Critical upper limb ischemia caused by initially undiagnosed thoracic outlet syndrome--case report

A case of a progressive ischemia of the right upper extremity in a 57-year-old male caused by primarily undiagnosed compression of a subclavian artery by an accessory cervical rib is presented. Critical limb ischemia persisting for 7 years despite conservative treatment and a thrombectomy of upper extremity arteries and thoracic sympathectomy, led to a loss of three fingers and development of a non-healing ulceration of right upper extremity. Eventually a cervical rib resection together with a subclavio-brachial venous bypass graft permanently reversed the critical limb ischemia and allowed the ulceration to heal. The presented case underscores the importance of an early surgical intervention in patients with upper limb ischemia and anatomic abnormalities in a thoracic outlet.     

Neurography of the brachial plexus in the thoracic outlet syndrome

Summary Neurography of the brachial plexus was carried out in 180 patients with suspected thoracic outlet syndrome and in 30 normal subjects. In the thoracic outlet syndrome, abnormalities were found in 85% of suspected cases. Narrowing was seen in the scalenus triangle (30%), in the costoclavicular-space (75%) and at the subcoracoid level (6%). Translucent lines were present in 53%, and in 28% of the controls. After successful operation, the appearances returned to normal. Neurography was helpful in making the diagnosis and in determining the correct surgical procedure.

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Résumé L'auteur, ayant mis au point une technique de neurographie du plexus brachial, l'a utilisée depuis 1981 chez 180 patients suspects de présenter un syndrome du défilé costo-claviculaire (S. D. C. C.) ainsi que chez 30 sujets normaux. Chez les patients atteints de S. D. C. C on peut trouver des anomalies anatomiques: rétrécissement au niveau du triangle des scalènes (30%), de l'espace costo-claviculaire (75%) et sous-coracoïdien (6%). La fréquence d'un neurogramme anormal est de 85% chez les patients avec S. D. C. C. Dans certains cas s'observent des lignes transparentes (28% chez les sujets normaux, 53% chez les patients avec S. D. C. C.). Chez les malades améliorés par le traitement les images se normalisent. La neurographie constitue donc une aide au diagnostic et permet de choisir la technique chirurgicale la mieux appropriée.

     

Anomalous vasculature as direct cause of upper brachial plexus thoracic outlet syndrome

Direct vascular etiologies of upper plexus thoracic outlet syndrome (TOS) other than the subclavian vessels are exceptional. This is a unique case of an anomalous artery and its accompanying vein causing direct compression to the upper brachial plexus causing TOS. All symptoms resolved after successful treatment consisting of ligation and resection of the vessels. This case demonstrates that although direct vascular etiologies causing upper plexus TOS are extremely uncommon, they should be considered in the differential diagnosis.     

Diagnosis of thoracic outlet syndrome by magnetic stimulation of the brachial plexus

The abductor pollicis brevis (APB) and abductor digiti minimi (ADM) compound muscle action potential (CMAP) latencies, and median and ulnar motor conduction velocities (MCVs), obtained by magnetic stimulation of the brachial plexus, were evaluated for the diagnosis of thoracic outlet syndrome (TOS). These measurements were compared in three groups of limbs: (1) the symptomatic limbs of patients with TOS (symptomatic group), (2) the asymptomatic con-tralateral limbs of these patients (asymptomatic group), and (3) the limbs of healthy control subjects (control group). Although no significant differences were observed in MCVs among the three groups, the APB CMAP latency in the sym-ptomatic group (12.0 ± 1.2 ms) was significantly prolonged compared with that in the control group (10.4 ± 0.64 ms; P < 0.01), and the ADM CMAP latency in the symptomatic group (11.0 ± 0.82 ms) was also significantly prolonged compared with that in the control group (10.1 ± 0.59 ms; P < 0.01). The possibility is suggested that the evaluation of APB and ADM CMAP latencies by magnetic stimulation of the brachial plexus may be helpful for the diagnosis of TOS. Received: March 14, 2001 / Accepted: October 9, 2001     

小针刀治疗上干型胸廓出口综合征

目的:探讨小针刀治疗上干型胸廓出口综合征的效果。方法:1998年1月-2002年1月共收治上干型胸廓出口综合征11例,男5例,女6例;平均年龄36.2岁(25~46岁),病程2个月~3年,均采用小针刀治疗,在颈部压痛最明显的颈椎横突后结节上用小针刀对前、中斜角肌的腱性起始纤维作切割和剥离。结果:所有患者均无血肿形成,术后10 min 10例的症状、肌力和感觉明显好转。6个月后随访6例症状消失,肌力、感觉恢复正常,2例有好转,2例无效。4年后仍有7例有效。结论:小针刀治疗上干型胸廓出口综合征创伤小,操作简单,效果可靠。     

Intracranial germinoma and Down's syndrome--case report.

A germinoma in the basal ganglia developed in a 9-year-old boy with Down's syndrome, presenting as left hemiparesis. An initial computed tomographic (CT) scan demonstrated no notable abnormalities, but serial CT scans followed the entire course of tumor growth. Subtotal removal and irradiation achieved tumor remission. This is the first case reported of intracranial germinoma associated with Down's syndrome.     

小针刀定点松解法治疗上干型胸廓出口综合征

目的：观察小针刀定点松解治疗上干型胸廓出口综合征的疗效及探讨其作用机制。方法：共治疗32例上千型胸廓出口综合征患者,其中女22例,男10例;年龄25-55岁。病程1个月～3年,均为单侧发病。采用小针刀对C。关节突关节及冈下窝痛性条索定点快速松解,每周1次,治疗1-4次。结果：所有患者术后即刻都有不同程度的颈肩部主观症状缓解,26例术前有肌力下降的患者中术后即刻测试有20例肌力明显增加;18例术前有皮肤痛触觉减弱的患者中术后即刻测试痛触觉有8例感觉明显改善。随访1年,根据Wood评价标准,优19例,良7例,可3例,差3例,其中1例转为手术治疗,无并发症发生。结论：小针刀定点松解法治疗上干型胸廓出口综合征操作安全简便,疗效确切,并同时具有肌松和镇痛作用。     

Vascular thoracic outlet syndrome

Abstract The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib (n = 16), soft tissue anomalies (n = 12), and scar tissue after clavicle fracture (n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia (n = 11), transient ischemic attack (TIA) (n = 1), and claudication or vasomotor phenomena during the arm hyperabduction (n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision (n = 12), combined cervical and first rib excision (n = 4), and first rib excision (n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies. Electronic Publication     

Recurrent thoracic outlet syndrome

Recurrent symptoms develop in 15% to 20% of patients undergoing either first rib resection or scalenectomy for thoracic outlet syndrome. Over the past 22 years 134 operations for recurrence were performed in 97 patients. Four operations were used: transaxillary first rib resection (26); supraclavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial plexus neurolysis (35). Complications included temporary plexus injury (0.7%), temporary phrenic palsy (3.7%), and permanent phrenic palsy (1.4%). The combined primary success rate of all four operations for recurrence was 84% in the first 3 months. This fell to 59% at 1 to 2 years; 50% at 3 to 5 years; and 41% at 10 to 15 years. No significant difference was found in results between the four operations used for recurrence. When recurrence was caused by trauma the results of reoperations were better than when recurrence was spontaneous. The primary success rates of three initial operations for thoracic outlet syndrome were compared to their secondary success rates (improved after reoperation). By use of life-table methods, reoperation improved the 5- to 10-year success rate of transaxillary first rib resection from 69% to 86% and for scalenectomy from 69% to 84%. Reoperation is successful in most cases of recurrent thoracic outlet syndrome and better when recurrence is the result of a neck injury.     

Venous thoracic outlet syndrome

Venous thoracic outlet syndrome is caused by subclavian vein obstruction with or without thrombosis. The primary symptom is arm swelling, frequently accompanied by cyanosis, pain, and occasionally paresthesias. Venography is the only reliable diagnostic tool. Therapy has three goals: (1) remove the thrombus (in thrombotic cases), (2) remove the extrinsic compression, and in a minority of cases, (3) remove the intrinsic stenosis.     

Neurogenic thoracic outlet syndrome

Current concepts for the diagnosis of neurogenic thoracic outlet syndrome are presented together with the surgical experience and results in series of 51 patients caused by a cervical rib. Surgical treatment is recommended in patients with persistent and disabling symptoms not responding to conservative therapy. In carefully selected patients good to excellent results can be achieved.     

Diagnosing thoracic outlet syndrome

Diagnosing and treating thoracic outlet syndrome can be challenging and frustrating. It must be emphasized that the diagnosis of TOS is a clinical one based on a detailed history and physical examination. This takes time and effort and is often confounded by the patient's research on the internet and emotional problems usually resulting from the symptoms and lack of appropriate treatment. Years of inappropriate diagnosis and ineffective therapy take a heavy toll on these patients. Some have psychologic problems to the point that no treatment, no matter how well indicated, will make them well. Some have had symptoms so long that there is permanent neurologic damage. Each patient presents his or her own diagnostic challenge. Solving the problem and providing effective therapy can be rewarding for doctor and patient.     

Superior thoracic outlet syndrome

The authors discuss Superior Thoracic Outlet Syndrome (STOS), which is characterized by aspecific symptomatology. However, some tests may be used to reveal the specificity of the disease. In the past, treatment was often followed by recurrence of the disease. In the last ten years, the Roos operation has been used with a high success rate.     

Surgical treatment of Sturge-Weber syndrome--case report

It is well known that when Sturge-Weber syndrome manifests with seizures in early infancy, hemiparesis develops early, seizures become intractable, and motor weakness and mental retardation are progressive. In North America and Europe, early surgical intervention is recommended in such cases. However, neurosurgical management of Sturge-Weber syndrome has not been reported in Japan. The authors describe a 4-month-old boy with Sturge-Weber syndrome accompanied by intractable seizures who was successfully treated by a two-stage hemispherectomy. Two years postoperatively he remains free of seizures and is active, although his psychomotor development is moderately retarded. Surgical treatment of Sturge-Weber syndrome, including long-term results, is discussed in detail.     

Post-traumatic thoracic outlet syndrome

Background  

To evaluate the clinical presentation, diagnostic and therapeutic management and outcome of 27 cases of post-traumatic thoracic outlet syndrome (PT TOS).     

Arterial thoracic outlet syndrome

Arterial vascular complications resulting from thoracic outlet compression, although rare, can be substantial and potentially limb threatening. Bony abnormalities such as cervical ribs can lead to chronic trauma to the subclavian artery. Early on, the clinical symptoms can be subtle and confusing, causing potential delay in diagnosis.     

Recurrent thoracic outlet syndrome

In the author's experience, the rate of recurrence is lower (5%-10%) when a combined procedure (transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy) is performed as the primary operation. The author strongly believes this combined procedure accomplishes an excellent decompression of the thoracic outlet area and decreases the rate of recurrence and reoperation. In addition, spontaneous recurrence most likely is caused when scar tissue gradually builds up in the surgical area. For this reason, as mentioned previously, the author instructs and encourages patients to start postoperative exercises the day after surgery and to continue these exercises for at least 6 months and preferably 1 year to improve brachial plexus and subclavian vessel gliding and to minimize the harmful effects of scar tissue.     

Dynamic neuromusculoskeletal ultrasound documentation of brachial plexus/thoracic outlet compression during elevated arm stress testing

Background

The diagnosis and validation of thoracic outlet syndrome/brachial plexopathy (TOS) remains a difficult challenge for surgeons, neurologists, and radiologists. This is due to the fact that the responses of standard elevated arm stress tests can be considered somewhat subjective and can vary. Therefore, non-vascular TOS cases are presently diagnosed clinically, and any objective diagnosis has been controversial.

Methods

This is a technique paper describing the use of dynamic neuromusculoskeletal ultrasound to assist in the diagnosis of thoracic outlet/brachial plexus pathology. We propose a new way to observe the brachial plexus dynamically, so that physical verification of nerve compression between the anterior and middle scalene muscles can be clearly made at the onset of clinical symptoms. This gives a way to objectively identify clinically significant brachial plexus compression.

Results

Dynamic testing can add objective analysis to tests such as the elevated arm stress tests and can correlate the onset of symptoms with plexus compression between the anterior and middle scalene muscles. With this, the area of pathologic compression can be identified and viewed while performing the dynamic testing. If compression is seen and the onset of symptoms ensues, this is a positive confirmatory test for the presence of TOS and a clinically significant disease.

Conclusions

This paper offers a simple, objective, and visual diagnostic test that can validate the presence or absence of brachial plexus compression during arm elevation in patients with brachial plexus injury and thoracic outlet syndrome.