RESUMO
BACKGROUND: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). METHODS: We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS: Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. CONCLUSIONS: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.
Assuntos
Flebografia , Costelas , Síndrome do Desfiladeiro Torácico , Grau de Desobstrução Vascular , Humanos , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/cirurgia , Síndrome do Desfiladeiro Torácico/fisiopatologia , Feminino , Masculino , Estudos Retrospectivos , Adulto , Costelas/cirurgia , Costelas/diagnóstico por imagem , Adulto Jovem , Resultado do Tratamento , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Fatores de Tempo , Veia Subclávia/diagnóstico por imagem , Veia Subclávia/cirurgia , Veia Axilar/diagnóstico por imagem , Veia Axilar/cirurgia , Cuidados Intraoperatórios , Valor Preditivo dos Testes , Terapia Trombolítica/efeitos adversosRESUMO
Se presenta el caso clínico de un paciente de 47 años de edad, quien acudió al Servicio de Ortopedia y Traumatología del Hospital Docente Clinicoquirúrgico Joaquín Albarrán de La Habana por presentar dolor en el cuello irradiado al miembro superior izquierdo. En la exploración física se destacó atrofia de los músculos romboides de la escápula izquierda y deformidad alar, acentuada durante la maniobra. Se realizó radiografía y electromiografía; en la primera, se observó costilla cervical supernumeraria izquierda y, en la segunda, lesión del nervio dorsal escapular, por lo cual se diagnosticó síndrome del nervio dorsal escapular secundario a síndrome del escaleno anterior. Se indicó tratamiento fisioterapéutico y el paciente evolucionó satisfactoriamente.
The case report of a 47 years patient is presented, who went to the Orthopedics and Traumatology Service of Joaquín Albarrán Teaching Clinical Surgical Hospital in Havana due to a pain in the neck irradiated to the left superior member. In the physical exploration atrophy of the left scapula romboid muscles and alar deformity were notable, accented during the maneuver. Radiography and electromyography were carried out; in the first one, left supernumerary cervical rib was observed and, in the second one, dorsalscapular nerve leison, reason why the secondary dorsal scapular nerve syndrome to anterior scalene syndrome was diagnosed. Physiotherapeutic treatment was indicated and the patient had a favorable clinical course.
Assuntos
Síndrome do Desfiladeiro Torácico , Costela Cervical , EscápulaRESUMO
Introducción: El síndrome de la salida torácica abarca diversos trastornos, que se producen como consecuencia de la compresión intermitente o persistente de los distintos elementos que salen del tórax hacia el brazo y ocasionan síntomas vasculares, neurológicos o combinados, los cuales frecuentemente tienen una indicación quirúrgica para su resolución. Objetivo: Evaluar los resultados de diez años de experiencia del tratamiento quirúrgico del síndrome de la salida torácica en los pacientes intervenidos en el Hospital General Docente "Dr. Agostinho Neto", de Guantánamo. Métodos: Se realizó un estudio retrospectivo de corte transversal en pacientes diagnosticados en el servicio de Angiología y Cirugía Vascular del Hospital General Docente "Dr. Agostinho Neto", de Guantánamo, con el síndrome de la salida torácica, los cuales se sometieron a tratamiento quirúrgico en el período 2009-2019. Se evaluaron las siguientes variables: edad, sexo, síndromes diagnosticados, técnicas quirúrgicas, complicaciones, y sintomatología antes y después de la cirugía. Resultados: Predominó el sexo femenino, fundamentalmente entre 40 y 50 años. El dolor fue el síntoma predominante y el síndrome más diagnosticado resultó el costo-clavicular. Se destacó como la técnica quirúrgica más empleada la desinserción del escaleno anterior, seguida por la resección de la primera costilla. La lesión pleural y neural aparecieron como las complicaciones más frecuentes. Se constató la mejoría clínica de los pacientes luego de la intervención quirúrgica en la mayoría de los casos. Conclusiones: Se demostró que el tratamiento quirúrgico del síndrome de la salida torácica puede ser una alternativa efectiva para los pacientes aquejados por esta entidad(AU)
Introduction: Thoracic outlet syndrome covers various disorders, which occur as a result of intermittent or persistent compression of the different elements that leave the chest to the arm and cause vascular, neurological or combined symptoms, which often have a surgical indication for their resolution. Objective: Assess the results of ten years of experience in the surgical treatment of thoracic outlet syndrome in patients operated on at "Dr. Agostinho Neto" General Teaching Hospital in Guantánamo. Methods: A retrospective cross-sectional study was conducted in patients diagnosed with thoracic outlet syndrome in the Angiology and Vascular Surgery Service of "Dr. Agostinho Neto" General Teaching Hospital, Guantánamo , who underwent surgical treatment in the period 2009-2019. The following variables were evaluated: age, sex, diagnosed syndromes, surgical techniques, complications, and symptoms before and after surgery. Results: The female sex predominated, mainly in the ages from 40 to 50. Pain was the predominant symptom, and the costo-clavicular syndrome turned out to be the most diagnosed one. The most used surgical technique was the disinsertion of the anterior scalene, followed by the resection of the first rib. Pleural and neural injury appeared as the most frequent complications. The clinical improvement of patients after surgical intervention was found in most cases. Conclusions: It was demonstrated that surgical treatment of thoracic outlet syndrome can be an effective alternative for patients suffering from this entity(AU)
Assuntos
Humanos , Feminino , Adulto , Síndrome do Desfiladeiro Torácico/cirurgia , Procedimentos Cirúrgicos Vasculares , Dor , Procedimentos Cirúrgicos Operatórios , Estudos TransversaisRESUMO
BACKGROUND: True neurogenic thoracic outlet syndrome (TNTOS) is rare, and evaluation of surgical treatment is limited to a few studies in the literature. The purpose of this study is to present the results from a surgical series of 21 patients with TNTOS. METHODS: Retrospective analysis on 21 patients diagnosed with TNTOS who underwent surgery. Demographic data and neurological status were characterized, and patients were classified in accordance with a pre-established scale for assessing the severity of hand impairment before and after surgery. Neuropathic pain was assessed using a visual analogue scale (VAS) and functional disability was quantified using the QuickDASH questionnaire. The results from before and after surgery were compared using the Wilcoxon test, and the significance level was taken to be 5%. RESULTS: There was a significant difference in VAS values from before to after the operation (Wilcoxon test: p = 0.0001; r = 0.86). Most patients (90%) improved after surgery, and in 85% of these patients, the VAS improvement was greater than 50%. Improvement in hand function occurred in seven patients (33.3%), and in most of these cases (28.6%), this improvement was classified as mild. Most patients (93.3%) showed moderate to very severe functional disability at the end of the follow-up. CONCLUSION: After surgery, only one-third of the cases showed improvement in motor function and most patients had significant functional disability. However, the improvement regarding pain was significant. Surgery to control this symptom should be recommended, even in cases of late presentation and severe motor impairment.
Assuntos
Síndrome do Desfiladeiro Torácico , Descompressão Cirúrgica/métodos , Mãos/cirurgia , Humanos , Estudos Retrospectivos , Síndrome do Desfiladeiro Torácico/diagnóstico , Síndrome do Desfiladeiro Torácico/cirurgia , Resultado do Tratamento , Extremidade Superior/cirurgiaAssuntos
Anormalidades Musculoesqueléticas , Costelas , Síndrome do Desfiladeiro Torácico , Descompressão Cirúrgica , Humanos , Anormalidades Musculoesqueléticas/complicações , Costelas/anormalidades , Costelas/diagnóstico por imagem , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: The cervical rib can be a rare finding in asymptomatic subjects. When it produces compression, it affects variably the vasculo-nervous structures of the brachial plexus; the clinical history is progressive. The imaging studies indicate the site of osteo-neuro-vascular conflict and electrophysiological studies indicate the degree of neural involvement. CASE REPORT: We present a patient with an eight-month history of paresis and right dysesthesias, with an image of bilateral cervical ribs with different anatomical characteristics. This case discusses how a variant of the anatomy produces pathology and when it is not related to compression.
ANTECEDENTES: La costilla cervical puede ser un raro hallazgo en sujetos asintomáticos. Cuando produce compresión, afecta variablemente a las estructuras vasculonerviosas del plexo braquial. El cuadro clínico es progresivo. Los estudios de imagen indican el sitio de conflicto osteoneurovascular, y los electrofisiológicos, el grado de afección neural. CASO CLÍNICO: Presentamos un paciente con historia de 8 meses de paresia y disestesias derechas, con imagen de costillas cervicales bilaterales con diferentes características anatómicas. Con este caso se discute cómo una variante de la anatomía produce patología y cuando no está relacionada a compresión.
Assuntos
Plexo Braquial , Costela Cervical , Síndrome do Desfiladeiro Torácico , Costela Cervical/diagnóstico por imagem , Costela Cervical/cirurgia , Humanos , Pressão , Síndrome do Desfiladeiro Torácico/complicações , Síndrome do Desfiladeiro Torácico/diagnóstico por imagemRESUMO
Introducción: El Síndrome del Desfiladero Torácico lo conforma una serie de síntomas y signos causados por la compresión de las estructuras neurovasculares en su salida por el desfiladero torácico a nivel supraclavicular.2 Dependiendo de la estructura afectada se habla de Síndrome del Desfiladero Torácico Neurológico, cuando la compresión es neurológica, SDTA cuando es arterial y SDTV cuando la compresión es venosa.3La presentación en la infancia es excepcional y la aparición con déficits motores se presenta en uno entre un millón de casos.1-6Los síntomas de dolor, debilidad y parestesias en la mano son orientativos y obligan a descartar esta entidad, así como signos clínicos de atrofia de musculatura son indicativos de la cronicidad.Los estudios preoperatorios como la electromiografía, RMN y angiografía asociada a RMN y pruebas dinámicas contribuyen al diagnóstico de esta entidad.7 La resección de la primera costilla y la escalenotomía es el procedimiento quirúrgico habitual en estos casos.8Presentamos el caso de una niña de 8 años que inicia sintomatología coincidiendo con la toma de biopsia a nivel supraclavicular en estudio de tumoración.
Introduction: The Thoracic Outlet Syndrome (TOS) conforms series of symptoms and signs caused by a compression of the neurovascular structures in the output thoracic pass at supraclavicluar level2. Depending on the affected structure, the syndrome can be Nerve Thoracic Outlet Syndrome (NTOS), Arterial Thoracic Outlet Syndrome (ATOS) or Venous Thoracic Outlet Syndrome (VTOS).3 The presentation in childhood is exceptional and the appearance with motor deficits occurs in one in a million cases.1The main clinical signs of TOS in adults include ip-silateral upper limb pain and discomfort, weakness, cold intolerance, and numbness of the hand. During physical examination, the muscles of the ipsilateral limb are relatively weak, and anesthesia, or pinprick sensation without pain is present on the inner sur- face of the hand and forearm. Thenar and hypothenar muscle atrophy may also be seen.In contrast, in children and teenagers, TOS usually presents as neck discomfort, upper limb numbness, weakness, and sensory loss.9We present the case of an 8-years-old girl started symptomatology coinciding with a biopsy taken for supraclavicular tumor at this level.
Assuntos
Feminino , Criança , Síndrome do Desfiladeiro Torácico , Artéria Subclávia , Procedimentos Cirúrgicos Operatórios , Plexo BraquialRESUMO
Resumo A forma arterial da síndrome do desfiladeiro torácico é rara e está associada a uma anomalia anatômica, geralmente uma costela cervical. Suas manifestações são muito variadas. Este artigo tem como proposta relatar dois casos de apresentações clínicas distintas: microembolização e aneurisma. Em ambos, uma costela cervical estava presente. O diagnóstico foi realizado através da história, do exame físico, das manobras posturais e das radiografias. A angiotomografia computadorizada proporcionou o detalhe anatômico necessário para o planejamento operatório. O tratamento cirúrgico foi realizado pela abordagem supraclavicular, com sucesso em ambos casos.
Abstract The arterial form of thoracic outlet syndrome is rare and is associated with anatomic anomalies, generally a cervical rib. It has a varied range of manifestations. The aim of this article is to describe two cases with different clinical presentations: microembolization and aneurysm. A cervical rib was present in both cases. Diagnosis was made on the basis of history, physical examination, postural maneuvers, and X-rays. Computed tomography angiography provided the anatomic detail necessary to plan surgery. Surgical treatment was performed via supraclavicular access, successfully, in both cases.
Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Síndrome do Desfiladeiro Torácico/cirurgia , Costela Cervical/fisiopatologia , Artéria Subclávia , Síndrome do Desfiladeiro Torácico/diagnóstico , Descompressão Cirúrgica , Angiografia por Tomografia ComputadorizadaRESUMO
BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.
Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/anormalidades , Descompressão Cirúrgica/efeitos adversos , Traumatismos dos Nervos Periféricos/etiologia , Nervo Frênico/anormalidades , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Humanos , Masculino , Maryland , Traumatismos dos Nervos Periféricos/fisiopatologia , Philadelphia , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Resultado do TratamentoRESUMO
The Thoracic Outlet Syndrome (TOS) results from compression of the brachial plexus, the subclavian artery and the subclavian vein in the thoracic outlet region. This compression may take place between the clavicle and the first rib or by a number of anatomical variations. Neurological compression is the most common form of thoracic outlet syndrome. Vascular complications occur infrequently. Arterial complications usually result from compression of the subclavian artery by a complete cervical rib. Venous complications are often related to muscle compression of the subclavian vein. The neurogenic form, previously described, is the most common, constituting more than 95% of cases, while the venous represents 2% to 3%, and the arterial, about 1%. Risk factors include biotype and individual variations such as genetics, age and gender. In Brazil, there are no data on the epidemiology of TOS. Given the suspicion of TOS, a detailed clinical evaluation is necessary, followed by complementary exams to elucidate the cause. The treatment is directed according to the etiology and the presence or absence of complications. The purpose of this study was to perform a narrative review on TOS, focusing on its etiology, pathophysiology, epidemiology, clinical evaluation, complementary exams, differential diagnoses, and treatment.
A Síndrome do Desfiladeiro Torácico (SDT) é causada pela compressão do plexo braquial, artéria subclávia e veia subclávia na região do desfiladeiro torácico. Estas estruturas podem ser comprimidas entre a clavícula e a primeira costela ou por um número de variações anatômicas. A compressão neurológica é a forma mais comum da síndrome do desfiladeiro torácico. Complicações vasculares ocorrem com pouca frequência. Complicações arteriais geralmente resultam da compressão da artéria subclávia por costela cervical completa. As complicações venosas estão muitas vezes relacionadas à compressão muscular da veia subclávia. A forma neurogênica, anteriormente descrita, é a mais comum, constituindo mais de 95% dos casos. Já a forma venosa representa 2% a 3% e, a arterial, cerca de 1% dos casos. Fatores de risco incluem biótipo e variações individuais, como genética, idade e sexo. No Brasil, não há dados acerca da epidemiologia da SDT. Diante da suspeita de SDT é necessária uma avaliação clínica detalhada, seguida de exames complementares para elucidação da causa. O tratamento é direcionado de acordo com a etiologia e a presença ou não de complicações. A proposta do presente trabalho foi realizar uma revisão narrativa sobre a SDT, versando sobre sua etiologia, fisiopatologia, epidemiologia, avaliação clínica, exames complementares, diagnósticos diferenciais e tratamento.
Assuntos
Síndrome do Desfiladeiro Torácico , Diagnóstico Diferencial , Humanos , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/fisiopatologia , Síndrome do Desfiladeiro Torácico/terapiaRESUMO
The cervical rib (CR) is a rare skeletal anomaly, which generally articulated with the transverse process of the 7th cervical vertebra, and commonly lead to compression of neurovascular structures in the region of the thoracic outlet. CRs are divided into 2 classes as complete and incomplete forms. A clarifying description of the so-called complete CR form has not been found with sufficient information in the literature. We aimed to present a novel case of an anomalous, supernumerary, extra, or additional rib which arises from the seventh cervical vertebra. We present the case of a 23-year-old female who presented with a mass described as slowgrowing since her childhood in the supraclavicular region. The patient complained of pain, numbness, weakness, and difficulty in lifting her right arm, which increased gradually over in the last 6 months. Physical examination revealed findings of thoracic outlet syndrome (TOS). Radiographic analysis demonstrated a huge cervical rib, which resembles the size of a real thoracic rib. The cervical rib was completely resected through the supraclavicular approach. There is not enough data in theliterature about different morphologic properties of CRs. It is presented with 3-D CT images before and after surgical resection. The final version of the transformation of C7 transverse process to an original Thoracic Rib is shown. As a result, the following question presented, can it be called a Zeroth Rib?.
La costilla cervical (CC) es una anomalía esquelética rara, que generalmente se articula con el proceso transverso de la séptima vértebra cervical y generalmente conduce a la compresión de estructuras neurovasculares en la región de salida torácica. Las CC se dividen en 2 clases, como formas completas e incompletas. No se ha encontrado una descripción aclaratoria de la forma completa de CC, con información insuficiente en la literatura. El objetivo de este trabajo fue presentar un nuevo caso de costilla anómala, supernumeraria, extra o adicional que surge de la séptima vértebra cervical. Exponemos el caso de una mujer de 23 años que presentó una masa descrita como de crecimiento lento desde su infancia en la región supraclavicular. La paciente relató dolor, entumecimiento, debilidad y dificultad para levantar el miembro superior derecho, con un aumento gradual de sus síntomas en los últimos 6 meses. El examen físico reveló hallazgos del síndrome de salida torácica (SST). El análisis radiográfico demostró una costilla cervical de tamaño importante, que se asemejaba al tamaño de una costilla torácica real. La costilla cervical fue resecada completamente a través de un abordaje supraclavicular. No hay suficientes datos en la literatura sobre las diferentes características morfológicas de las CC. Se presentan imágenes tridimensionales de tomogracía computarizada, antes y después de la resección quirúrgica. Se muestra la versión final de la transformación del proceso transverso de C7 a una costilla torácica original. Como resultado, se plantea la siguiente pregunta, ¿se puede denominar a esta costilla como "costilla cero"?.
Assuntos
Humanos , Feminino , Adulto Jovem , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Costela Cervical/cirurgia , Costela Cervical/diagnóstico por imagem , Costelas/anormalidadesRESUMO
OBJECTIVE: A clinical, placebo-controlled, randomized, double-blind trial with two parallel groups. OBJECTIVE: to evaluate the efficacy of ropivacaine injection in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome (TOS) compared to cutaneous pressure. METHODS: 38 patients, 19 in the control group (skin pressure in each belly of the anterior and middle scalene muscles) and 19 in the intervention group (ropivacaine). Subjects with a diagnosis of Nonspecific Thoracic Outlet Syndrome, pain in upper limbs and/or neck, with no radiculopathy or neurological involvement of the limb affected due to compressive or encephalic root causes were included. The primary endpoint was functionality, evaluated by the Disabilities of the Arm, Shoulder, and Hand - DASH scale validated for use in Brasil. The time of the evaluations were T0 = before the intervention; T1 = immediately after; T2 = 1 week; T3 = 4 weeks; T4 = 12 weeks; for T1, the DASH scale was not applied. RESULTS: Concerning the DASH scale, it is possible to affirm with statistical significance (p> 0.05) that the intervention group presented an improvement of functionality at four weeks, which was maintained by the 12th week. CONCLUSION: In practical terms, we concluded that a 0.375% injection of ropivacaine at doses of 2.5 ml in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome helps to improve function.
Assuntos
Anestésicos Locais/administração & dosagem , Injeções Intramusculares/métodos , Músculos do Pescoço/efeitos dos fármacos , Ropivacaina/administração & dosagem , Síndrome do Desfiladeiro Torácico/tratamento farmacológico , Ultrassonografia de Intervenção/métodos , Método Duplo-Cego , Feminino , Humanos , Masculino , Fatores de Tempo , Resultado do TratamentoRESUMO
SUMMARY A clinical, placebo-controlled, randomized, double-blind trial with two parallel groups. OBJECTIVE to evaluate the efficacy of ropivacaine injection in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome (TOS) compared to cutaneous pressure. METHODS 38 patients, 19 in the control group (skin pressure in each belly of the anterior and middle scalene muscles) and 19 in the intervention group (ropivacaine). Subjects with a diagnosis of Nonspecific Thoracic Outlet Syndrome, pain in upper limbs and/or neck, with no radiculopathy or neurological involvement of the limb affected due to compressive or encephalic root causes were included. The primary endpoint was functionality, evaluated by the Disabilities of the Arm, Shoulder, and Hand - DASH scale validated for use in Brasil. The time of the evaluations were T0 = before the intervention; T1 = immediately after; T2 = 1 week; T3 = 4 weeks; T4 = 12 weeks; for T1, the DASH scale was not applied. RESULTS Concerning the DASH scale, it is possible to affirm with statistical significance (p> 0.05) that the intervention group presented an improvement of functionality at four weeks, which was maintained by the 12th week. CONCLUSION In practical terms, we concluded that a 0.375% injection of ropivacaine at doses of 2.5 ml in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome helps to improve function.
RESUMO Ensaio clínico, controlado por placebo, aleatorizado, duplo-cego, com dois braços paralelos. OBJETIVO Avaliar a eficácia da injeção de ropivacaína em cada ventre dos músculos escalenos anterior e médio, guiada por ultrassonografia, no tratamento da Síndrome do Desfiladeiro Torácico Neurogênico inespecífico comparado com o toque cutâneo. MÉTODOS Trinta e oito pacientes, sendo 19 no grupo controle (toque cutâneo em cada ventre dos músculos escalenos anterior e médio) e 19 no grupo intervenção (ropivacaína). Foram incluídos sujeitos com diagnóstico de Síndrome do Desfiladeiro Torácico Neurogênico inespecífico com dor em membros superiores e/ou cervicalgia sem radiculopatia ou comprometimento neurológico do membro em questão por causas radiculares compressivas ou encefálicas. O desfecho primário foi a funcionalidade avaliada pela escala Disabilitie of the Arm, Shoulder and Hand - Dash, validada no Brasil. O tempo das avaliações foram T0 = antes da intervenção; T1 = imediatamente após, T2 = 1 semana, T3 = 4 semanas e T4 = 12 semanas, sendo que para o T1 não foi aplicado o Dash. RESULTADOS Com relação ao Dash, de forma estatisticamente significante (p>0,05), é possível afirmar que o grupo intervenção apresentou melhora da funcionalidade a partir de quatro semanas, e essa melhora se manteve até a 12a semana. CONCLUSÃO Em termos práticos, conclui-se que a injeção de ropivacaína 0,375% nas doses de 2,5 ml em cada ventre dos músculos escalenos anterior e médio, guiada por ultrassonografia, no tratamento da Síndrome do Desfiladeiro Torácico Neurogênico inespecífico auxilia na melhora da função.
Assuntos
Humanos , Masculino , Feminino , Síndrome do Desfiladeiro Torácico/tratamento farmacológico , Ultrassonografia de Intervenção/métodos , Ropivacaina/administração & dosagem , Injeções Intramusculares/métodos , Anestésicos Locais/administração & dosagem , Músculos do Pescoço/efeitos dos fármacos , Fatores de Tempo , Método Duplo-Cego , Resultado do TratamentoRESUMO
ABSTRACT: Metastatic spread of cancer via the thoracic duct may lead to an enlargement of the left supraclavicular node, known as the Virchow node (VN), leading to an appreciable mass that can be recognized clinically a Troisier sign. The VN is of profound clinical importance; however, there have been few studies of its regional anatomical relationships. Our report presents a case of a Troisier sign/VN discovered during cadaveric dissection in an individual whose cause of death was, reportedly, chronic obstructive pulmonary disease. The VN was found to arise from an antecedent pulmonary adenocarcinoma. Our report includes a regional study of the anatomy as well as relevant gross pathology and histopathology. Our anatomical findings suggest that the VN may contribute to vascular thoracic outlet syndrome as well as the brachial plexopathy of neurogenic thoracic outlet syndrome. Further, the VN has the potential to cause compression of the phrenic nerve, contributing to unilateral phrenic neuropathy and subsequent dyspnea. Recognition of the Troisier sign/VN is of great clinical importance. Similarly, an appreciation of the anatomy surrounding the VN, and the potential for the enlarged node to encroach on neurovascular structures, is also important in the study of a patient. The presence of a Troisier sign/VN should be assessed when thoracic outlet syndrome and phrenic neuropathy are suspected. Conversely, when a VN is identified, the possibility of concomitant or subsequent thoracic outlet syndrome and phrenic neuropathy should be considered.
Assuntos
Humanos , Feminino , Idoso , Nervo Frênico , Síndrome do Desfiladeiro Torácico/etiologia , Adenocarcinoma , Doenças do Sistema Nervoso Periférico/etiologia , Neoplasias Pulmonares , Linfonodos/patologia , Autopsia , Síndrome do Desfiladeiro Torácico/patologia , Evolução Fatal , Doenças do Sistema Nervoso Periférico/patologiaRESUMO
RESUMO A Síndrome do Desfiladeiro Torácico (SDT) é causada pela compressão do plexo braquial, artéria subclávia e veia subclávia na região do desfiladeiro torácico. Estas estruturas podem ser comprimidas entre a clavícula e a primeira costela ou por um número de variações anatômicas. A compressão neurológica é a forma mais comum da síndrome do desfiladeiro torácico. Complicações vasculares ocorrem com pouca frequência. Complicações arteriais geralmente resultam da compressão da artéria subclávia por costela cervical completa. As complicações venosas estão muitas vezes relacionadas à compressão muscular da veia subclávia. A forma neurogênica, anteriormente descrita, é a mais comum, constituindo mais de 95% dos casos. Já a forma venosa representa 2% a 3% e, a arterial, cerca de 1% dos casos. Fatores de risco incluem biótipo e variações individuais, como genética, idade e sexo. No Brasil, não há dados acerca da epidemiologia da SDT. Diante da suspeita de SDT é necessária uma avaliação clínica detalhada, seguida de exames complementares para elucidação da causa. O tratamento é direcionado de acordo com a etiologia e a presença ou não de complicações. A proposta do presente trabalho foi realizar uma revisão narrativa sobre a SDT, versando sobre sua etiologia, fisiopatologia, epidemiologia, avaliação clínica, exames complementares, diagnósticos diferenciais e tratamento.
ABSTRACT The Thoracic Outlet Syndrome (TOS) results from compression of the brachial plexus, the subclavian artery and the subclavian vein in the thoracic outlet region. This compression may take place between the clavicle and the first rib or by a number of anatomical variations. Neurological compression is the most common form of thoracic outlet syndrome. Vascular complications occur infrequently. Arterial complications usually result from compression of the subclavian artery by a complete cervical rib. Venous complications are often related to muscle compression of the subclavian vein. The neurogenic form, previously described, is the most common, constituting more than 95% of cases, while the venous represents 2% to 3%, and the arterial, about 1%. Risk factors include biotype and individual variations such as genetics, age and gender. In Brazil, there are no data on the epidemiology of TOS. Given the suspicion of TOS, a detailed clinical evaluation is necessary, followed by complementary exams to elucidate the cause. The treatment is directed according to the etiology and the presence or absence of complications. The purpose of this study was to perform a narrative review on TOS, focusing on its etiology, pathophysiology, epidemiology, clinical evaluation, complementary exams, differential diagnoses, and treatment.
Assuntos
Humanos , Síndrome do Desfiladeiro Torácico/diagnóstico , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/fisiopatologia , Síndrome do Desfiladeiro Torácico/terapia , Fatores de Risco , Diagnóstico DiferencialRESUMO
A compressão da artéria subclávia no desfiladeiro torácico é um fenômeno amplamente conhecido. Anormalidades ósseas, como a pseudoartrose da clavícula, podem raramente causar compressão arterial a esse nível. A pseudoartrose pode desenvolver-se em decorrência de um trauma, que é a forma mais comum, ou ser congênita. Os autores descrevem o caso de uma paciente de 44 anos com quadro de isquemia crítica de membro superior direito. Apresentava história de fratura não tratada de clavícula direita aos 9 meses de idade que evoluiu com pseudoartrose e compressão extrínseca com oclusão da artéria subclávia. O segmento da clavicula acometido pela pseudoartrose foi ressecado e realizada uma tromboembolectomia tardia das artérias subclávia, braquial e distais, com boa evolução.
Compression of the subclavian artery in the thoracic outlet is a well-known phenomenon. In rare cases, bone abnormalities, such as pseudarthrosis of the clavicle, can cause arterial compression at this level. Pseudarthrosis may develop as a result of trauma, which is the more common form, or it may be congenital. Here, the authors describe the case of a 44-year-old patient with critical ischemia of the right upper limb. She had a history of untreated right clavicle fracture at 9 months of age which had progressed to pseudarthrosis and extrinsic compression of the subclavian artery causing occlusion. The segment of the clavicle involved was resected and late thromboembolectomy of the subclavian, brachial, distal arteries was performed, with good results.
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Clavícula/anormalidades , Pseudoartrose/patologia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/reabilitação , Extremidade Superior/patologia , Artéria Subclávia/anatomia & histologia , Fatores de Tempo , Varfarina/administração & dosagemRESUMO
Purpose To evaluate the quality of life of patients with neurogenic thoracic outlet syndrome (N-TOS) who underwent surgery via the supraclavicular approach. Method Sociodemographic and clinical data were collected, and an evaluation of the pain and quality of life of 29 patients was performed. Results The average age of the patients was 42 years, and most of them were female. All of them had one or more associated pathologies. They all worked in occupations that involved repetitive movement of the upper limbs. The evaluation of the degree of pain showed that the pain remains preponderant and incapacitating in the life of these individuals, who consequently enjoy a low quality of life. Conclusion These patients presented low quality of life, with persistent pain probably resulting from the associated pathologies, in addition to their psychosocial context. Thus, in order to treat the TOS, an intervention of a multidisciplinary team with a holistic view of the patient is required.
Objetivo Avaliar a qualidade de vida de pacientes com síndrome do desfiladeiro torácico (SDT) do tipo neurogênico submetidos a cirurgia por via supraclavicular. Metodologia Foram coletados dados sociodemográficos e clínicos, e foram avaliadas a dor e a qualidade de vida de 29 pacientes. Resultados Os pacientes tinham idade média de 42 anos, sendo a maioria do sexo feminino, e todos com uma ou mais patologias associadas. Todas as ocupações profissionais exercidas envolviam movimentos repetitivos de membros superiores. A avaliação do quadro álgico evidenciou que a dor ainda permanece preponderante e incapacitante na vida desses indivíduos, que, consequentemente, apresentam baixa qualidade de vida. Conclusão Estes pacientes apresentaram baixa qualidade de vida, com persistência da dor, provavelmente em decorrência das patologias associadas, além do contexto psicossocial. Desse modo, para o tratamento da SDT, faz-se necessária a intervenção de uma equipe multidisciplinar com visão holística do paciente.
Assuntos
Humanos , Masculino , Feminino , Síndrome do Desfiladeiro Torácico , Dor Crônica , Qualidade de Vida , Transtornos Traumáticos CumulativosRESUMO
SUMMARY: During routine anatomical dissection of the left supraclavicular and infraclavicular regions of a male cadaver, a supernumerary muscle was observed, which, by its position and insertions, consistent with the subclavius posticus muscle (posterior subclavius muscle). It had its anterior insertion by a thin tendon in the cranial surface of the first costal cartilage next to the subclavius muscle's insertion, and ran dorso-laterally crossing over the brachial plexus and subclavian vessels to end on the posterior surface of the serratus anterior muscle's fascia near to the superior margin of the scapula, without taking insertion on it, which differentiates it from the muscles described in the bibliography. This aberrant muscle has clinical implication since it has been described as a cause of thoracic outlet syndrome and it may appear in diagnostic imaging techniques simulating different pathological processes.
RESUMEN: Durante una disección de rutina de las regiones supraclavicular e infraclavicular izquierdas de un cadáver masculino, observamos un músculo supernumerario, el cual según su ubicación, origen e inserción, se corresponde con la descripción del músculo subclavius posticus (subclavio posterior). Presenta su inserción anterior mediante un delgado tendón en la cara superior del primer cartílago costal, a un lado de la inserción del músculo subclavio, y corre hacia posterior y lateral, cruzando por encima de los troncos del plexo braquial y los vasos subclavios para terminar en la superficie posterior de la fascia del músculo serrato anterior, cerca del margen superior de la escápula, sin prestar inserción en él, lo cual lo diferencia de los músculos descritos en la bibliografía. Este músculo tiene implicancia clínica debido a que ha sido descrito como causa del síndrome del estrecho superior torácico, y puede aparecer simulando procesos patológicos en estudios por imágenes.
Assuntos
Humanos , Masculino , Adulto , Variação Anatômica , Músculo Esquelético/anormalidades , Síndrome do Desfiladeiro Torácico , CadáverRESUMO
ABSTRACT OBJECTIVE: To assess the anatomical variations of the pronator teres muscle (PTM) and its implication in the compression of the median nerve, which passes through the humeral and ulnar heads of the PTM. METHODS: For the present study, 100 upper limbs from human cadavers from the anatomy laboratory were dissected. Forty-six specimens were male and four, female, whose aged ranged from 28 to 77 years; 27 were white and 23, non-white. A pilot study consisting of six hands from three fresh cadaver dissections was conducted to familiarize the authors with the local anatomy; these were not included in the present study. RESULTS: The humeral and ulnar heads of PTM were present in 86 limbs. In 72 out of the 86 limbs, the median nerve was positioned between the two heads of the PTM; in 11, it passed through the muscle belly of ulnar head of the PTM, and in three, posteriorly to both heads of the PTM. When both heads were present, the median nerve was not observed as passing through the muscle belly of the humeral head of PTM. In 14 out of the 100 dissected limbs, the ulnar head of the PTM was not observed; in this situation, the median nerve was positioned posteriorly to the humeral head in 11 limbs, and passed through the humeral head in three. In 17 limbs, the ulnar head of PTM was little developed, with a fibrous band originating from the ulnar coronoid process, associated with a distal muscle component near the union with the humeral head. In four limbs, the ulnar head of the MPR was represented by a fibrous band. In both limbs of one cadaver, a fibrous band was observed between the supinator muscle and the humeral head of the PTM, passing over median nerve. CONCLUSION: The results suggest that these anatomical variations in relationship median nerve and PTM are potential factors for median nerve compression, as they narrow the space through which the median nerve passes.
RESUMO OBJETIVO: Analisar as variações anatômicas do músculo pronador redondo (MPR) e suas implicações na compressão do nervo mediano, que passa entre as cabeças umeral e ulnar do MPR. MÉTODO: Foram dissecados 100 membros superiores de cadáveres adultos pertencentes ao laboratório de anatomia; 46 cadáveres eram do sexo masculino e quatro do feminino. A idade variou entre 28 e 77 anos; 27 eram da etnia branca e 23, não branca. Um estudo piloto que incluiu três cadáveres frescos foi feito, para familiarização dos autores com a anatomia regional. Esses não foram incluídos no estudo. RESULTADOS: Em 86 membros, observou-se a presença das cabeças umeral e ulnar do MPR. Em 72 dos 86 membros, o nervo mediano estava posicionado entre as cabeças umeral e ulnar do MPR; em 11, esse encontrava-se através da massa muscular da cabeça ulnar do MPR e em três, o nervo mediano estava posicionado posteriormente às duas cabeças do MPR. Nos casos em que as duas cabeças do músculo estavam presentes, não se observou o nervo mediano passando através da massa muscular da cabeça umeral do MPR. Em 14 dos 100 membros dissecados, a cabeça ulnar do MPR não estava presente. Nessa situação, o nervo mediano posicionava-se posteriormente à cabeça umeral em 11 membros e através da cabeça umeral em três membros. Em 17 membros, a cabeça ulnar estava muito pouco desenvolvida, com conformação fibrosa em sua origem no processo coronoide da ulna, associada a um componente muscular distal, próximo a sua união com a cabeça umeral. Em quatro membros, a cabeça ulnar do MPR estava representada apenas por uma banda fibrosa. Nos dois membros de um cadáver, observou-se uma expansão fibrosa que saía do músculo supinador para a cabeça umeral do MPR, passando como uma cinta sobre o nervo mediano. CONCLUSÕES: Esses resultados sugerem que as variações anatômicas na relação nervo mediano e MPR representam fatores potenciais para compressão nervosa, por estreitar o espaço no qual passa o nervo mediano.
Assuntos
Adulto , Pessoa de Meia-Idade , Idoso , Cadáver , Nervo Mediano , Pronação , Síndrome do Desfiladeiro TorácicoRESUMO
BACKGROUND: Transaxillary approach to first rib resection and scalenectomy (TAFRRS) is a well-established technique for treatment of thoracic outlet syndrome (TOS). Although anatomic features encountered during TAFRRS are in general constant, vascular anomalies may be encountered but have not been described to date. Herein we describe vascular abnormalities encountered during TAFRRS. METHODS: We performed a retrospective review of a prospective practice database of 224 operations for TOS performed in 172 patients from March 2000 to March 2014. We excluded 10 patients with missing operative reports, 3 reoperations on the same patient, and 8 non-transaxillary resections. We recorded vascular anomalies identified in operative reports and reviewed computed tomography imaging to delineate the nature of these abnormalities. RESULTS: The overall incidence of vascular anomalies was 11% (22 of 203 TAFRRS). Most patients with anomalies had venous TOS (vTOS) (9 patients, 41%), followed by 7 (32%) with neurogenic TOS (nTOS). The remainder of the patients had arterial TOS (aTOS) (6 patients, 27%). Seven patients (32%) had an abnormal subclavian artery (SCA) with 5 (23%) having an abnormal arterial course in the anterior scalene muscle (ASM); 6 patients (27%) had an abnormal internal mammary artery (IMA) originating from distal SCA; 4 (18%) had abnormalities in the supreme thoracic artery (bifurcation or duplication); 2 (9%) had an abnormal branch from the SCA with anomalous location in the operative field; and 3 (14%) had an abnormal large venous branch penetrating the ASM. In the 19 patients with arterial anomalies, 8 (42%) were recognized as arterial branches penetrating the ASM, and 11 (58%) were noticed as they had anomalous arterial locations within the operative field. Most arterial anomalies were seen in vTOS (9, 45%), followed by nTOS (7, 35%). No intraoperative vascular complications occurred. Perioperative complications included 1 occurrence of postoperative transfusion for bleeding following axillary drain discontinuation and 2 Horner's syndromes. One aberrant IMA was electively ligated to allow complete thoracic outlet decompression. CONCLUSIONS: Arterial anomalies during TAFRRS are encountered in 11% of operations, and may present with vessel locations in unusual areas within the operative field, or as abnormal vessels penetrating the ASM, thus making scalenectomy precarious. Careful attention must be paid to possible abnormal locations of vessels in the thoracic outlet to avoid bleeding complications.