclear. We conducted a study to determine the clinical predictors of surgical outcome in patients with TOS. METHODS: We examined the data charts of patients with TOS who underwent operation via transaxillary approach. We investigated the possible correlations between the clinical features and surgical outcomes, and analyzed the data with logistic regression model to clarify the effect of clinical features on surgical outcome. RESULTS: A total of 127 patients with a mean age of 32.1+/-10.0 years (range 14-62 years) were analyzed. The rates of favorable and poor surgical outcomes were 82.7 and 17.3%, respectively. The subgroups of symptom duration (P=0.023), the subgroups of ulnar nerve conduction velocity (P=0.033) and the presence of cervical rib (P=0.003) showed a significant correlation with surgical outcome. Multivariate analysis revealed that the shorter duration of symptoms (P=0.017) and the presence of a cervical rib (P=0.026) had a significantly unfavorable effect on surgical outcome. CONCLUSIONS: The shorter duration of symptoms and the presence of a cervical rib may imply an unfavorable surgical outcome in patients with TOS.     

Snapping scapula syndrome: Conservative and surgical treatment

The aim of this work was to assess the clinical results in 13 snapping scapulas treated between 1990 and 1996. This is an infrequent source of shoulder discomfort characterized by painful, audible and palpable abnormal scapulothoracic motion. It may or may not have a demonstrable mechanical etiology, but often no obvious cause can be identified with imaging techniques. We report a series of 13 cases, of whom 8 were operated. The mean age was 23 years; there were 4 women and 9 men. All patients underwent a CT-scan and X-ray imaging. Initial treatment was conservative in 10 cases without obvious etiology, and surgical in three osteochondromas. Five patients who did not improve by a nonoperative approach were operated. After a mean follow-up of 24 months, pain and snapping were completely relieved. Surgery was the appropriate treatment in the cases of failure of conservative treatment and allowed patients to return to normal activities and work.     

Diagnosis and treatment of thoracic outlet syndrome

Patients who develop symptoms of thoracic outlet syndrome (TOS) have a predisposing anatomic abnormality. In most patients with TOS, the symptoms are caused by entrapment of the brachial plexus and they do not arise from compression of the subclavian artery, as was previously thought. The tests advocated for diagnosing this common syndrome (i.e., evaluating the positional compression of the artery when the arms are raised, the neck is turned, or the shoulders are braced) cannot accurately diagnose this syndrome. There are two reasons for this. The symptoms of TOS are not related to the compression of the artery in the outlet in 98% of patients, and 75% of normal individuals without symptoms show diminished radial pulse on various provocation tests. We employed four timed provocation tests (minute tests) to diagnose TOS: the timed Morley test, timed Wright test, timed Eden test, and elevated arm stress exercise, all of which are very sensitive. In normal individuals without symptoms, 20% experience transitional symptoms such as slight pain and tiredness, on these tests indicating a subclinical state. TOS is treated by keeping the thoracic outlet wide, this being done either conservatively or surgically. In 1993 and 1994, we conservatively treated 418 of 422 patients with TOS by means of active exercise, a brace, and by block therapy. These measures did not reduce the symptoms in 23 of these patients, so surgical treatment was indicated. In the remaining 4 of the 422 patients, conservative treatment was not indicated and surgery was performed directly. All the patients showed significant clinical improvement of varying degree. Presented at the 69th Annual Meeting of the Japanese Orthopaedic Association, Tokyo, April 12, 1996     

Formes déficitaires de syndrome de la traversée thoraco-brachiale. Étude rétrospective de 30 cas consécutifs

ObjectivesNeurologic TOS with amyotrophy is exceptional and the diagnosis is usually delayed compromising the outcome after treatment. The aims of this study were to define clinical features, anatomical causes, surgical results and prognostic factors of this disease.MethodsAll of the TOS with objective neurologic deficit treated in our unit between 1989 and 2011 were assessed retrospectively. Thirty cases were identified in 28 patients (two bilateral cases). The mean-age was 44 years (16 to 70).ResultsMuscular atrophy always predominated in the lateral thenar muscles. Seventeen also had sensory symptoms. Twenty-two patients (24 cases) were surgically treated. Twenty-three cases could be assessed with a mean follow-up of 39 months. Recovery was complete in four cases (17%), marked in nine cases (39%) and minimal in ten cases (44%).ConclusionsNeurological TOS with objective manifestations have to be distinguished from other types of neurological TOS. Muscular atrophy in the hand appears insidiously and the pain, which is inconstant, stays always in the background. Duration of symptoms before surgical treatment is the main prognostic factor.     

Different methods and results in the treatment of obstetrical brachial plexus palsy

Mallet's test was used to evaluate shoulder and elbow functional results following conservative treatment, neurolysis, and nerve transfer and grafting in 31 patients with obstetrical brachial plexus palsy, who had no recovery of biceps contraction by 3 months of age. Twelve of them had been treated conservatively for 3 to 4 years. Nine patients with upper trunk conducting neuromas underwent neurolysis at the age of 4 to 6 months. Nerve transfer and grafting were performed in 10 patients at the age of 3 to 6 months. Upper trunk conducting neuromas were found in six of them. The follow-up period was, on average, 44.3 and 51.5 months in the nerve transfer and grafting group and in the neurolysis group, respectively. Excellent and good results in shoulder abduction, external rotation, and elbow flexion were found in 70 percent of patients in the nerve transfer and grafting group. However, none of the conservative treatment and neurolysis groups had a good result. The authors conclude that when there is no recovery of biceps contraction by 3 months of age, surgical intervention is indicated. Neuroma should be managed by nerve transfer and grafting, even though intraoperative electrophysiologic studies show that the neuroma is a conducting one.     

Neurovascular compression in the thoracic outlet: changing management over 50 years.

SUMMARY BACKGROUND DATA: During the past five decades, significant improvements have been made in the diagnosis and treatment of thoracic outlet syndrome (TOS) secondary to sports activities, breast implants, or median sternotomy. METHODS, RESULTS, AND CONCLUSIONS: Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular decompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurysm or occlusion was treated successfully in 240 patients. Dorsal sympathectomy was performed concomitantly in 71 patients for occlusion or embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained pain syndrome and causalgia that did not improve with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal sympathectomy. The use of hyaluronic acid significantly reduced recurrent scarring.