非手术疗法治疗胸廓出口综合征

胸廓出口综合征系臂丛神经及锁骨下血管在胸廓上口部受压而引起患肢血管神经功能障碍为特征的症候群。我科自1987年以来收治148例,采用理疗、针灸、臂丛神经水针疗法和推拿等综合治疗,收到满意效果,现报告如下。临床资料1.本征148例中男88例,女60例;年龄12～73岁;左侧65例,右侧77例,双侧6例;病程1周～8个月;疼痛型76例,瘫痪型8例,混合型64例。2.诊断依据:(1)臂丛神经激惹或损伤征:患肢出现疼痛、皮肤麻木或肌肉萎缩、肌力减退等症状。有的呈现上肢某一神经受卡压的瘫痪症状。(2)血管神经营养功能障碍征:患肢肤温低,排汗功能障碍。桡动脉搏动…     

临床治疗44例臂丛神经血管受压征的疗效分析

目的探讨臂丛神经血管受压征的治疗效果。方法2001-2005年，对44例臂丛神经血管受压征的患者，采用中西医结合阶梯方法进行治疗（第一阶段为中医药治疗，第二阶段为未经第一阶段治疗或经第一阶段中医药治疗症状未好转者采用局部封闭、小针刀和西药治疗，最后阶段为手术治疗）。结果治疗后平均随访时间为2年。第一阶段经中草药热敷等治疗（25例），18例症状完全改善。治疗后经第二阶段治疗后（26例），5例症状完全改善，3例部分改善。手术治疗（18例）13例症状完全改善。治疗后总有效率达81．7％（36／44）。结论运用中西医结合治疗的阶梯方法治疗臂丛神经血管受压征是行之有效的方法。     

斜角肌切断术治疗臂丛神经血管受压征的远期疗效

了解斜角肌切断术治疗丛神经血管受压征的远期疗效。对１９７６－１９９３年间手术的１９例进行随访，平均随访时间８．７年，随访１０种症状的恢复情况，主要以患者的主观感觉评价疗效。结果：手及前臂孓侧麻木主后改善的有效分别是８２．４％和７６．５％，手部肌肉萎缩改善的有效率为５３．３％，手术后时间超过５年的则达到８０％。患者对手术的满意率为７５％。     

骨髓动员刺激后自体骨髓源单个核细胞移植治疗下肢缺血的初步临床研究

目的观察骨髓动员刺激后自体骨髓单个核细胞移植治疗下肢缺血的初步疗效。方法2005年5月～2005年12月收治下肢缺血35例43侧患肢，男23例，女12例。年龄34～90岁，平均71．3岁。病因：糖尿病下肢缺血30例38侧患肢，单纯动脉硬化闭塞症2例2侧患肢，血栓闭塞性脉管炎3例3侧患肢。其中间歇性跛行期5例5侧患肢；静息痛期15例19侧患肢；组织缺损期15例19侧患肢，其中组织溃疡期9例12侧患肢；组织坏疽期6例7侧患肢。在抽取骨髓前使用粒细胞集落刺激因子刺激骨髓2～3d，每天300μg；抽取骨髓血130-200ml，经分离纯化后再行移植。采用下肢肌肉局部注射13例19侧患肢，下肢动脉腔内注射16例16侧患肢，下肢肌肉局部注射与动脉腔内同时注射6例8侧患肢进行移植。结果术后2个月肢体疼痛改善率为94．7％，冷感改善率为97．1％，肢体麻木改善率为93．3％。5例5侧患肢间歇性跛行距离均有不同程度增加。44．2％患者的踝肱比值（ankle／brachial index ABI）有不同程度增加。39侧患肢行经皮氧分压（transeutaneous oxygen pressure，TeP02）测定，92．3％有不同程度增高。患肢溃疡：在9例11侧患肢中，愈合1侧，明显缩小或缩小3侧，无变化7侧，其中3侧患肢被截肢。术后行血管造影评估25例34侧患肢，91．2％患肢的侧支循环有不同程度增加。并发症：骨髓动员刺激出现发热和轻微乏力各1例，均自行缓解；单个核细胞移植后1周出现轻度心肌梗死1例，药物治疗1周后恢复出院，1个月后因患肢疼痛加重行膝下截肢。32例40侧患肢获随访3412个月，症状消失13侧，明显改善15侧，改善8侧，复发2侧，无效2侧。客观评价标准与术前比较ABI增加25侧；TcPOz测定增加36侧；21侧患肢的血管造影显示90．5％患肢有新生侧支形成；10侧患肢足部溃疡7侧愈合，3侧明显缩小；3侧患肢截除坏疽足趾者于术后2～3个月愈合出院。结论经骨髓动员刺激后的骨髓单个核细胞移植下肢缺血，具有抽取骨髓血少、细胞量多、近期效果好且安全性高的优点，是除自体骨髓单个核细胞移植和外周血干细胞移植外的又一种治疗下肢缺血的新方法。远期效果尚需进一步随访。     

健侧颈7移位术后的远期功能随访

目的 随访全臂丛根性撕脱伤患者行健侧颈，移位术后远期功能恢复的情况，及该术式对健侧肢体的影响。方法 对28例行健侧颈，移位术的全臂丛损伤患者进行远期随访。其中健侧颈7移位于正中神经20例（一期手术2例，二期手术18例），桡神经3例，肌皮神经2例，同时移位于正中神经和桡神经2例，同时移位于正中神经和肌皮神经1例。随访内容：了解患肢受体神经所支配肌肉的肌力及其支配区域皮肤感觉恢复、电生理表现、双侧肢体协同活动和颈，神经根切断后对健侧肢体功能影响等情况。结果 术后28例患者远期随访发现，健侧肢体功能均无障碍。1．健侧颈7移位于正中神经：屈腕、指肌群电生理呈单纯相或单纯混合相10例（10／20），屈腕肌肌力达M3或以上者12例（12／20），屈指肌肌力达M1或以上者9例（9／20）；感觉恢复达S3或以上者10例（10／20）。2．健侧颈7移位于肌皮神经：屈肘肌群电生理呈单纯相或单纯混合相2例（2／2），屈肘肌肌力均达M3以上；前臂外侧皮肤感觉达S3或以上者l例（1／2）。3．健侧颈7移位于桡神经：伸腕、指肌群电生理呈单纯相或单纯混合相1例（1／3），伸腕肌力达M3或以上者2例（2／3），伸指肌力达M3或以上者1例（1／3）；感觉恢复达S3或以上者2例（2／3）。4．同时移位于正中神经和桡神经：屈腕肌肌力达M3或以上者2例（2／2），屈指肌肌力达M3或以上者1例（1／2）；正中神经支配区感觉均为S2。而桡神经支配区伸腕、指肌力仅为M2和‰，感觉均为S1。5．同时移位于正中神经和肌皮神经1例，其电生理均呈单纯相，屈腕肌和肱二头肌肌力均已达M3。28例中能自主活动患肢者仅为6例（6／28），22例需靠健侧肢体带动以活动患肢。结论 健侧颈，移位术是治疗全臂丛根性撕脱伤的理想术式，分期手术效果更好。如需同时修复2根神经，则应选择相互无拮抗作用的受体神经。     

妊娠合并腕管综合征的诊治

调查５００例妊娠２８周至分娩的妇女，发现２４例患有腕管综合征。因此，我们认为妊娠可诱发或加重腕管综合征。一、资料与方法一般资料：５００例妊娠妇女，年龄２３－４１岁，经检查发现有腕管综合征症状者２４例，发病率为４．８％（２４／５００）。１８例妊娠前无症状；２例有轻微手部麻木；４例因夜间痛醒就诊，其中桡侧３指半感觉减退，鱼际肌轻度萎缩各１例。１７例为双侧，７例为单侧。临床表现：手部间隙性麻木、麻痛者１８例，其中１０例有夜间痛醒史（早期）；除上述症状外，伴有桡侧３指半感觉减退者２例；伴有鱼际肌轻度萎缩…     

糖尿病性腰神经根病

神经病变是糖尿病常见的并发症．有人报告至少10％的糖尿病人体有症状性神经病。本文报告6例糖尿病有腰神经很症状的息者，对其临床症状和鉴别诊断进行了分析，现报告如下：临床资料本组男4例，女2例，年龄45～65岁，病程3～20年；胰岛素依赖型2例．非胰岛素依赖型4例，确诊时空腹血糖8．3～16mmol／L，平均10．8mmol／L。临床表现：肢端感觉异常4例，袜套样感觉障碍2例。下肢抽痛4例；股四头肌萎缩5例，小腿三头肌萎缩1例；膝反射减退4例．消失1例，踝反射减退1例，Babinski征阳性3例。腰椎CT检查4例．MRI检查2例，均未见椎间盘突出；…     

全臂丛神经损伤健侧颈7移位术后大鱼际肌功能的远期随访

目的 随访全臂丛神经根性撕脱伤患者行健侧颈7移位术后手内在肌的远期功能恢复情况.方法 对5例行健侧颈7移位于正中神经的全臂丛神经损伤患者进行远期随访,随访时间24～ 118个月,了解患肢受体神经所支配肌肉的肌力及其支配区域皮肤感觉恢复、神经电生理检测结果等.结果 5例患者(2例儿童,3例成人),其患侧大鱼际肌均获得不同程度的恢复.拇短展肌肌力恢复达M2者为4例,M1者1例;电生理检测拇短展肌动作电位有2例为单纯相,3例为少量运动单位电位(MUP);感觉恢复达S3者4例,S2者1例.结论 健侧颈7移位术治疗全臂丛神经损伤可使大鱼际肌得到一定程度的恢复.     

小切口治疗臂丛神经血管受压征

目的研究小于5cm的臂丛神经血管受压征的手术切口。方法对11例患者用该切口,成功地切断了前、中小斜角肌的腱性部分,手术时间为1h左右。该切口为最终用内窥镜治疗臂丛神经血管受压征打下了基础。结果10例的近期疗效良好,感觉有明显改善,肌力增加;1例颈部疼痛不适同术前。结论采用5cm及小于5cm的臂丛神经血管受压征切口,可切断前、中小斜角肌,达到手术治疗臂丛神经血管受压征的目的。     

外伤性肋锁综合征诊断及治疗(附11例报告)

在解剖上,第一肋骨与锁骨之间构成上肢神经、血管经过的狭窄通道。如该通道周围的软组织肌肉挫裂伤或骨折畸形、骨片、骨痂压迫等因素,导致上肢神经血管受压而出现一系列症状者,称之为外伤性肋锁综合征。我院自1992年1月至1996年12月。收治11例,报告如下。1　临床资料11　一般资料　本组11例均为单侧。左侧4例,右侧7例;男性9例,女性2例。锁骨骨折11例。其中合并肩胛骨骨折3例,第1肋骨骨折2例。所有病例伤前均无臂丛神经及血管卡压病史。12　症状及体征　受伤当天出现症状者7例,2周后出现症状者有2例,1～2个月出现症状者有2例。9例表现出臂丛…     

Successful use of Shakuyaku-kanzo-to, a traditional herbal medicine, for intractable symptoms of thoracic outlet syndrome: a case report

Shakuyaku-kanzo-to (SKT) is a traditional herbal medicine that is widely used for muscular cramp and abdominal pain. We administered SKT for a patient with thoracic outlet syndrome (TOS) complaining of several resting symptoms. A 28-year-old female patient complained of intractable pain in the left arm, shoulder, and back and weakness, numbness, and muscular cramp in the left arm. She was diagnosed as TOS by digital subtraction angiography. Two days after the start of administration of SKT, her severe pain was markedly improved. Although numbness of the left arm was not improved, her overall pain score was reduced by 2 on the 7th day after the start of SKT. SKT has several pharmacological effects including analgesic and antiinflammatory effects, vasodilation, and muscle relaxation. Thus, our report suggests that SKT could be a first-line agent for the conservative treatment of TOS.     

Thoracic outlet syndrome of pectoralis minor etiology mimicking cardiac symptoms on activity: a case report

Thoracic outlet syndrome is the result of compression or irritation of neurovascular bundles as they pass from the lower cervical spine into the arm, via the axilla. If the pectoralis minor muscle is involved the patient may present with chest pain, along with pain and paraesthesia into the arm. These symptoms are also commonly seen in patients with chest pain of a cardiac origin. In this case, a patient presents with a history of left sided chest pain with pain and paraesthesia into the left upper limb, which only occurs whilst running. The symptoms were reproduced on both digital pressure over the pectoralis minor muscle and on provocative testing for thoracic outlet syndrome. The patient’s treatment therefore focused on the pectoralis minor muscle, with a complete resolution of symptoms. This illustrates that not all cases of chest pain with associated arm symptoms that occur on physical activity are of cardiac origin.     

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。     

在内窥镜辅助下手术治疗胸廓出口综合征10例报告

目的 报告并探讨一个治疗胸廓出口综合征(thoracic outlet syndrome，TOS)的新方法，即在内窥镜辅助下进行手术治疗。方法 局部麻醉下在颈外侧作1．5cm长的小切口，在内窥镜的辅助观察下，切断部分前中斜角肌的腱性起始纤维。结果 2092年3月11日至2002年12月16日，共作10例。手术当天10例的症状和体征均完全消失。术后随访4个月～1年，平均6个月。5例的症状和体征完全消失。4例的肌力恢复正常，前臂和小指的刺痛觉稍减退。1例仅偶有颈部不适的症状，术侧锁骨区有麻痛，针刺有痛觉过敏。结论 在内窥镜辅助下经颈部微小切口切断部分前中斜角肌的腱性起始纤维，可解除斜角肌对臂丛神经的压迫，是一个创伤很小的治疗胸廓出口综合征的新方法。     

胸廓出口综合征非手术和手术治疗的长期随访

目的 了解胸廓出口综合征的解剖学基础，分析颈神经根受压的临床特点、诊断和治疗。方法 对1995—1999年间的18例胸廓出口综合征患者作平均6．9年的随访，其中8例作手术治疗，10例作非手术治疗（局部封闭为主）。胸廓出口综合征的特点是颈神经根在椎间孔外受压，以颈肩痛、手麻痛为主要表现，可伴有上肢的酸痛及功能障碍。结果 治疗后颈肩痛消失或明显缓解，并有较大的功能改善。非手术治疗和手术治疗的疗效分别为60％和75％。结论 胸廓出口综合征的非手术治疗和手术治疗均有效，并都有一定的反复，需长期反复治疗，应严格掌握手术指征。     

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     

The anterior scalene muscle in thoracic outlet compression syndrome. Histochemical and morphometric studies

Histochemical studies and morphometric fiber type analysis were done on biopsy specimens of anterior scalene muscle (ASM) from patients with thoracic outlet compression syndrome (TOS), without structural abnormality. Hypertrophy and atrophy factors were determined from muscle fiber histograms of ASM from controls, patients with TOS, and after scalene tenotomy. Scalene muscle from patients with TOS showed marked type 1 (tonic contracting) fiber predominance (85.1% +/- 5.1%) and type 1 fiber hypertrophy (55.6 +/- 2.7 microns). After tenotomy there is a reduction of type 1 fiber representation, selective atrophy in the type 1 fiber system (atrophy factor, 0.66 +/- 0.24), and increase of type 2 fibers. These distinctive changes indicate that ASM is uniquely structured in fiber composition to sustain prolonged contraction. The ASM in patients with TOS demonstrates an extraordinary adaptive transformation and recruitment response in the type 1 fiber system reflecting chronic increased tone or motor neuron stimulation. These observations form a basis for clarifying the structural and pathophysiologic changes in TOS.     

Treatment of Thoracic Outlet Syndrome: Long-term Results

Thoracic outlet syndrome (TOS) refers to a complex of symptoms in the upper extremity caused by compression of the neural and vascular structures at some point between the interscalene triangle and the inferior border of the axilla. A review of our experience in treating this controversial syndrome is presented. Between 1989 and 1997 a series of 23 patients (5 men, 18 women) were operated on for TOS. The average age of the patients was 26.4 years (range 17–60 years). All patients complained of pain typically in the shoulder and proximal upper extremity with radiation to the neck, and most had paresthesias and numbness in the forearm and hand. Their symptoms had been present for 8 months to 9 years (mean 2.6 years). All were evaluated by history, physical examination, radiographs of the chest and cervical spine, electromyography, and nerve conduction studies; computed tomography, magnetic resonance imaging, angiography, and myelography were conducted selectively. When TOS was suspected, a cooperative concept was utilized employing the aid of the neurologist, orthopedist, and occasionally a cardiologist. The initial treatment was physical therapy for a minimum of 6 weeks. If no relief occurred they underwent surgery. In all patients in the present series the first rib was removed through a transaxillary approach. A cervical rib was also removed in four cases. Postoperatively, they were evaluated by questionnaire and reexamination. Nineteen (82.6%) had complete relief, and four had partial relief of symptoms. Complications included pneumothorax and temporary brachial paralysis in one case each. We concluded that careful selection of patients for surgery can yield satisfactory results, and a coordinated team of thoracic surgeons, neurologists, and physical therapists is important for management of these patients.     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is an often misdiagnosed cause of neck, shoulder, and arm disability. Neurovascular compression may be seen in the interscalene triangle, costoclavicular space, or posterior to the pectoralis minor, although any cause of abnormalities of shoulder girdle alignment may cause a localized area of brachial plexus compression. Nerve compression in this way may lead to upper extremity weakness, pain, paresthesias, and numbness. A careful and detailed medical history and physical examination are essential to proper identification of thoracic outlet syndrome, which remains primarily a clinical diagnosis. Diagnostic testing may differentiate other causes of pain or neurologic symptoms of the upper extremity from TOS. Clinical management is often challenging.     

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