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     

胸廓出口综合征手术方法改良

目的 在解剖学研究和临床分析的基础上提出了胸廓出口综合征手术方法的改良。方法 ３０例尸体解剖,研究前、中、小斜角肌的起止点和臂丛神经的关系。随访了术后６个月￣２年的１９例颈肩痛和手部麻木,肌肉萎缩的胸廓出口综合征患者,均做前,中斜角肌起点和小斜角肌切断术。     

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。     

Applied anatomy for upper limb nerve blocks

The brachial plexus derives from C5, C6, C7, C8 and T1 nerves. It is made up of five roots, between the scalene muscles, three trunks (upper, middle and lower) lying in the posterior triangle, each of which divide into anterior and posterior divisions behind the clavicle to form lateral, medial and posterior cords in the upper axilla. The plexus gives rise to the definitive motor and cutaneous nerve supply to the upper limb. The plexus can be blocked by local anaesthetic infiltration at its root/trunk level in the fascial sheath compartment between the scalenes, or as it crosses the first rib. Block can also be performed around the axillary artery. Peripherally, the nerves may be blocked at the elbow, wrist or finger level.     

Applied anatomy for upper limb nerve blocks

The brachial plexus derives from C5, C6, C7, C8 and T1 nerves. It is made up of five roots, between the scalene muscles, three trunks (upper, middle and lower) lying in the posterior triangle, each of which divide into anterior and posterior divisions behind the clavicle to form lateral, medial and posterior cords in the upper axilla. The plexus gives rise to the definitive motor and cutaneous nerve supply to the upper limb. The plexus can be blocked by local anaesthetic infiltration at its root/trunk level in the fascial sheath compartment between the scalenes, or as it crosses the first rib. Block can also be performed around the axillary artery. Peripherally, the nerves may be blocked at the elbow, wrist or finger level.     

Surgical anatomy of the cervical and infraclavicular parts of the long thoracic nerve

OBJECT: There is insufficient information in the neurosurgical literature regarding the long thoracic nerve (LTN). Many neurosurgical procedures necessitate a thorough understanding of this nerve's anatomy, for example, brachial plexus exploration/repair, passes for ventriculoperitoneal shunt placement, pleural placement of a ventriculopleural shunt, and scalenotomy. In the present study the authors seek to elucidate further the surgical anatomy of this structure. METHODS: Eighteen cadaveric sides were dissected of the LTN, anatomical relationships were observed, and measurements were obtained between it and surrounding osseous landmarks. The LTN had a mean length of 27 +/- 4.5 cm (mean +/- standard deviation) and a mean diameter of 3 +/- 2.5 mm. The distance from the angle of the mandible to the most proximal portion of the LTN was a mean of 6 +/- 1.1 cm. The distance from this proximal portion of the LTN to the carotid tubercle was a mean of 3.3 +/- 2 cm. The LTN was located a mean 2.8 cm posterior to the clavicle. In 61% of all sides the C-7 component of the LTN joined the C-5 and C-6 components of the LTN at the level of the second rib posterior to the axillary artery. In one right-sided specimen the C-5 component directly innervated the upper two digitations of the serratus anterior muscle rather than joining the C-6 and C-7 parts of this nerve. The LTN traveled posterior to the axillary vessels and trunks of the brachial plexus in all specimens. It lay between the middle and posterior scalene muscles in 56% of sides. In 11% of sides the C-5 and C-6 components of the LTN traveled through the middle scalene muscle and then combined with the C-7 contribution. In two sides, all contributions to the LTN were situated between the middle scalene muscle and brachial plexus and thus did not travel through any muscle. The C-7 contribution to the LTN was always located anterior to the middle scalene muscle. In all specimens the LTN was found within the axillary sheath superior to the clavicle. Distally, the LTN lay a mean of 15 +/- 3.4 cm lateral to the jugular notch and a mean of 22 +/- 4.2 cm lateral to the xiphoid process of the sternum. CONCLUSIONS: The neurosurgeon should have knowledge of the topography of the LTN. The results of the present study will allow the surgeon to better localize this structure superior and inferior to the clavicle and decrease morbidity following invasive procedures.     

The treatment of thoracic outlet syndrome: a comparison of different operations

Although transaxillary first rib resection is one of the popular treatments for thoracic outlet syndrome today, recurrences and nerve injuries have led to investigation of other operations that might reduce complications and improve results. This article compares the results of transaxillary first rib resection with (1) scalenectomy (anterior and middle) and (2) supraclavicular first rib resection with scalenectomy. Between 1964 and 1987, 668 primary operations were performed for thoracic outlet syndrome on 491 patients. Seventy-one percent were women. Eight-six percent gave histories of neck trauma, often a whiplash injury (traumatic thoracic outlet syndrome); 4.5% had cervical ribs. Common symptoms included paresthesia in the hands (90%); arm pain (80%); neck pain (86%); and occipital headaches (69%). On physical examination, tenderness over the scalene muscles and duplication of symptoms with the arms abducted to 90 degrees in external rotation were present in over 90% of patients. By use of life-table analysis methods, success after surgery was found to be the same for all operations: 91% to 93% at 3 months; 76% to 79% at 1 to 2 years; 70% to 73% at 3 to 5 years; and 69% to 72% at 5 to 10 years. After rib resection plexus injuries occurred in 2.6%, with partial disability in 0.5%. No plexus injuries occurred after scalenectomy, but temporary phrenic nerve palsy occurred in 4.4%. Scalenectomy is as successful an operation as first rib resection for traumatic thoracic outlet syndrome and has fewer serious complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

臂丛神经卡压综合征的诊治

目的探讨位于臂丛神经及其前中斜角肌周围的神经卡压综合征的特点及其诊治方法。方法2003年7月～2006年1月,采用门诊收集病例,根据病情轻重分组,分别采用药物、局部封闭及手术方法治疗179例确诊为臂丛神经和(或)其属支卡压综合征的患者。其中采用药物、手法治疗89例；注射治疗74例,其中需要第二次注射32例；手术治疗16例,同时或分别进行双侧手术2例,需要第二次手术者1例。结果128例患者得到1个月～2年5个月随访。其中,药物手法治疗55例,症状均有不同程度改善或能维持现状。局部注射治疗58例(其中接受第二次注射者24例),2例出现心跳减缓,其余病例无并发症发生,VAS评分情况：1分2例,2分16例,3分20例,4分12例,5分3例,6分3例,7分2例；第二次注射结果：2分5例,3分16例,4分3例。手术治疗15例,其中10例术后症状得到明显改善,恢复工作。结论臂丛神经及其属支涉及其周围众多神经,可产生众多症状；明确病因后,治疗上以保守治疗为主,效果欠佳者采用手术治疗,均可取得较好疗效。     

经典与改良斜角肌切断术治疗胸廓出口综合征疗效的长期随访

目的 比较经典及改良的斜角肌切断术治疗胸廓出口综合征（thoracic outlet syndrome，TOS）的远期疗效。方法 对1985—1994年TOS26例29侧行经典斜角肌切断术，1996—2000年TOS28例30侧行改良斜角肌切断术的患者进行长期随访（5～19年）。分别测定手部肌力、手及前臂尺侧感觉、颈肩部不适及患肢血运等情况。结果 经典与改良方法对手内肌萎缩、前臂及手尺侧感觉减退的缓解率分别为80．0％、80．8％、88．5和88．8％、85．2％、92．0％，两组差异无统计学意义；经典与改良方法对患肢发冷、发白以及颈肩部不适的缓解率较低，分别为47．1％、44．4％和80．0％、78．9％．两组相比差异有统计学意义（P〈0．05）。结论 改良的斜角肌切断术能更好地缓解TOS的各种症状，尤其对颈肩部不适及患肢血运情况的改善疗效明显好于经典方法。     

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.     

770 Consecutive supraclavicular first rib resections for thoracic outlet syndrome

During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occurred and only 12 patients (2%) required operative intervention for recurrent TOS. First rib resection and scalenectomy can be performed by the supraclavicular route with an acceptable outcome, minimal morbidity, and long-lasting results.     

Variations of the course of the upper trunk of the brachial plexus and their clinical significance for the thoracic outlet syndrome: a study on 93 cadavers

The aim of this study is the recording of the variations of the course of the upper trunk (UT) of the brachial plexus (BP) and their clinical significance for the thoracic outlet syndrome (TOS) and the anesthetic blockade of the BP. Five different anatomical variations of the course of the UT of the BP, in relation to the anterior scalene muscle (ASM), were observed in 24 out of the 186 sides of the 93 cadavers we studied (12.9%). The C5 root was passing anteriorly to the ASM in six cases. The UT was located anteriorly to the ASM in four cases and was perforating the ASM's belly in 12 cases. In one cadaver, the ASM was double and the UT was passing between the two bellies of the double ASM. Finally, in another cadaver, the C5 root was found to be anterior to the anterior scalene muscle, while the C6 root was perforating the ASM's belly. These variations are predisposing factors for the TOS; they cause specific symptomatology and require a different surgical approach in comparison with other causes of the syndrome. Moreover, knowledge of these is important during the performance of the anesthetic blockade of the BP.     

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.     

Observations on the Use of Seprafilm® on the Brachial Plexus in 249 Operations for Neurogenic Thoracic Outlet Syndrome

Purpose

Seprafilm® was initially used successfully as a membrane to reduce abdominal adhesions. Subsequently it was tried in a number of other areas to reduce postoperative scarring. Seprafilm® was employed in this study to see if it would reduce postoperative scarring after supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome (NTOS).

Material and methods

There were 249 operations for primary NTOS (185) and recurrent NTOS (64). Seprafilm® was applied to the nerve roots at the end of each procedure. Diagnosis was established by careful history and extensive physical exam consisting of several provocative maneuvers. Scalene muscle block confirmed the diagnosis.

Results

Success rates for primary operations, 1–2 years postoperation were 74% for scalenectomy without first rib resection and 70% for scalenectomy with first rib resection. For reoperations, success rate for scalenectomy and neurolysis after transaxillary rib resection was 78% whereas success rate for neurolysis after supraclavicular scalenectomy was 68%. Seprafilm® did not significantly improve overall results compared to our results 15 years ago, although in reoperations there was a trend toward improvement with Seprafilm®. Observations in 10 reoperations after use of Seprafilm® revealed that there were fewer adhesions between fat pad and nerve roots, making it much easier to find the nerve roots. Recurrence was because of scar formation around individual nerve roots.

Conclusion

Seprafilm® made reoperations easier by reducing scarring between scalene fat pad and brachial plexus. However, it did not prevent scar tissue forming around the individual nerve roots nor did it significantly lower the failure rate for primary operations. The trend supported the use of Seprafilm® in reoperations.     

Neurogenic thoracic outlet decompression: rationale for sparing the first rib

A total of 168 primary supraclavicular decompressions were performed on 146 patients with neurogenic thoracic outlet syndrome. This report compares the results of rib resection (supraclavicular anterior and middle scalenectomy and first rib resection) with rib-sparing (supraclavicular anterior and middle scalenectomy alone) operations. All patients with cervical ribs were excluded. In total, 125 rib resections and 43 rib-sparing procedures were performed between 1983 and 1992 by a single surgeon. The patients were otherwise comparable in symptoms and physical signs. During surgery there was a significantly higher proportion of pleural injury associated with rib resection (59%) than with rib-sparing (40%) procedures. The mean hospital stay was also prolonged by 1 day in patients undergoing rib resection (P = 0.005). There was no significant difference in early success between the two groups (83% for rib resection, 91% for rib sparing) and no difference in those resuming employment (52% and 63% respectively). Life-table analysis showed that the two groups have similar long-term results (69% and 76% at 2 years). The only important factor determining clinical outcome in primary supraclavicular thoracic outlet syndrome decompression was the duration of symptoms before operation. Some 83% of patients with symptoms less than 2 years had a successful result compared with only 68% in those with symptoms longer than 2 years (P < 0.05). Spontaneous or post-traumatic neurogenic symptoms responded to operation identically. The theoretical benefit of first rib resection to relieve mechanical compression of the brachial plexus is not evident from this review. Thorough removal of the scalene musculature and other myofascial anomalies, preferably through the supraclavicular approach, leads to less patient morbidity, shortens hospitalization, and is recommended for patients with neurogenic thoracic outlet syndrome requiring operative intervention.     

Scalene muscle abnormalities in traumatic thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is not a single disorder but a collection of abnormalities in the same anatomic area that elicit similar symptoms. The many causes of TOS are best classified into one of three groups: osseous, traumatic, and nontraumatic. Although patients with traumatic TOS constituted 86% of our last 600 patients with TOS who underwent surgical treatment, the precise mechanism underlying the condition remains obscure. To determine if there was microscopic abnormalities, 45 anterior and middle scalene muscles from patients with traumatic TOS were studied by means of histochemical stains applied after freezing of the muscles. The results revealed a consistent abnormal histologic pattern in patients with traumatic TOS: type II fibers were atrophied; there was an increase in the average number of type I fibers (78% versus 53% in muscles from control patients); and there was a significant increase (mean: 36%) in connective tissue (muscles from control patients averaged less than 15%). Although type II fiber atrophy and type I fiber predominance are seen in a variety of other conditions, their association with fibrosis is rare. Following neck injuries, the changes in the anterior and middle scalene muscles are compatible with trauma, suggesting that fibrotic scalene muscles are an important cause of symptoms in traumatic TOS.     

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。     

Identification of the phrenic nerve in surgical exploration of the brachial plexus in obstetrical palsy

This report describes a simple technique for identifying the phrenic nerve at the beginning of exploration of the brachial plexus in obstetrical palsy. Both the phrenic and supraclavicular nerves originate from the C4 root; therefore, retrograde dissection of the supraclavicular nerve will end at the C4 root and identify the phrenic nerve. This technique is very useful to less experienced surgeons but may also be helpful when the experienced surgeon encounters excessive scarring of the anterior scalene muscle. Finally, the dissected supraclavicular nerve may be used as a cable graft in brachial plexus reconstruction.     

Surgical anatomy of the dorsal scapular nerve

OBJECT: There is a paucity of literature regarding the surgical anatomy of the dorsal scapular nerve (DSN). The aim of this study was to elucidate the relationship of this nerve to surrounding anatomical structures. METHODS: Ten formalin-fixed human cadavers (20 sides) were dissected, and measurements made between the DSN and related structures. The nerve pierced the middle scalene muscle at a mean distance of 3 cm from its origin from the cervical spine and was more or less centrally located at this exit site. It lay a mean distance of 1.5 cm medial to the vertebral border of the scapula between the serratus posterior superior, posterior scalene, and levator scapulae muscles. It was found to have a mean distance of 2.5 cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle. The nerve intertwined the dorsal scapular artery in all specimens and was found along the anterior border of the rhomboid muscles. On 19 sides the DSN originated solely from the C-5 spinal nerve, and on one side it arose from the C-5 and C-6 spinal nerves. CONCLUSIONS: Knowledge of the anatomy of the DSN will aid the surgeon who wishes to explore and decompress this structure.     

颈肩痛伴同侧手握力减弱的临床分析

目的：研究颈肩痛伴同侧手握力减弱的病因。方法：共17例患者,首先均经非手术治疗,包括颈部痛点封闭及颈椎牵引,其中效果不明显的5例手术治疗,术中切断中小斜角肌及C5、6神经根旁的前中斜角肌的肌起。结果：全部患者均随访2年以上,17例非手术治疗,8例症状完全消失,4例症状明显改善,5例症状改善不明显。手术5例症状均完全消失。结论：颈肩痛伴同侧手握力减弱的原因是中中小斜角肌引起的臂丛下干或C8神经根受压所致。