内镜辅助下手术治疗上干型胸廓出口综合征的临床应用

目的 报告内镜辅助下手术治疗上干型胸廓出口综合征的方法及临床疗效。方法 16例上干型胸廓出口综合征患者局麻下通过颈外侧区作长1．5cm切口，在内镜辅助下切断部分前、中斜角肌的腱性起始纤维。结果 术后平均随访25个月（16-36个月），按WOOD等的评定标准评价：优9例，良5例，可2例。结论 在内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，是一种治疗上干型胸廓出口综合征的有效微创手术方法。     

Thoracic outlet syndrome: a rare case with bilateral cervical ribs and bilateral anterior scalene hypertrophy

Thoracic outlet syndrome (TOS) is a rare neurovascular disorder generally caused by the presence of a cervical rib or hypertrophic scalene anterior muscle that can compress the brachial plexus and/or subclavian vessels. In the vascular form, the symptoms are caused by the compression of the artery and/or the subclavian vein. In the first case, the compression is caused by the cervical rib and leads to hypo-perfusion with cooling and cyanosis of the upper limb, while in the second case, the compression is caused by the anterior scalene muscle and leads to congestion, cyanosis, swelling and pain in the higher limb. In this paper, we describe a case with the simultaneous presence of a bilateral cervical rib and bilateral hypertrophy of the anterior scalene muscle. TOS diagnosis is based on neurological, clinical and instrumental tests, such as chest radiography and color Doppler ultrasonography. The treatment of these patients can be surgical or conservative.     

A Sledgehammer on the Brachial Plexus: Thoracic Outlet Syndrome, Subclavius Posticus Muscle, and Traction in Aggregate

Özçakar L, Güney M?, Özda? F, Alay S, K?ralp MZ, Görür R, Saraço?lu M. A sledgehammer on the brachial plexus: thoracic outlet syndrome, subclavius posticus muscle, and traction in aggregate.Reported here is a 30-year-old man who was seen because of pain and weakness in the upper extremities after a tractional injury. Physical examination revealed significant atrophy in the left deltoid and right intrinsic hand muscles, generalized hypoesthesia, decreased deep tendon reflexes bilaterally, and decreased strength in various muscle groups. Roos (right) and hyperabduction (bilateral) tests were positive. Electrodiagnostic studies were consistent with bilateral brachial plexopathy. Cervical radiographs showed long transverse process of C7 on the right side and a small rudimentary rib articulating with C7 on the left side. Brachial plexus magnetic resonance imaging demonstrated an aberrant muscle and compressive brachial plexus injury on the left side. Surgery via transaxillary approach was performed on the left side. The occurrence of traumatic brachial plexopathy in the presence of underlying thoracic outlet syndrome and subclavius posticus muscle is discussed for the first time in the literature.     

Psoas compartment block

The psoas compartment acts as a conduit for the nerve roots of the lumbar plexus. Originating at approximately the 12th thoracic vertebrae, this potential compartment continues on caudally, bordered posterolaterally by fascia of the quadratus lumborum and iliacus muscles, medially by the fascia of the psoas major muscle, and anteriorly by the transversalis fascia. This natural "gutter" acts as a repository for local anesthetic agents and provides an excellent method of unilateral anterior lower extremity anesthesia. After elicitation of a motor evoked response in the muscles of the anterior thigh, 30 to 40 milliliters of local anesthetic is incrementally injected into the compartment. Spread of the anesthetic to all roots of the plexus occurs in 15 to 20 minutes. Profound sensory and motor blockade can be achieved providing surgical anesthesia as well as long duration postoperative pain relief.     

The brachial plexus

The brachial plexus arises from the lower cervical and upper thoracic spinal nerve roots. It courses between the anterior and middle scalene muscles and adjacent to the subclavian artery. The brachial plexus may be visualized by both MRI and CT. Symptoms of a brachial plexopathy commonly are nonlocalizing. Traumatic injuries and involvement by tumors probably account for the majority of etiologies responsible for these plexopathies. Inflammatory processes also involve the brachial plexus. This article reviews the anatomy of the brachial plexus from both surgical and radiographic approaches and also addresses the symptomatology of brachial plexopathy underlying it.     

Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial

We studied the effect of botulinum toxin type A (BTX-A) injections to the scalene muscles on pain in subjects with thoracic outlet syndrome (TOS) in this double-blind, randomized, parallel group trial with follow-up at 6 weeks, 3 months, and 6 months. Thirty-eight patients referred to physiatrists for management of TOS with BTX-A injection were included. One subject was lost to follow-up and all other subjects completed the trial. A 75-unit dose of BTX-A reconstituted with 0.75 cc of normal saline was injected to the anterior scalene (37.5 units) and middle scalene (37.5 units) muscles using electromyographic guidance. The primary outcome measure was pain as measured on a horizontal visual analog scale (VAS) 6 weeks-post-injection. Secondary outcomes were paresthesias measured on a VAS and function measured with the Disabilities of the Arm, Shoulder and Hand (DASH) and Short-form 36 (SF-36) questionnaires. For the primary outcome measure of VAS scores for pain at 6 weeks, the difference in the means adjusted for baseline VAS scores between placebo and BTX-A was 5.03 mm in favor of BTX-A (95% confidence interval −15.7 to 5.7, P = .36). Changes in secondary outcome measures were also not statistically significant. We conclude that BTX-A injections to the scalene muscles did not result in clinically or statistically significant improvements in pain, paresthesias, or function in this population of subjects with TOS.     

Botulinum toxin type A improves blood flow in vascular thoracic outlet syndrome

A 28-yr-old man, diagnosed with vascular thoracic outlet syndrome, had his right anterior scalene muscle injected with botulinum toxin type A under ultrasound guidance. Subclavian artery flow rates were measured with Doppler ultrasound before and 3 wks after the injection. At 3 wks, symptoms had improved. The reduction in subclavian artery flow rate associated with the arm abducted to the side with 90-degree external rotation decreased from 132.8 to 87.7 cm/sec preinjection compared with a smaller decrease postinjection from 132.8 to 119.1 cm/sec. An improved subclavian artery flow was seen after scalene muscle chemodenervation for vascular thoracic outlet syndrome. This suggests its potential as a diagnostic test, treatment option, and predictor for surgical intervention.     

Ultrasonographic Identification of Fibromuscular Bands Associated with Neurogenic Thoracic Outlet Syndrome: The “Wedge-Sickle” Sign

Thoracic outlet syndrome (TOS) is a disorder characterized by compression of the lower trunk of the brachial plexus, most often in association with anomalous congenital fibromuscular bands in the scalenic region. Early diagnosis is important, because the neurologic deficit associated with TOS may be irreversible. Using high-resolution ultrasound, we investigated 20 consecutive patients with clinical signs suggestive of TOS (all females, average age: 40.4 ± 14.9 y) and 25 control patients. In 19 patients, we identified a hyper-echoic fibromuscular structure at the medial edge of the middle scalene muscle, which indented the lower trunk of the brachial plexus (“wedge-sickle sign”). It was associated with the significant enlargement (p < 0.0001) and hypo-echogenicity of the lower trunk. This novel and distinctive ultrasonographic sign allows pre-surgical identification of anomalous fibromuscular bands causing TOS. It is especially useful in patients without neurologic deficit, in whom the diagnosis may not be as straightforward.     

Essentials of thoracic outlet syndrome: A narrative review

Thoracic outlet syndrome (TOS) is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region. TOS results in pain, numbness, paresthesia, and motor weakness in the affected upper limb. We reviewed the pathophysiology, clinical evaluation, differential diagnoses, and treatment of TOS. TOS is usually classified into three types, neurogenic, venous, and arterial, according to the primarily affected structure. Both true neurogenic and disputed TOS are considered neurogenic TOS. Since identifying the causative lesions is complex, detailed history taking and thorough clinical investigation are needed. Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS. The existence of a disputed TOS remains controversial. Neuromuscular physicians tend to be skeptical about the existence of disputed TOS, but thoracic surgeons argue that disputed TOS is under-diagnosed. Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.     

Ultrasound anatomy of the neck: The infrahyoid region

The infrahyoid region of the neck includes the visceral, anterior cervical, posterior cervical, carotid, retropharyngeal, and perivertebral spaces. The visceral space contains the thyroid, parathyroid glands, larynx, hypopharynx, the cervical trachea, and esophagus, the recurrent laryngeal nerve. The carotid space contains two parts, which extend from the skull base to the aortic arch and are delimited by the three layers of the deep cervical fascia (superficial, middle, and deep). It contains the internal carotid artery, the internal jugular vein, cranial nerves (IX–XII), the sympathetic plexus (suprahyoid compartment), the common carotid artery, the internal jugular vein, vagus nerve (infrahyoid compartment). The retropharyngeal space is a midlinespace containing adipose tissue that extends from the skull base to the upper mediastinum. It is located posterior to the pharynx and cervical esophagus, anterior to the danger area and the perivertebral space.The perivertebral space extends from the skull base to the clavicles and includes two parts: prevertebral and paraspinal. The prevertebral space includes the prevertebral muscles (long muscles of the neck and head), the scalene muscles (anterior, middle, and posterior), the roots of the brachial plexus, the phrenic nerve, the vertebral arteries and veins, and the vertebral bodies. The paraspinal space contains the paraspinal muscles and the posterior elements of the cervical spine.The posterior cervical space is a deep space located posterior to the sternocleidomastoid muscle. It contains the accessory nerve, the accessory chain lymph nodes, the pre-axillary component of the brachial plexus, and the dorsal scapular nerve. The anterior cervical space is located deep to the strap muscles and sternocleidomastoid muscle. It surrounds the front and sides of the visceral space and is related posteriorly to the carotid space. This article reviews the ultrasound features of the structures located in the infrahyoid region of the neck.     

Subluxation of the first rib: a possible thoracic outlet syndrome mechanism

Twenty-two cases of both the thoracic outlet syndrome (TOS) and reflex sympathetic dystrophy (RSD) are described, four in detail. Each case had a hypomobile first rib on the painful side. A simple test was used to evaluate the first rib mobility. After isometric exercises of the scalene muscles, the mobility of the first rib was restored and the symptoms completely relieved in 13 patients. We concluded that the subluxation of the first rib may irritate the neural network and the stellate ganglion in the neighborhood of the first costotransverse joint. This in turn can cause the radiating pain and RSD symptoms.     

Thoracic outlet syndrome: resectioning the first rib as a last resort

1. Thoracic outlet syndrome is a general term referring to compression neuropathies of the brachial plexus and subclavian vessels. 2. The symptoms result from compression of the brachial plexus or the subclavian vessels; the most common are pain and paresthesia but these may be accompanied by complaints of muscle weakness and easy fatigability of the extremity. 3. First rib resection has been proven valuable; however, because of the possibility of severe and irreversible complications, surgery should be used as a last resort.     

Thoracic outlet syndrome

Of the many clinical entities involving the neck region, one of the most intriguing is thoracic outlet syndrome (TOS). TOS is an array of disorders that involves injury to the neurovascular structures in the cervicobrachial region. A classification system based on etiology, symptoms, clinical presentation, and anatomy is supported by most physicians. The first type of TOS is vascular, involving compression of either the subclavian artery or vein. The second type is true neurogenic TOS, which involves injury to the brachial plexus. Finally, the third and most controversial type is referred to as disputed neurogenic TOS. This article aims to provide the reader some understanding of the pathophysiology, workup, and treatment of this fascinating clinical entity.     

The study of respiratory muscles activation during respiratory muscle strength effort in adult females with chronic neck pain

[Purpose] This study aimed to compare maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) values and muscle activity during MIP and MEP between chronic neck pain and healthy participants. [Participants and Methods] Twenty chronic neck pain and 20 non-symptomatic females participated in this study. Maximal airway pressure (MIP and MEP) and surface electromyography (sEMG) for both sides of the upper trapezius, anterior scalene, pectoralis major and 6th intercostal muscles were recorded simultaneously. [Results] Significant differences of MIP and MEP values were found between the groups. The muscle activities of both sides of upper trapezius and 6th intercostal muscles during MEP were significantly higher in the chronic neck pain group than the healthy group except both sides of anterior scalene and pectoralis major muscles. During MIP, the activities of upper trapezius, 6th intercostal muscles and anterior scalene were significantly different between the two studied groups. Higher activity of left pectoralis major was found in the chronic neck pain group. [Conclusion] Decreasing values of MEP and MIP as well as muscles activities elevation in chronic neck pain participants were clearly demonstrated. Besides the musculoskeletal treatment, we suggest breathing exercise training to be considered in treatment programs.     

True Neurogenic Thoracic Outlet Syndrome Following Hyperabduction during Sleep - A Case Report -

True neurogenic thoracic outlet syndrome (TOS) is an uncommon disease and is difficult to diagnose at the early stage and then completely cure. We experienced a case of true neurogenic TOS with typical clinical symptoms and electrophysiologic findings as a result of repetitive habitual sleep posture. A 31-year-old woman who had complained of progressive tingling sensation on the 4th and 5th fingers with shoulder pain was diagnosed of brachial plexopathy at the lower trunk level by electrodiagnostic studies. There was no other cause of brachial plexopathy except her habit of hyperabduction of shoulder during sleep. This case demonstrated that the habitual abnormal posture can be the only major cause of neurogenic TOS. It is of importance to consider TOS with the habitual cause because simple correction of the posture could stabilize or even reverse disease progress.     

Neurogenic Thoracic Outlet Syndrome and Pectoralis Minor Syndrome: A Common Sequela of Whiplash Injuries

Thoracic outlet syndrome (TOS) presents with pain and paresthesia in the neck and upper extremity, weakness in the arm, and occipital headaches. Over 80% of cases are a result of compression of the brachial plexus after hyperextension neck injuries such as whiplash. The diagnosis is often missed because it cannot be made by x-ray or nerve tests; diagnosis requires clinical evaluation by history and physical examination. The popular Adson test is misleading and should be replaced by more specific provocative maneuvers that elicit symptoms. In addition, many patients with neurogenic TOS also have chest pain that often is from an associated pectoralis minor (PM) compression syndrome. Because PM syndrome is easily treated by a no-risk outpatient procedure, its distinguishing features and recognition are important. The clinical diagnostic features of both conditions are the focus of this article.     

Blockade of the Superior Hypogastric Plexus Block for Visceral Pelvic Pain

Abstract: Visceral pelvic pain is a common problem with variable etiology. The sympathetic nervous system plays an important role in the transmission of visceral pain independent of its etiology. Five major pathways by which pelvic pain is transmitted can be identified. One of them, the superior hypogastric plexus, an extension of the preaortic plexus, is easily assessable to blockade by local anesthetics and neurolytic agents. Several techniques have been described. Long-lasting pain relief with this procedure has been achieved in patients with pelvic cancer pain. However, there is a discrepancy between diagnostic and therapeutic blockade in patients with nonmalignant pain. Because a diagnostic blockade can give significant pain relief in a large variety of patients, it is worthwhile to investigate new methods that provide lasting neural blockade of the superior hypogastric plexus and long-lasting relief of this devastating condition.     

神经刺激仪定位下臂丛神经阻滞效果观察

目的探讨神经刺激仪引导下定位行臂丛神经阻滞的临床效果。方法将68例拟在臂丛神经阻滞下行择期手术的患者按随机数字表法分为2组,每组34例。Ⅰ组应用周围神经刺激仪行腋路、肌间沟联合臂丛神经阻滞：Ⅱ组运用传统方法行联合臂丛神经阻滞。阻滞后30min观察感觉和运动阻滞效果,对2组患者臂丛神经阻滞实施时间、阻滞起效时间、手术时间及术后并发症进行比较。结果2组手术时间比较差异无统计学意义（P〉0．05）。Ⅰ组阻滞时间及阻滞起效时间分别为（10．1±2．8）min和（12．9±1．8）min,Ⅱ组阻滞时间及阻滞起效时间分别为（11．5±2．7）min和（14．6±2．2）min,I组臂丛神经阻滞实施时间及阻滞起效时间较Ⅱ组明显缩短（均P〈0．05）。2组均未出现动脉损伤、气胸等并发症。结论神经刺激仪定位下臂丛神经阻滞较传统方法联合臂丛神经阻滞成功率更高．阻滞实施更快。     

Fentanyl improves analgesia but prolongs the onset of axillary brachial plexus block by peripheral mechanism. (Sapporo Medical University, School of Medicine, Sapporo, Japan) Anesth Analg 2000;91:384–387.

This double‐blinded study evaluated the effects of fentanyl added to lidocaine for axillary brachial plexus block in 66 adult patients scheduled for elective hand and forearm surgery. All patients received 40 mL of 1.5% lidocaine with 1:200,000 epinephrine, injected into the brachial plexus sheath using the axillary perivascular technique, and they were randomized into 3 groups. Group 1 was given lidocaine containing 2 mL of normal saline plus 2 mL of normal saline IV. Patients in Group 2 received lidocaine containing 100 μg fentanyl plus 2 mL of normal saline IV. Group 3 patients received lidocaine containing 2 mL of normal saline plus 100 μg fentanyl IV. Sensory and motor blockade were evaluated by using a pinprick technique and by measuring the gripping force, respectively. The success rate of sensory blockade for radial and musculocutaneous nerves and the duration of the sensory blockade significantly increased in Group 2 (323 ± 96 min) as compared with Group 1 (250 ± 79 min). However, the onset time of analgesia was prolonged in every nerve distribution by adding fentanyl to the brachial plexus block. IV fentanyl had no effect on the success rate, onset, or duration of the blockade. Conclude that the addition of fentanyl to lidocaine causes an improved success rate of the sensory blockade, but a delayed onset of analgesia, although this may be accounted for by the decreased pH caused by the fentanyl. Comment by Alan Kaye, M.D. The addition of opioids to regional blocks is controversial. This is due in part to the potential uptake and distribution centrally of the opioid agent. In 66 patients undergoing axillary block, all had 40 mL of 1.5% lidocaine with epinephrine. One group had normal saline, another group has fentanyl plus saline, and a third had just fentanyl. The authors found that the addition of fentanyl caused an improved success rate with regard to sensory blockade. However, onset of the blockade was delayed with fentanyl and this was theorized by a decreased pH caused by the fentanyl. More studies are needed to better elucidate mechanistic effects of opioids and other agents in enhancing or modulating local anesthetics in regional blockade.