采用经锁骨上入路切除斜角肌和第一肋方法治疗非特异性胸廓出口综合征
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摘要
目的探讨经单一锁骨上入路切除斜角肌和第一肋治疗非特异型胸廓出口综合征(DTOS)的中期效果。方法回顾分析2009年1月至2014年12月北京积水潭医院手外科收治的12例DTOS患者的病历资料。其中男4例,女8例。年龄32(15～53)岁。左侧8例,右侧4例。12例患者均采用经单一锁骨上入路,探查松解臂丛神经和锁骨下动脉起点,切除前中斜角肌和第一肋的手术方式。利用X线判断有无第7颈椎横突过长、颈肋等骨性异常。体格检查采用Adson试验、反向Adson试验及Wright试验。采用前臂-肩-手功能障碍评分(QuickDASH)评估手术前后上肢功能。结果随访24个月以上。术前X线检查未发现第7颈椎横突过长、颈肋等骨性异常。上肢张力试验阳性12例,锁骨上窝斜角肌三角间隙内神经压迫试验阳性12例,Adson试验阳性8例,反向Adson试验阳性5例,Wright试验阳性8例。电生理检查前臂内侧皮神经支配区域异常电位8例。术后伤口均顺利愈合,未发生血肿、气胸、淋巴漏及感染等并发症。末次随访时,症状完全消除5例,明显改善5例,有改善1例。术后中位QuickDASH评分较术前改善38分。结论经单一锁骨上入路切除斜角肌和第一肋治疗DTOS效果显著,单一手术入路可同时显露臂丛神经和锁骨下动脉。
Objective To investigate the effect of supraclavicular scalenectomy and first rib resection for disputed thoracic outlet syndrome(DTOS). Methods A total of 12 patients(4 males and 8 females) with DTOS in Department of Hand Surgery, Beijing Jishuitan Hospital between January 2009 and December 2014 were retrospectively analyzed. The mean age was 32 years(range 15-53 years). The single supraclavicular approach was adopted in all cases. The origin of brachial plexus and subclavian artery were explored and released. Most of the anterior and middle scalene were resected and the first rib was removed. The presence or absence of overlength transverse process of C7 and cervical rib were evaluated by X-ray. Physical examination was performed by the Adson test, the reverse Adson test, and the Wright test. The QuickDASH was used to assess the function of upper limb before and after surgery. Results At least 24 months follow-up was conducted since the final surgery. No osseous abnormality was found in X-ray before surgery, such as cervical rib and overlong transverse process of C7. The upper limb tension test was positive in 12 cases, Adson test was positive in 8 cases and reverse Adson test was positive in 5 cases, Wright test was positive in 8 cases, Brachial plexus compression test was positive in 12 cases. The electromyography showed abnormal potential in medial cutaneous nerve of forearm in 8 cases.The surgical wound was healed in 12 cases without hematoma formation, pneumothorax, lymphatic leakage, infection and other complications. At the final follow-up, the symptoms disappeared entirely in 5 cases, markedly improved in 6 cases and moderately improved in one case. The postoperative median QuickDASH score improved 38 points comparing with that of preoperation. ConclusionThe single supraclavicular approach can reveal the subclavian artery and brachial plexus at the same time. Through this approach, the resection of the anterior and middle scalene and the first rib can be performed. This technique is effective for disputed thoracic outlet syndrome.
Objective To investigate the effect of supraclavicular scalenectomy and first rib resection for disputed thoracic outlet syndrome(DTOS). Methods A total of 12 patients(4 males and 8 females) with DTOS in Department of Hand Surgery, Beijing Jishuitan Hospital between January 2009 and December 2014 were retrospectively analyzed. The mean age was 32 years(range 15-53 years). The single supraclavicular approach was adopted in all cases. The origin of brachial plexus and subclavian artery were explored and released. Most of the anterior and middle scalene were resected and the first rib was removed. The presence or absence of overlength transverse process of C7 and cervical rib were evaluated by X-ray. Physical examination was performed by the Adson test, the reverse Adson test, and the Wright test. The QuickDASH was used to assess the function of upper limb before and after surgery. Results At least 24 months follow-up was conducted since the final surgery. No osseous abnormality was found in X-ray before surgery, such as cervical rib and overlong transverse process of C7. The upper limb tension test was positive in 12 cases, Adson test was positive in 8 cases and reverse Adson test was positive in 5 cases, Wright test was positive in 8 cases, Brachial plexus compression test was positive in 12 cases. The electromyography showed abnormal potential in medial cutaneous nerve of forearm in 8 cases.The surgical wound was healed in 12 cases without hematoma formation, pneumothorax, lymphatic leakage, infection and other complications. At the final follow-up, the symptoms disappeared entirely in 5 cases, markedly improved in 6 cases and moderately improved in one case. The postoperative median QuickDASH score improved 38 points comparing with that of preoperation. ConclusionThe single supraclavicular approach can reveal the subclavian artery and brachial plexus at the same time. Through this approach, the resection of the anterior and middle scalene and the first rib can be performed. This technique is effective for disputed thoracic outlet syndrome.
引文
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[12] Laulan J.Thoracic outlet syndromes.The so-called "neurogenic types"[J].Hand Surg Rehabil,2016,35(3):155-164. DOI:10.1016/j.hansur.2016.01.007.
[13] Machleder HI,Moll F,Verity A.The anterior scalene muscle in thoracic outlet compression syndrome:histochemical and morphometric studies[J].Arch Surg,1986,121(10):1141-1144. PMID:3767646.
[14] Crosby CA,Wehbe MA.Conservative treatment for thoracic outlet syndrome[J].Hand Clin,2004,20(1):43- 49. PMID:15005383.
[15] Novak CB.Conservative management of thoracic outlet syndrome[J].Semin Thorac Cardiovasc Surg,1996,8(2):201-207. PMID:8672574.
[16] Mackinnon SE,Novak CB.Thoracic outlet syndrome[J].Curr Probl Surg,2002,39(11):1070-1145. PMID:12407366.
[17] Sanders RJ,Hammond SL,Rao NM.Thoracic outlet syndrome, a review[J].The Neurologist,2008,14(6):365-373. DOI:10.1097/NRL.0b013e318176b98d.
[18] Sanders RJ,Pearce WH.The treatment of thoracic outlet syndrome:a comparison of different operations[J].J Vasc Surg,1989,10(6):626- 634. PMID:2585651.
[19] Leonhard V,Caldwell G,Goh M,et al.Ultrasonographic diagnosis of thoracic outlet syndrome secondary to brachial plexus piercing variation[J].Diagnostics(Basel),2017,7(3):E40. DOI:10.3390/diagnostics7030040.
[2] Sanders RJ,Hammond SL,Rao NM.Thoracic outlet syndrome,a review[J].Neurologist,2008,14(6):365-373. DOI:10.1097/NRL.0b013e318176b98d.
[3] Povlsen S,Povlsen B.Diagnosing thoracic outlet syndrome:current approaches and future directions[J].Diagnostics (Basel),2018,8(1):E21. DOI:10.3390/diagnostics8010021.
[4] Peet RM,Henriksen JD,Anderson TP,et al.Thoracic-outlet syndrome:evaluation of a therapeutic exercise program[J].Proc Staff Meet Mayo Clin,1956,31(9):281-287. PMID:13323047.
[5] Roos DB.Thoracic outlet syndromes:update[J].Am J Surg,1987,154:568-573. PMID:3425795.
[6] Orlando MS,Likes KC,Mirza S,et al.A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome[J].J Am Coll Surg,2015,220(5):934- 939. DOI:10.1016/j.jamcollsurg.2014.12.046.
[7] Gilliatt R,Le Quesne P,Logue V,et al.Wasting of the hand asso-ciated with a cervical rib or band[J].J Neurol Neurosurg Psychiatry,1970,33(5):615- 624. PMID:5478944.
[8] Huang JH,Zager EL.Thoracic outlet syndrome[J].Neurosurgery,2004,55(4):897- 903. PMID:15458598.
[9] Hudak P,Amadio PC,Bombardier C.Development of an upper extremity outcome measure:the DASH (disabilities of the arm,shoulder and hand) [corrected].The Upper Extremity Collaborative Group (UECG) [J].Am J Ind Med,1996,29(6):602- 608. DOI:10.1002/(SICI)1097- 0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L.
[10] Beaton DE,Wright JG,Katz JN.Upper extremity collaborative group.Development of the QuickDASH:comparison of three item-reduction approaches[J].J Bone Joint Surg Am,2005,87(5):1038-1046. DOI:10.2106/JBJS.D.02060.
[11] Peek J,Vos CG,ünlü ?,et al.Long-term functional outcome of surgical treatment for thoracic outlet syndrome[J].Diagnostics(Basel),2018,8(1):E7. DOI:10.3390/diagnostics8010007.
[12] Laulan J.Thoracic outlet syndromes.The so-called "neurogenic types"[J].Hand Surg Rehabil,2016,35(3):155-164. DOI:10.1016/j.hansur.2016.01.007.
[13] Machleder HI,Moll F,Verity A.The anterior scalene muscle in thoracic outlet compression syndrome:histochemical and morphometric studies[J].Arch Surg,1986,121(10):1141-1144. PMID:3767646.
[14] Crosby CA,Wehbe MA.Conservative treatment for thoracic outlet syndrome[J].Hand Clin,2004,20(1):43- 49. PMID:15005383.
[15] Novak CB.Conservative management of thoracic outlet syndrome[J].Semin Thorac Cardiovasc Surg,1996,8(2):201-207. PMID:8672574.
[16] Mackinnon SE,Novak CB.Thoracic outlet syndrome[J].Curr Probl Surg,2002,39(11):1070-1145. PMID:12407366.
[17] Sanders RJ,Hammond SL,Rao NM.Thoracic outlet syndrome, a review[J].The Neurologist,2008,14(6):365-373. DOI:10.1097/NRL.0b013e318176b98d.
[18] Sanders RJ,Pearce WH.The treatment of thoracic outlet syndrome:a comparison of different operations[J].J Vasc Surg,1989,10(6):626- 634. PMID:2585651.
[19] Leonhard V,Caldwell G,Goh M,et al.Ultrasonographic diagnosis of thoracic outlet syndrome secondary to brachial plexus piercing variation[J].Diagnostics(Basel),2017,7(3):E40. DOI:10.3390/diagnostics7030040.