Tratamento de oclusão arterial em membro superior causada por costela cervical / Treatment of upper limb arterial occlusion caused by a cervical rib

Resumo A síndrome da costela cervical ocorre quando o triângulo intercostoescalênico é ocupado por uma costela cervical, deslocando o plexo braquial e a artéria subclávia anteriormente, o que pode gerar dor e espasmo muscular. O objetivo deste estudo é discutir sobre o diagnóstico da síndrome da costela cervical e as possibilidades de tratamento. Este desafio terapêutico descreve a condução clínica e cirúrgica de uma paciente de 37 anos com obstrução arterial em membro superior causada por costela cervical.

Abstract The cervical rib syndrome occurs when the interscalene triangle is occupied by a cervical rib, displacing the brachial plexus and the subclavian artery forward, which can cause pain and muscle spasms. The objective of this study is to discuss diagnosis of the cervical rib syndrome and treatment possibilities. This therapeutic challenge describes clinical and surgical management of a 37-year-old female patient with upper limb arterial occlusion caused by a cervical rib.

Síndromes compresivos vasculares: un desafío diagnóstico / Vascular Compressive Syndromes: A Challenge Diagnosis

Resumen Los síndromes de compresión vascular constituyen un grupo de patologías poco frecuentes con prevalencia incierta, no solo por el desconocimiento que se tiene de estos, sino también por su presentación clínica inespecífica. Eso conlleva a que sean infradiagnosticados o detectados en etapas tardías, con secuelas a largo plazo. Su fisiopatología y clínica dependen del tipo de vaso comprometido, el sitio anatómico afectado y la causa subyacente que lo esté produciendo. La anamnesis, el examen físico dirigido y el uso de métodos complementarios como la ultrasonografía Doppler y la angiografía por tomografía computarizada (ATC) o angiografía por resonancia magnética (ARM), son herramientas vitales para su correcto diagnóstico, planificación terapéutica y seguimiento.

Abstract Vascular compression syndromes constitute a group of rare pathologies with uncertain prevalence not only because of their unawareness, but also for its nonspecific clinical presentation. This leads to their underdiagnosis, or detection in late stages with long-term sequelae. Its pathophysiology and presentation depends on the type of vessel involved, the affected anatomical site and the underlying cause producing it. Clinical history, physical examination and use of complementary methods such as Doppler ultrasonography, Computed Tomography Angiography (CTA) or Magnetic Resonance Angiography (MRA), are essential tools for its proper diagnosis, therapeutic planning and follow-up.

Claviculectomía total como procedimiento de rescate: Reporte de un caso y revisión bibliográfica / Total claviculectomy as a rescue procedure. Case report and literature review

La seudoartrosis de clavícula es una causa infrecuente de síndrome del opérculo torácico. Se describe un caso de plexopatía braquial por seudoartrosis previamente infectada de clavícula. La paciente fue sometida a una claviculectomía total para aliviar los síntomas. Del análisis de la literatura citada, se concluye en que la claviculectomía total es una opción por considerar si se han agotado las opciones terapéuticas. Los resultados funcionales pueden ser satisfactorios cuando se la indica por infección, plexopatía o sarcoma. Nivel de Evidencia: IV

Clavicle non-union is an uncommon cause of thoracic outlet syndrome. A case of brachial plexopathy by previously infected clavicle pseudarthrosis is described. Total claviculectomy was performed for symptom relief. From literature analysis we conclude that total claviculectomy is an option to be taken into account when therapeutic options have exhausted. Functional results could be adequate when total claviculectomy is indicated in cases of infection, plexopathy or sarcoma. Level of Evidence: IV

Reporte de Caso Clínico y discusión de tema: Síndrome del opérculo Torßcico / Descrição do caso clínico e discussão do tema: síndrome do desfiladeiro torßcico / Report and discussion of a study case: Thoracic Outlet Syndrome

Introdución: El síndrome del Opérculo Torßcico (SOT) es un grupo heterogéneo y potencialmente disfuncional de síndromes relacionados con compresión extrínseca de estructuras neurovasculares a su paso, desde el cuello hacia el miembro superior, por diferentes estructuras anatómicas congénitas o adquiridas, siendo mßs frecuente la compresión neurológica, ocasionando una variedad de sintomatología que varía según grado de compresión y estructura afectada, que en algunos casos hacen difícil su diagnóstico. Es una entidad mal diagnosticada teniendo en cuenta que no hay criterios diagnósticos establecidos; por eso, el examen físico es primordial para su sospecha clínica. El tratamiento inicial es conservador, siendo el tratamiento quirúrgico, una opción con múltiples procedimientos personalizados para cada tipo de paciente, según etiología. Objetivo: El propósito del artículo es realizar una discusión del caso clínico basada en la evidencia, para permitir un conocimiento general de esta patología, y comprender que hace parte de las causas de dolor en miembro superior, para así orientar al profesional de la salud a realizar un diagnóstico oportuno y un tratamiento efectivo que disminuya el riesgo de complicaciones irreversibles.

Introduction: Thoracic Outlet Syndrome - TOS - is a heterogeneous and potentially dysfunctional group of syndromes related to extrinsic compression of neurovascular structures from the neck to the upper limb for different congenital or acquired anatomical structures, being more frequent the neurological compression, causing a variety of symptoms that vary according to the degree of compression and affected structure that in some cases make it difficult to diagnose. Due to the lack of established diagnostic criteria, the physical exam is the most important element used to formulate a diagnosis. The initial treatment is conservative. The surgical treatment becomes an option with multiple personalized procedures for each type of patient according to the etiology. Objective: The purpose of the article is to discuss the clinical case based on the evidence allowing general knowledge of that pathology, and understanding the causes of pain in the upper limb, to therefore guide medical staff to perform a timely diagnosis and effective treatment that decreases the risk of irreversible complications.

Introdução: A Síndrome do desfiladeiro Toraxico (SOT) é um grupo heterogéneo e potencialmente disfuncional de síndromes relacionadas à compressão extrínseca de estruturas neurovasculares da passagem do pescoço para o membro superior por diferentes estruturas anatômicas congênitas ou adquiridas, sendo a compressão neurológica mais frequente, sua varieda sintomatología depende do grau de compressão e da estrutura afectada, o que em alguns casos podem dificultar o seu diagnóstico. É uma doença mal diagnosticada porque não hß criterios estabelecidos para o diagnóstico; por esta razão o exame físico é fundamental na suspeita clínica. O tratamento inicial é conservador, sendo a opção cirúrgico uma intervenção com múltiplos procedimentos personalizados acordo com a etiologia do paciente. Objetivo: O objetivo deste artigo é realizar uma discussão do caso clínico com base em provas, que permita um conhecimento geral da doença, e entender que faz parte das causas de dor no membro superior permitindo orientar o profissional de saúde a fazer um diagnóstico oportuno e um tratamento eficaz a fim de reduzir o risco de complicações irreversíveis. (au)

Cervical rib.

Cervical rib is a supernumerary rib. It is one of the deformities of the musculoskeletal system. According to Terves and Keith, there is always a rudiment of a cervical rib in the fetus which usually disappears but in 1-2 %, it persists throughout life. Only a part of this percentage has symptoms. Genetic Factors may play a role. Clinical important: It causes pressure on brachial-plexus or subclavian artery. These structures are entrapped between the cervical rib and scaleneus muscle. There is positive Adson’s sign i.e. radial pulse is lost in the arm during abduction and external rotation of the shoulder. There is compression of brachial plexus which causes weakness of muscles of the hand near base of the thumb. This is known as THORACIC OULET SYNDROME. A supernumerary rib develops from anterior tubercle of cervical vertebra- like Meckel’s Diverticulum. Incidence 5 – 6 % .Mostly an incidental finding

Resección transaxilar de la primera costilla con apoyo endoscópico en el síndrome de salida de tórax: una opción quirúrgica segura / Endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe surgical option

Introducción: La resección transaxilar con apoyo endoscópico es una técnica quirúrgica novedosa en el manejo del síndrome de salida de tórax que permite identificar con seguridad el paquete vasculonervioso y las diferentes estructuras. Nuestro objetivo fue valorar los resultados de morbilidad y mortalidad del tratamiento quirúrgico en el síndrome de salida de tórax con esta técnica. Material y métodos: Estudio longitudinal prospectivo de 22 intervenciones quirúrgicas de resección transaxilar de la primera costilla, con apoyo endoscópico a pacientes con síndrome de salida de tórax, entre enero de 2000 y enero de 2009, en un hospital privado de la cuidad de Puebla, México. De ellos, 16 mujeres y seis hombres, con edad promedio de 35 años. Encontramos 16/22 (72.7 %) pacientes con síntomas neurológicos y 6/22 (27.3 %) con síntomas venosos; entre ellos, 2/22 (9.09 %) presentaban trombosis venosa de esfuerzo axilosubclavia. Resultados: Entre las 22 intervenciones encontramos bandas fibrosas en 8/22 pacientes (36.3 %): 1/22 (4.5 %) con una banda cervical tipo 1 y costilla cervical grado II, 1/22 (4.5 %) con banda cervical tipo 2 y costilla cervical grado I, 2/22 (9.09 %) con banda tipo 3, 1/22 (4.5 %) con banda tipo IV, 1/22 (4.5 %) con banda tipo V y 2/22 (9.09 %) con banda tipo VII y trombosis axilosubclavia. Después del procedimiento, 20/22 (90.9 %) pacientes manifestaron mejoría total y 2/22 (9.1 %), parestesias leves. No hubo complicaciones por lesiones nerviosas, vasculares o pleurales. Conclusiones: La técnica escrita provee un margen de seguridad amplio y mejora la visibilidad, disminuyendo las complicaciones quirúrgicas.

BACKGROUND: Endoscopic-assisted transaxillary first rib resection is a novel approach in the management of thoracic outlet syndrome (TOS) and allows us to safely identify the neurovascular package and different structures. Our main objective is to assess the results of morbidity and mortality of the surgical treatment in TOS with this technique. METHODS: We carried out a prospective, longitudinal study with 22 surgical interventions of transaxillary first rib resection with endoscopic support in patients with TOS from January 2000 to January 2009 in a private hospital located in Puebla, Mexico. There were 16 females and six males with a mean age of 35 years. We found 16/22 (72.7%) patients with neurological symptoms and 6/22 (27.3%) with venous symptoms; 2/22 (9.09%) patients had effort thrombosis of the axillary-subclavian vein. RESULTS: Of the 22 interventions, we found fibrous bands in 8/22 patients (36.3%); 1/22 (4.5%) with type 1 cervical band and cervical rib grade II, 1/22 (4.5%) with type 2 cervical band and cervical rib grade I, 2/22 (9.09%) with band type 3, 1/22 (4.5%) with band type IV, 1/22 (4.5%) with band type V and 2/22 (9.09%) with band type VII and axillary-subclavian thrombosis. After the procedure, 20/22 (90.9%) patients showed total symptom improvement and 2/22 (9.1%) patients had mild paresthesias. There were no complications from nerve, vascular or pleural damage. CONCLUSIONS: This technique provides an ample margin of safety and improves visibility, reducing surgical complications.

Síndrome del opérculo torácico: reporte de caso / Thoracic outlet syndrome: case report

Se reporta un caso de síndrome del opérculo torácico vascular en un hombre joven, diagnosticado por arteriografía del miembro superior. Este síndrome ocasiona embolias arterioarteriales repetidas, originadas en un aneurisma postestenótico de la arteria subclavia. Es de interés debido a su baja incidencia y al poco número de casos diagnosticados por arteriografía que se encuentran reportados. El opérculo torácico es el camino a través del cual pasan las estructuras vasculonerviosas del cuello a la axila; tiene tres estrecheces anatómicas que, al ser pronunciadas, pueden ocasionar compresión del plexo braquial o del paquete vascular subclavio, lo cual lleva a diversos síntomas y signos.

We report a case of vascular thoracic outlet syndrome in a young man, diagnosed with upper limb arteriography, leading to repeated arterio-arterial emboli originating from a post-stenotic subclavian artery aneurism. It is of our interest due to its low incidence and the small number ofcases reported that have been diagnosed by arteriography. The thoracic outlet is the path throughwhich vascular and neural structures goes from the neck to the axilla, and it has three anatomical strictures, that when pronounced, can compress the brachial plexus or subclavian vessels, leading to different symptoms and signs.

Cervical Rib Syndrome: 2 Cases Report / 대한정형외과학회잡지

Cerivical rib syndrome, one of four common causes of thoracic outlet syndromes, have similar symptoms which accidentally discovered in simple x-ray and needs to be distinguished with other syndromes. Thoracic outlet syndromes are classified according to anatomical structures that causes symptoms; cervical rib syndrome, scalenus anticus syndrome, costoclavicular syndrome and hyperabduction syndrome. Various treatments for thoracic outlet syndromes have been introduced, such as; conservative care, excision of cervical rib and first rib and release of anterior scalenus muscle by supraclavicular approach and excision of cervical rib and first rib by axillary approach. We would like to report a case on a 16 years old girl and a 21 years old man who had cervical rib syndrome and treated successfully without excision of the first rib but excised cervical rib and released anterior scalenus muscle by supraclavicular approach.

Vascular thoracic outlet compression syndrome

The aim of this study was to describe our experience with the surgical treatment of arterial and venous thoracic outlet syndrome. This prospective study included 25 patients with vascular compression at thoracic outlet area. They were admitted to Vascular Surgery Unit, Mansoura University Hospital during the period from July 2004 to July 2007. Patients were classified into two main groups. Group I [arterial thoracic outlet syndrome, n = 16]. Group II [venous thoracic outlet syndrome, n = 9]. The operations of arterial reconstruction were worthwhile for all patients with excellent results in 11 patients [84.6%], only 2 patients [15.4%] developed early postoperative thrombosis which was managed by transbrachial thrombectomy. The success rate of surgical interference for venous non-thrombotic patients was 100% while conservative treatment of thrombotic patients showed success in 4 patients [57%] and failure in 3 patients [43%]. In patients with vascular compression, resection of the first rib, resection of cervical rib, scalenectomy and neurolysis of the brachial plexus are recommended in addition to vascular reconstruction. Our experience using the supraclauicular approach indicate that this is a safe route with good results and minimal risk to the patients health

Síndrome del opérculo torácico: revisión bibliográfica / Thoracic operculum syndrome: bibliographic review

En el presente caso clínico valoramos a una paciente con síndrome del opérculo toráxico, la cual padecía de una larga historia de síntomas y signos variables e inespecíficos en su miembro superior derecho, cuello y región occipital. El estudio semiológico, de imágenes y fisiológico de esta paciente, mostró que el cuadro que padecía, se debía a una costilla cervical redundante. La paciente mejoró mucho con el tratamiento médico, postergando una intervención quirúrgica si el caso en un futuro lo requiera. Este síndrome afecta con mayor frecuencia a mujeres de entre 10 y 50 años, y conlleva a una serie de limitaciones físicas, y posteriormente anatómicas, que afectarían la calidad de vida del paciente; su identificación oportuna nos permite prevenir dicha evolución y en muchos de los casos, ya sea con tratamiento médico y sobre todo con tratamiento quirúrgico, eliminar la causa que desencadenó este síndrome.

In this opportunity we examined a female patient with thoracic operculum syndrome. She had had a long history of changing and no specific symptoms and signs in her right upper limb, neck and occipital region. Studies of signs, images, and physiology of this patient showed that the abnormality she suffered was caused by a redundant cervical rib. The patient got a lot better with medical treatment postponing surgery that could be necessary in the future. This syndrome affects more frequently to women between 10 and 50 years old and implies many physical limitations and subsequently anatomical ones that would affect the quality of life of the patient; its timely identification allows us to prevent such an evolution, and in many cases either with medical treatment or specially with surgical treatment eliminate the cause that triggered this syndrome.

Síndrome do desfiladeiro torácico: revisão teórica / Thoracic outlet syndrome: review

Este artigo apresenta uma revisão teórica sobre os principais pontos pertinentes à Síndrome do Desfiladeiro Torácico (SDT), em virtude de ser uma entidade com prevalência limitada, complexidade no diagnóstico e tratamento controverso...

Tratamento cirúrgico da síndrome do desfiladeiro torácico por via supraclavicular: estudo série de casos / Surgical treatment of thoracic outlet syndrome through a supraclavicular approach: case series

Introdução: A Síndrome do Desfiladeiro Torácico (SDT) se caracteriza por uma variedade de sintomas decorrentes da compressão neurovascular ao nível do desfiladeiro cervicotoracobraquial, geralmente decorrente de anomalias ósseas e/ou musculoligamentosas. Seu diagnóstico é considerado difícil e seu tratamento cirúrgico é controverso. Este estudo teve o objetivo de verificar a efetividade da cirurgia de descompressão do desfiladeiro torácico por via supraclavicular realizada pela equipe de Angiologia e Cirurgia Vascular do Hospital Nossa Senhora da Conceição (HNSC). Participantes e métodos: Estudo série de casos envolvendo 20 pacientes submetidos ao tratamento cirúrgico da SDT por via supraclavicular no HNSC, no período entre 1983 a 2003. Foi realizado por um observador único e previamente treinado: análise de prontuários, entrevista com os pacientes e exame físico dirigido. Foram criadas planilhas próprias para armazenamento dos dados. As variáveis foram descritas em números absolutos e proporções, em medidas de tendência central e dispersão. Resultados: A série de casos foi composta por 19 mulheres e 1 homem; o tempo médio decorrido do procedimento foi 9,4 anos. Dez pacientes se apresentaram completamente assintomáticos. Sintomas importantes como dor no membro, cervicalgia e parestesia tiveram uma redução importante. Quanto à limitação funcional, 10 pacientes relataram continuar com alguma dificuldade, entretanto, 8 deles referiram limitação menos intensa. 18 pacientes ficaram satisfeitos com o resultado, destes, 12 relataram estar muito melhor e 8 melhor. Dois pacientes referiram estar muito pior. Todas as cicatrizes ficaram com bom aspecto.Discussão: Comparando com a literatura, esta série de casos obteve uma baixa morbidade, boa satisfação pessoal, um bom índice de melhora da sintomatologia e de reabilitação funcional dos pacientes...

Supraclavicular decompression for neurogenic thoracic outlet syndrome; an individually tailored approach

The objective of this study was to evaluate the clinical outcome of supraclavicular decompression for thoracic outlet syndrome, and whether first rib resection is needed in all cases. 51 patients underwent 58 procedures, 7 being bilateral. There were 48 females and 3 males. The mean age was 26 years. 88% had lower plexus symptoms, and 5% had a motor deficit. The most sensitive provocative test was the plexus compression test [95%]. Through a supraclavicular approach, the plexus was explored, and the compressing agents resected. Intraoperative dynamic assessment of the plexus was an important part of the procedure. Using the Balci et al, staging system, 90% obtained a good to excellent result at latest follow up. Minimal complications were encountered in this series. In conclusion, the supraclavicular approach affords an excellent exposure of the plexus elements and its compressing agents, and allows dealing with them successfully. The extent of the decompression is individually assessed based upon the patient symptoms, the provocative positioning aggravating his symptoms, the operative findings and the intraoperative dynamic assessment of the plexus including provocative tests, and longitudinal traction of the arm. The final aim should be a plexus free of compression

Reeducation du syndrome de la traversee thoraco-brachiale. A propos de 60 malades

Sixty patients were treated by physical therapy for thoracic outlet syndrome [TOS] between 1995 and 1999. Females were predominant [76%] the average age was 34.5 years [I8 to 60]. Risk factors were hypermobility, cervical traumatism and profession. Neurological signs were predominant and positive provocation tests were found Adson [4S%], sonnette [62%], E.A.S.T. [51%]. Thoracic pain inaugurated the symptoms in 3 times pseudo-angina [2], dyspnea [1]. Radiological results were positive for cervical rib [8], apophysomegaly of C7 [25], clavicular traumatism [1]. Electromyogram was positive in 2 out of 3 patients, RMI in 2 of 4, and dynamic echo doppler in 3 of 4. After rehabilitation, immediate results were satisfactory in more than 70% of cases. After six months one patient had recurrence of symptoms, 66% were compliant with treatment, and 84% were satisfied. At one year the symptoms recurred in 2 patients, 15% were still compliant, and 81% were satisfied. Surgery was needed in 4 patients with cervical ribs

Resección transaxilar de la primera costilla en el síndrome de salida del tórax / Transaxillary resection of the first rib for treatment of the thoracic outlet syndrome

Se presentan 9 pacientes operados en el periodo comprendido entre octubre de 1993 y mayo de 1999, de los cuales 5 fueron mujeres y 4 hombres, con una edad promedio de 30 años. En 2 pacientes se encontró una costilla cervical, 2 casos correspondieron al síndrome de Paget-Schroetter, un caso presentó obstrucción de la vena subclavia sin llegar a la trombosis. En los 9 casos se manifestaron síntomas neurológicos, en 8 síntomas venosos y en un solo caso se presentó obstrucción arterial con necrosis del quinto dedo de la mano derecha. En todos los casos se realizó resección transaxilar de la primera costilla y escalenectomía. En un solo caso se presentó neumotórax resuelto con toracostomía transoperatoria. Hasta el momento no se han presentado recidivas

Síndrome de la entrada torácica / Thoracic enter syndrome

Se presenta una actualización y revisión sobre un conjunto de síndromes muy poco conocidos y de mucha importancia para la practica clínica, por las estructuras anatómicas involucradas; y por las molestias y la incapacidad funcional, que provoca en los pacientes, el cual es conocido coomo SINDROMES DEL EXTREMO SUPERIOR TORACICO (SINDROME DE LA ENTRADA TORACICA). Anatomicamente dichos síndromes se han dividido en cuatro variedades: El primero y más frecuente, es el Síndrome de la Costilla Cervical, localizado a nivel de C6-C7. El segundo, es el Síndrome del escaleno anterior, en el cual se encuentra involucrados, los tríangulos anatómicos del cuello. El tercero, es el Síndrome Costoclavicular (Síndrome de Falconer Weddell) el cual involucra y produce manifestaciones nerviosas, venosas arteriales a nivel de la primera costilla y la clavícula.- y por último el Síndrome de Hiperabducción detras del pectoral menor y por debajo de la apófisis coracoides