Reoperation for rib-lock syndrome recurrence

Definition Thoracic outlet syndrome is a series of symptoms and signs of subclavian and brachial plexus compression at the thoracic entrance. 2. Anatomy The subclavian vessels and brachial plexus reach the upper limbs through the cervical collar. The proximal segment of the cervical sacral canal is the oblique muscle triangle and the rib lock gap, and the distal segment is the sacral segment, and the boundary is the outer edge of the first rib. The upper segment of the proximal segment of the cervical canal is the clavicle and subclavian muscle; the lower boundary is the first rib; the anterior medial border is the sternal border, the thoracic fascia and the rib sacral ligament; the posterolateral border is the middle scalene and chest length nerve. The anterior scalene muscle is inserted into the scalene nodules attached to the first rib, and the rib lock gap is divided into two parts, the subclavian vein is inside the anterior portion, and the subclavian artery and brachial plexus are inside the posterior part. The distal segment is a fistula, and the anatomical structure has a small chest muscle, a condyle, and a humeral head. This area is also a potential area for neurovascular compression. Thoracic outlet syndrome neurovascular compression often occurs in the proximal segment of the cervical sacral canal. 3. Causes Congenital or traumatic factors lead to anatomical abnormalities or arteriosclerosis. Common compression factors include cervical ribs, first ribs, anterior scalene muscles, clavicle, and hardened arteries. The neck rib is a common cause, starting from the 7th cervical vertebra, and the free end is between the anterior and middle scalene muscles. Compression of the brachial plexus, cervical rib syndrome. (cervical rib syndrome). The first rib deformity, accompanied by anterior and middle oblique muscle hypertrophy, sputum-like, or abnormal attachment sites, make the triangular space of the scalene muscle smaller, causing scalenus anticus syndrome. The rib cage gap is narrow, and when the shoulder is stretched, the subclavian blood vessels are squeezed, causing costoclavicular syndrome. When the upper extremity is excessively abducted, the outer edge of the pectoralis minor muscle oppresses the subclavian artery, causing hyperabduction syndrome. 4. Clinical examination methods (1) Adson test or scalene test: let the patient breathe deeply after inhaling, the neck is fully extended, the face is turned to one side, the front and middle scalene muscles are tightened, the scalene muscle space is reduced, and the clavicle is compressed. In the vascular nerve, the brachial artery pulsation weakened or disappeared, indicating oppression. (2) Rib lock test (Eden test): the shoulders are pulled down, and the first rib is brought close to the clavicle, and the rib lock gap is reduced, and the nerve bundle is compressed to produce symptoms. (3) Excessive abduction test of upper extremity: The upper extremity was abducted by 180°, and the upper extremity vascular nerve was compressed by the surrounding thoracic muscle spasm and humeral head. Positive is a weakened pulsation of the radial artery. (4) Intermittent pain test of the arms: the shoulders are up and back, the arms are raised to the horizontal position, and the elbows are bent to 90°. As the hand moves, if there is pressure, the hands and forearms appear numb and pain. (5) Ulnar nerve conduction velocity test (UNCV): Electromyography was performed, and nerve conduction was measured using a needle electrode. If the brachial plexus is compressed, the conduction velocity is slowed down, and the nerve conduction velocity of the thoracic outlet syndrome can be reduced to 32-65 m/s (the average value of the normal chest outlet UNCV is 72 m/s), and the brachial plexus nerve can be judged accordingly. Degree. (6) After the compression of the clavicle, the formation of venous thrombosis, called Paget schroetter syndrome, vascular antegrade or retrograde angiography can confirm the diagnosis. Patients with chest and back pain should be differentiated from angina pectoris. Electrocardiogram should be performed and coronary angiography should be performed if necessary. Different surgical methods are used depending on the cause of the treatment. Treatment of diseases: rib lock syndrome Indication Recurrence of rib cage syndrome reoperation is applicable to: 1. After thoracic outlet syndrome, there are still persistent pain and numbness in the upper limbs, which can not be recovered by physical therapy, accounting for 1.6%. 2. Electromyography UNCV is still below 60m/s. Surgical procedure Incision The incision of the posterior thoracoplasty was performed to reveal the first rib or cervical rib stump, the cervical thoracic nerve root, the brachial plexus, and the subclavian artery and vein. 2. Free removal of rib stump The first rib or cervical rib stump is separated to the periosteum, and the rib head is completely resected backward; and the new bone is removed. 3. Brachial plexus, nerve root release Separation should be beyond the scope of the scar, dissect the nerve bundle outside the nerve sheath, carefully stop bleeding, adequate drainage, to prevent hematoma or infection. After rinsing, 80 mg of methylprednisolone acetate (methylprednisolone) for injection can be placed to reduce nerve adhesion. 4. Thoracic sympathectomy Usually remove the chest 1-3 sympathetic ganglia, do not remove the neck 8 stellate ganglia, or Horner syndrome. The first rib stump was removed, and the posterior end of the second rib was removed by 2.5 cm. The pleural tract 1 to 3 ganglia were excised and excised. To relieve the symptoms of chest pain. complication Intraoperative cranial and venous injury may occur unexpectedly during surgery. It must be kept under the periosteum during surgery to be safer. In addition, as long as the abnormal bone and sacral structures seen during surgery are completely removed, and the periosteum is removed or destroyed, it usually does not recur after surgery.

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