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。     

颈肋畸形的外科治疗

目的：探讨颈肋的手术治疗方法与技巧，以提高颈肋的诊疗水平。方法：颈肋切除术12例，主要症状为臂丛和周围血管卡压症状，Adson试验阳性。术中用尖嘴咬骨钳直视下逐段咬除颈肋，并切除颈肋的骨膜和周围纤维束带，切除范围以使颈肋残端距离受压组织1cm以上。结果：全部病例于术后即获得上肢疼痛症状解除，麻木症状改善。随访1．5—4年，平均随访2．5年，无1例复发。结论：颈肋畸形并臂丛和周围血管卡压症状者，需手术治疗。手术可获良好疗效。     

臂丛神经血管受压症的手术治疗

我们于1992～2001年共手术治疗臂丛神经血管受压症64例,并对其中50例进行2～5年随访,现报道如下。1资料与方法1.1一般资料本组64例,女性49例,男性15例;年龄16～47岁,平均26岁。其中骨性畸形21例,包括颈肋13例,第七颈椎横突过长6例,锁骨畸形1例,第一肋骨畸形1例;软组织异常43例,包括斜角肌先天性束带10例,斜角肌挛缩28例,锁骨下肌或颈部异常肌肉6例。临床分型:臂丛神经下干受压型45例,全臂丛受压型14例,臂丛神经上干受压型5例。1.2手术方法斜角肌切断术:适用于无骨性压迫、Adson's试验阳性、术中发现有典型斜角肌束带或挛缩者;颈肋切除术或…     

颈肋畸形的外科治疗

目的:探讨颈肋的手术治疗方法与技巧,以提高颈肋的诊疗水平.方法:颈肋切除术12例,主要症状为臂丛和周围血管卡压症状,Adson试验阳性.术中用尖嘴咬骨钳直视下逐段咬除颈肋,并切除颈肋的骨膜和周围纤维束带,切除范围以使颈肋残端距离受压组织1cm以上.结果:全部病例于术后即获得上肢疼痛症状解除,麻木症状改善.随访1.5～4年,平均随访2.5年,无1例复发.结论:颈肋畸形并臂丛和周围血管卡压症状者,需手术治疗.手术可获良好疗效.     

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。     

有关颈肩痛问题的研讨

２　胸腔出口综合征类此为一组引起胸腔出口部位受压的综合征。凡在该部位及邻近病变引起颈根部血管神经症状者均属之。２１　前斜角肌综合征锁骨上窝部臂丛与锁骨下动脉经第一肋上缘处或神经根自椎间孔发出经颈椎横突前方,在以下情况（１）肌肉炎症、水肿、渗出、纤维化、痉挛、疤痕、粘连,（２）臂丛神经变异,均可压迫神经血管束。臂丛变异的一种情况是前中斜角肌并合,血管神经束穿过肌腹,可因肌痉挛而受压。另一情况是颈４（前固定型）及胸２（后固定型）神经根参予臂丛组成。但此不易在术前检出。２２　颈肋胎儿期常有一颈肋残…     

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。     

《中国骨伤》2006年第7期继续教育试题

以下是有关胸腔出口综合征的单项选择题,请选出正确答案的序号填在答题卡中。1·臂丛经颈部向上臂走行,紧靠第一肋的是:A.上干B.中干C.下干D.后束E.外侧束2·易于使臂丛下干受压的因素为:A.颈肋与C7过长的横突B.颈椎增生C.颈椎间盘突出D.C2-C6侧块后结节E.C3-C6侧块前结节3·外     

手术治疗无骨性异常的臂丛神经血管受压征

目的 观察9例无骨性异常的臂丛神经血管受压征的手术疗效。方法 对9例无骨性异常的臂丛神经血管受压征进行手术，其中1例为全臂丛型，8例为臂丛下干型。采用前、中、小斜角肌切断并解除一切压迫臂丛神经的纤维束带。结果 术后平均随访2年9个月(1年6个月—3年7个月)，以患者的主观感觉评价疗效，6例对手术结果满意，2例对手术结果基本满意，1例对手术不满意。结论 斜角肌切断及纤维束带切除术是治疗无骨性异常的臂丛神经血管受压征的一种简单、有效的方法。     

经腋路第一肋切除治疗胸廓出口综合征

目的：总结经腋路第一肋切除治疗胸廓出口综合征的经验，方法：采用经腋路第一肋切除术治疗下臂丛型胸廓出口综合征16例，结果：3例术中胸膜破裂，术后有胸闷和胸前区压迫感，其中1例前胸部可摸到少量的皮下捻发音；X线片示均有轻度气胸，除吸氧外，未做其它处理，术后3d基本恢复。16例中1例在术后3个月复发，再次行前中斜角肌切除术，术后症状缓解，2例在术后8个月复发,4例在术后12个月出现前臂内侧和手尺侧轻度麻木及肩颈部不适，但比术前要轻得多；该6例经用药后症状基本消失，其余患者症状完全解除，未复发，总治愈率为81．25％，8例第一肌间背仙肌萎缩者，3例患者完全恢复（术后25－28个月），2例部分恢复（术后18－23个月），该5例的爪形手畸形均已消失，结论：经腋路切除第一肋治疗下臂丛型胸廓出口综合征，伤口隐蔽，损伤小，手术后复发率较低。     

Recurrent neurogenic thoracic outlet syndrome

BACKGROUND: Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience "excellent" or "good" results after thoracic outlet decompression, recurrent symptoms may develop in certain patients. METHODS: This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed. RESULTS: Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had "excellent" or "good" results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these). CONCLUSIONS: Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.     

Histopathological basis for neurogenic thoracic outlet syndrome. Laboratory investigation

OBJECT: To the best of the authors' knowledge, no report exists that has demonstrated the histopathological changes of neural elements within the brachial plexus as a result of cervical rib compression. METHODS: Four hundred seventy-five consecutive human cadavers were evaluated for the presence of cervical ribs. From this cohort, 2 male specimens (0.42%) were identified that harbored cervical ribs. One of the cadavers was found to have bilateral cervical ribs and the other a single right cervical rib. Following gross observations of the brachial plexus and, specifically, the lower trunk and its relationship to these anomalous ribs, the lower trunks were submitted for immunohistochemical analysis. Specimens were compared with two age-matched controls that did not have cervical ribs. RESULTS: The compressed plexus trunks were largely unremarkable proximal to the areas of compression by cervical ribs, where they demonstrated epi- and perineurial fibrosis, vascular hyalinization, mucinous degeneration, and frequent intraneural collagenous nodules. These histological findings were not seen in the nerve specimens in control cadavers. The epineurium was thickened with intersecting fibrous bands, and the perineurium appeared fibrotic. Many of the blood vessels were hyalinized. The nerve fascicles contained frequent intraneural collagenous nodules in this area, and focal mucinous degeneration was identified. CONCLUSIONS: Cervical ribs found incidentally may cause histological changes in the lower trunk of the brachial plexus. The clinician may wish to observe or perform further evaluation in such patients.     

Sibson筋膜导致胸廓出口综合症

本文分析了1987～1995年手术治疗45例胸廓出口综合症病人，经手术证实引起胸廓出口综合症之主要病因中除通常所述的斜角肌病变、预肋、胸小肌出点处病变和肋锁间隙病变外。还有一种病因，即胸膜上筋膜（Sibson筋膜）卡压臂丛下干而导致胸廓出口综合症。其中7列行手术探查肘，未发现其他卡压因素，仅发现臂丛下手表面覆盖一层薄的筋膜，遂对此筋膜进行了松解，术后症状明显缓解，因此认为此膜系卡压因素。     

Thoracic outlet syndrome

Thoracic Outlet Syndromes (TOS) consists of a group of distinct pathologies arising from compression or impingement of structures at the thoracic outlet. The structures at risk are, from anterior to posterior, subclavian vein (venous — VTOS), subclavian artery (arterial — ATOS) and brachial plexus (neurogenic — NTOS). NTOS is the most common presentation, usually caused by compression of the brachial plexus at the scalene triangle or pectoralis minor space. Neurogenic compression syndromes at the carpal and cubital tunnels should be excluded. Management of NTOS is usually conservative, employing physiotherapy and postural exercises, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction, resulting in venous thrombosis (Paget—Schroetter syndrome) often as a result of exercise in fit young muscular people or musicians. Positional swelling of the upper limb without thrombosis is termed McCleery's syndrome. In acute thrombosis, clot lysis, first rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery at the scalene triangle, often in association with an anomalous bony structure, such as cervical rib, causing post-stenotic aneurysmal dilation of the artery, thrombosis and distal embolization. Acute upper limb ischaemia necessitates urgent cervical rib excision and arterial reconstruction.     

Pseudarthrosis of cervical rib: an unusual cause of thoracic outlet syndrome

Thoracic outlet syndrome is uncommon in adolescence. Cervical rib fracture is an extremely rare cause of thoracic outlet syndrome in this age group. We report an unusual case of thoracic outlet syndrome in a 14-year-old girl caused by pseudarthrosis of the cervical rib. A magnetic resonance imaging scan showed significant compression of the brachial plexus by the pseudarthrosis mass. Excision of the cervical rib through a supraclavicular approach gave excellent results in this case.     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) consists of a group of distinct pathologies arising as a result of compression of structures at the thoracic outlet. The structures at risk are, from anterior to posterior, the subclavian vein, subclavian artery and brachial plexus. Compression or impingement causes venous (VTOS), arterial (ATOS) or neurogenic (NTOS) TOS. NTOS is the most common presentation, caused by compression of the brachial plexus at the scalene triangle or pectoralis minor space. Other compression syndromes at the carpal and cubital tunnels should be excluded. Management is usually conservative, employing physiotherapy and postural exercises, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction, resulting in venous thrombosis, the Paget-Schroetter syndrome, often as a result of exercise in fit young muscular people or musicians. Positional swelling of the upper limb without thrombosis is termed McCleery's syndrome. In the presence of thrombosis, clot lysis, first rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery at the scalene triangle, often in association with an anomalous bony structure, such as cervical rib, causing post-stenotic aneurysmal dilation of the artery, thrombosis and embolization. Acute upper limb ischaemia necessitates urgent cervical rib excision and arterial reconstruction.     

Cervical rib variant: Report of a case

It is taught that, when a cervical rib is present, the subclavian vessels and brachial plexus always arch over it. The present case reemphasizes that the brachial plexus may be split by the cervical rib.     

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