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About thoracic outlet upper bound collarbone, the lower bound for the first rib, the front lock for the rib ligament, posterior oblique to the
Thoracic outlet syndrome muscle. Brachial vessels and nerves reach the axillary clearance by the triangular rib bottom of the lock, any narrow channel can cause thoracic outlet will lead to the symptoms resulting from neurovascular compression. Bony entrapment of which include cervical rib, 7 cervical transverse process is too long, the first rib and clavicle fractures variation of callus formation. Soft tissue factors include abnormal fiber wrap, Sibson's fascia, scalene, subclavian muscle, pectoralis minor muscle and other congenital or acquired changes. Forlada other in the anatomy of the transverse scapular ligament was found between the first rib and the muscle is called a surplus after the subclavian muscle, the muscle may also be one of the reasons causing TOS. In addition, variability of congenital brachial plexus, shoulder and neck of the acute traction injury, long-term poor posture, neck and shoulder muscle imbalance, Big Breasts, obesity is caused by TOS can not be ignored. TOS into the brachial plexus upper trunk, lower trunk and mixed three categories. More than ever that under the pathological basis of dry TOS is scalene triangle elevation below the first rib or rib before the middle scalene muscle in the first part of the only points up the card for clemency or arched T1 and C8 nerve root compression . The anatom


y of Chen Desong etc. found in the T1 nerve root or lower trunk of brachial plexus in the proximal small scalene tendinous origin across the organization, so that small scalene tendon fibers are dry or T1 nerve following brachial plexus root compression causes. Meanwhile, they find the former in scalene in C4, C5 transverse cross-tendinous nodules before and after the starting point is the C5, C6, C7 nerve root, or sometimes including the brachial plexus upper trunk reasons. Thoracic outlet syndrome is the subclavian vein and brachial plexus compression in the thoracic catchy generated by a series of symptoms. Etiology of nerve and / or the reasons for abnormal bone tube, such as cervical rib, 7 cervical transverse process is too long, rib or collarbone two 1 fork deformity, exostosis, trauma resulting from the clavicle or a rib fracture dislocation of the humeral head and so on. In addition, there scalene muscle spasm, fibrosis; shoulder and upper limbs hanging over abduction can cause thoracic outlet narrowed, resulting in the subclavian vessels and brachial plexus nerve compression symptoms. Besides the normal upper limb movements such as the outreach arm, shoulders back down, neck extended, face turned to the opposite side, and deep breathing, also can lock the gap narrow ribs, nerves and blood vessels increase the degree of oppression. Pathogenesis of thoracic subclavian catchy upper bound, lower bound for the first 1 rib ligaments in front of the rib lock the rear for the middle scalene muscle. The gap was again before the lock rib scalene is divided into before and after the two parts. Subclavian vein in the anterior scalene muscle in the front and between the subclavian muscle; subclavian artery and brachial plexus is located behind the anterior scalene muscle scalene muscle and in between. Pathological changes in nerve compression injury in inflammatory swelling of the kind often false, the first sensory fibers involved, only in the advanced stage of motor nerve compression. The symptoms are severe, more difficult to recover. Nerve compression time is too long will cause through the sympathetic vasomotor disorder. Subclavian artery walls can be changed, adventitia thickening, interstitial edema and thickening of the same membrane with luminal thrombosis. Early platelet thrombus cellulose type, there may be Raynaud's (Raynaud) phenomenon. Withdrawal reflex sympathetic fibers can increase the finger blood vessel blockage. Vein in the over-time outreach or oppression within the collection can be observed upstream stagnation of blood and peripheral venous pressure increases, pressure returned to normal after the disappearance. Vein repeated injury can develop post-inflammatory fibrosis-like changes in a similar vein white, translucent lost, and the diameter was reduced, the formation of collateral circulation. Trend of the early development of venous thrombosis, such as collateral circulation has not yet formed, can cause the tip of finger necrosis. Divided into two types of nerve compression and vascular compression, nerve compression symptoms are more common, there are nerves and blood vessels while under pressure. Etiology of nerve and / or the reasons for abnormal bone tube, such as cervical rib, 7 cervical transverse process is too long, the first
Thoracic outlet syndrome, a rib or collarbone two fork deformity, exostosis, trauma resulting from the clavicle or a rib fracture, dislocation of the humeral head and so on. In addition, there scalene muscle spasm, fibrosis; shoulder and upper limbs hanging over abduction can cause thoracic outlet narrowed, resulting in the subclavian vessels and brachial plexus nerve compression symptoms. Besides the normal upper limb movements such as the outreach arm, shoulders back down, neck extended, face turned to the opposite side, and deep breathing, also can lock the gap narrow ribs, nerves and blood vessels increase the degree of oppression. Thoracic subclavian catchy upper bound, lower bound 1 rib, rib lock for the ligaments in front of the rear for the middle scalene muscle. The gap was again before the lock rib scalene is divided into before and after the two parts. Subclavian vein in the anterior scalene muscle in the front and between the subclavian muscle; subclavian artery and brachial plexus is located behind the anterior scalene muscle scalene muscle and in between. Nerve compression injury kind of inflammatory swelling often false, the first involved sensory fibers, motor neurons appeared only in the late pressure. The symptoms are severe, more difficult to recover. Nerve compression time is too long will cause through the sympathetic vasomotor disorder. Subclavian artery walls can be changed, adventitia thickening, interstitial edema and thickening of the same membrane with luminal thrombosis. Early platelet thrombus cellulose type, there may be Raynaud's (Raynaud) phenomenon. Withdrawal reflex sympathetic fibers can increase the finger blood vessel blockage. Vein in the over-time outreach or oppression within the collection can be observed upstream stagnation of blood and peripheral venous pressure increases, pressure returned to normal after the disappearance. Vein repeated injury can develop post-inflammatory fibrosis-like changes in a similar vein white, translucent lost, and the diameter was reduced, the formation of collateral circulation. Trend of the early development of venous thrombosis, such as collateral circulation has not yet formed, can cause the tip of finger necrosis. Divided into two types of nerve compression and vascular compression, nerve compression symptoms are more common, there are nerves and blood vessels while under pressure. Nerve compression symptoms of pain, paresthesia and numbness, often in the fingers and hand the ulnar nerve distribution area. Also available on the upper limb, shoulder girdle and upper limb ipsilateral shoulder pain to radiation. Late stage of sensory, motor weakness, muscle and bone between the thenar muscle atrophy, paralysis 4 to 5 refers to the formation of the extensor claw hand. Arterial pressure with ischemic arm or hand pain, numbness, fatigue, paresthesia, coldness and weakness. Distal arterial thrombosis compression expansion to remote ischemia. Venous compression are pain, swelling, pain, swelling and violet remote. Anatomy of the neck triangular space, deep to the sternocleidomastoid, both sides of the front, middle scalene muscle, rib bottom for the first one, forming a triangular space, brachial plexus nerve and subclavian artery pass through the gap. Therefore, its actions in the brachial plexus may have anterior scalene muscle, middle scalene muscle, the first rib, clavicle, pectoralis minor muscle clearance of these structures have their oppression scalene muscle contracture due to any reason (such as congenital, ischemic , injury and nerve irritation) can narrow the gap caused by scalene and the first rib elevation, causing brachial plexus compression. The first rib elevation or proliferation (such as tumor, callus) can cause the lock ribs space narrowing and compression of brachial plexus, especially the oppression of dry as significant. Clavicular subclavian muscle hyperplasia or hypertrophy can also result in narrow gap lock rib compression of brachial plexus. Diagnosis based on history, local examination, chest and cervical spine X-ray and ulnar nerve conduction velocity, generally clear
Diagnosis of thoracic outlet syndrome surgery. Thoracic outlet syndrome should be considered in the differential diagnosis of cervical disease, brachial plexus or peripheral nerve disease, vascular disease, heart, lung, mediastinal disease. Cases of suspected angina to be selective for the ECG and coronary angiography. Because clinical manifestations of TOS were complex, with a variety of nerve compression disorders (eg, elbows) and motor neuron disease and other symptoms similar, so an inspection methods can not meet the need. Skin pain threshold test and two-point discrimination test used in patients with advanced diagnosis, and symptoms of early stimulation test is the most important diagnostic methods, including the Adson test, Wright test, Moslege test, Roos test and so on. Is generally considered the most reliable Roos test, that is, double arm lift patients, forearm flexion 90 , shoulder abduction and external rotation, alternating with the loose fist, if produces 3min pain or discomfort in the side was forced to sag as positive. And Gillard, etc. are considered the best diagnostic value Adson test, he found in TOS patients Adson test positive rate was 85%. There are a large number of single test false positive and false negative test can reduce the joint of several false-positive rate. After the distal nerve compression may cause the proximal nerve reduced tolerance of external pressure, the distal nerve entrapment (eg, elbows, etc.) should be alert to early signs of TOS. Zheng Xiaojun, etc. in 20 cases of electromyography TOS found 3 patients with carpal tunnel, 2 patients had elbow, and 1 with a cubit tube. So in the diagnosis of nerve compression should pay attention to compression of the nerve vulnerable to the site should be examined to rule out the possibility of dual-card or cards. TOS patients feel some pain in the neck shoulder discomfort, which seems difficult to explain the neurovascular compression. Mackinnon and other patients that this is due to the long-term in a particular position, resulting in excessive use of some muscles, while the other part of the corresponding muscles disuse, have caused a muscle imbalance. Chende Song et al [8] consider this and the C5 nerve root and dorsal scapular nerve compression related. X ray imaging can rule out cervical spine films and chest X-ray cervical rib, 7 cervical transverse process too long, the clavicle, first rib bone deformity, or other sexually transmitted diseases. Doppler ultrasound can be found in blood pressure stenosis. Angiography can determine the site of stenosis and compression. CT and MRI is a sensitive and non-invasive method of diagnosis of TOS have some help. Bilbey et al reported a 60% TOS patients with abnormal findings on CT examination. Akal et al reported the 3D-CT can be found at the narrow thoracic outlet, the effective display of the thoracic outlet structure relationship. Xavier, etc. found in their study, MRI of neurovascular compression to determine the location and cause compression of the reasons help. Electrophysiology Electrophysiology early in the TOS no special value, F waves may appear extended,
Pectoralis major muscle is often no other abnormal findings. Late as the ulnar nerve motor conduction velocity slowing in the clavicle with the Ministry of greater diagnostic value. Somatosensory evoked potentials (SSEPs) was considered to be a more sensitive examination method. Machleder et al reported 74% of TOS patients had abnormal findings SSEPs. But the study found that SSEPs by Yilmaz and so the diagnosis of TOS useless. Misawa and other proposed using magnetic stimulation of the brachial plexus was measured pollicis brevis and abductor digiti minimi abductor muscle action potential latency help diagnose TOS, they are in the supraclavicular fossa 8 shaped coil with a magnetic field produced by stimulation of the brachial plexus in patients with TOS found that the short abductor muscle of thumb and little finger abductor muscle action potential latency was prolonged. Lei Xu discovered through animal experiments such as motor evoked potentials in the diagnosis of TOS sensitive and accurate, but also help in early diagnosis of TOS. Bureau neck seal test at the midpoint of posterior margin of sternocleidomastoid muscle into the needle, after the arrival transverse cervical 5 nodules, the triamcinolone acetonide 0.5% bupivacaine 2ml 2ml of the mixture slowly into the liquid, such as 1 2min significantly reduced symptoms, increased muscle strength, sensory improvements are often prompted to be TOS or cervical nerve root compression and soft tissue. In short, TOS diagnosis more difficult, despite the emerging new inspection methods, but mainly rely on a doctor's knowledge of the disease, careful history, comprehensive examination in order to obtain comprehensive judgments. Differential diagnosis with cervical nerve root type cervical spondylosis 5,6 differentiated from conventional 2ml of 0.5% bupivacaine plus song annai
2ml of thoracic outlet syndrome in the neck outside Germany and tender point (usually the midpoint of the posterior margin of sternocleidomastoid muscle) on the transverse cervical puncture, no blood Withdrawing slowly after the injection, if the patient feels after 1min significant improvement in muscle strength or completely back to normal Zhui, confirm the cervical nerve root compression is a healthy 56 search outside the intervertebral foramen is a muscular rather than skeletal Zhui's important to note that Zhui cervical spinal cord compression can also be accompanied by foramen external nerve compression can be diagnosed before surgery as well. Zhui in cervical surgery be cut off before the search in the neck in 56 healthy scalene nerve root next to the starting fiber, may avoid the discomfort of postoperative pain in the neck is still Zhui situation. Pathogenesis of thoracic subclavian catchy upper bound, lower bound for the first 1 rib ligaments in front of the rib lock the rear for the middle scalene muscle. The gap was again before the lock rib scalene is divided into before and after the two parts. Subclavian vein in the anterior scalene muscle in the front and between the subclavian muscle; subclavian artery and brachial plexus is located behind the anterior scalene muscle and the scalene (Fig. 1). Figure 1 scalene and the subclavian vein and brachial plexus anatomy between the (aly removed the clavicle). Pathological changes in nerve compression injury in inflammatory swelling of the kind often false, the first involved sensory fibers, motor out only in the late
Chest is under pressure. The symptoms are severe, more difficult to recover. Nerve compression time is too long will cause through the sympathetic vasomotor disorder. Subclavian artery walls can be changed, adventitia thickening, interstitial edema and thickening of the same membrane with luminal thrombosis. Early platelet thrombus cellulose type, there may be Raynaud's (Raynaud) phenomenon. Withdrawal reflex sympathetic fibers can increase the finger blood vessel blockage. Vein in the over-time outreach or oppression within the collection can be observed upstream stagnation of blood and peripheral venous pressure increases, pressure returned to normal after the disappearance. Vein repeated injury can develop post-inflammatory fibrosis-like changes in a similar vein white, translucent lost, and the diameter was reduced, the formation of collateral circulation. Trend of the early development of venous thrombosis, such as collateral circulation has not yet formed, can cause the tip of finger necrosis. Divided into two types of nerve compression and vascular compression, nerve compression symptoms are more common, there are nerves and blood vessels while under pressure. (A) of the nerve compression symptoms of pain, paresthesia and numbness, often in the fingers and hand the ulnar nerve distribution area. Also available on the upper limb, shoulder girdle and upper limb ipsilateral shoulder pain to radiation. Late stage of sensory, motor weakness, muscle and bone between the thenar muscle atrophy, paralysis 4 to 5 refers to the formation of the extensor claw hand. (B) of the arterial pressure with ischemic arm or hand pain, numbness, fatigue, paresthesia, coldness and weakness. Distal arterial thrombosis compression expansion to remote ischemia. Venous compression are pain, swelling, pain, swelling and cyanosis remote. Check first determine nerve compression secondary to occur in the ulnar nerve distribution area. Artery and brachial artery pressure with radial arterial pulse weakened or disappeared, supraclavicular and axillary hear the noise. Venous pressure venous engorgement, swelling and cyanosis remote. The following inspection methods have some help on the diagnosis. 1. Upper arm abduction test outreach 90 , 135 and 180 , external rotation of hands, neck stretching to take place. The subclavian neurovascular his tight pressure points in the pectoralis minor muscle just below the ribs and clavicle and the gap at 1, can feel the neck and upper limbs pain or pain intensified. Weakening or disappearance of the radial artery pulse, blood pressure decreased. 2.0kPa (15mmHg), subclavian artery area heard the systolic murmur. 3.Adson or scalene test palpable radial artery pulse in the next monitoring. Patients with deep inspiration, Shen Jing, and lateral mandibular shift subjects, such as the weakening or disappearance of the radial arterial pulse was positive findings. 4. Ulnar nerve conduction velocity were measured in thoracic outlet, elbow, forearm ulnar nerve conduction velocity. Normal thoracic outlet is 72m / s, elbow 55m / s, forearm 59m / s. Patients with thoracic outlet syndrome, ulnar nerve conduction velocity in thoracic outlet decreased to 32 ~ 65m / s, an average of 53m / s. 5. Doppler ultrasound and optical flow detection as an estimate of vascular thoracic outlet syndrome compression inspection method, but not specific examination methods. However, vascular disease can be excluded. According to preoperative and postoperative blood flow, estimated surgery. 6. Angiography for serious arterial and venous pressure, combined arterial aneurysm, atherosclerosis, embolism and venous thrombosis, in order to clear lesions and the exclusion of other vascular lesions. Clinical manifestations of thoracic outlet syndrome is divided into two types of nerve compression and vascular compression, the more common symptoms of nerve compression
Clinical manifestations, there are nerves and blood vessels while under pressure. (A) of the nerve compression symptoms of pain, paresthesia and numbness, often in the fingers and hand the ulnar nerve distribution area. Also available on the upper limb, shoulder girdle and upper limb ipsilateral shoulder pain to radiation. Late stage of sensory, motor weakness, muscle and bone between the thenar muscle atrophy, 4 and 5 refer to the formation of claw hand extensor paralysis of the subclavian artery walls can be changed, adventitia thickening, interstitial edema and increases with film thick with luminal thrombosis. Early platelet thrombus cellulose type, there may be Raynaud's (Raynaud) phenomenon. Withdrawal reflex sympathetic fibers can increase the finger blood vessel blockage. Vein in the over-time outreach or oppression within the collection can be observed upstream stagnation of blood and peripheral venous pressure increases, pressure returned to normal after the disappearance. Vein repeated injury can develop post-inflammatory fibrosis-like changes in a similar vein white, translucent lost, and the diameter was reduced, the formation of collateral circulation. Trend of the early development of venous thrombosis, such as collateral circulation has not yet formed, can cause the tip of finger necrosis. Common clinical manifestations of middle-aged women, 20 to 40 years old accounted for 80%, more than a history of neck trauma. Clinical symptoms vary widely, and not sustained, the general physical examination is often normal, it takes on a comprehensive examination of patients with upper limb (including motor and sensory). Entrapment site, and under the oppression of the nerves or blood vessels, the clinical manifestations vary. The most typical is the brachial plexus compression under the dry type, mainly for limb pain, malaise, weakness, cold, numb hands. Slightly lower limb muscle strength can be found in physical examination, especially the inside of the forearm the ulnar hand acupuncture significant changes in pain, but also may be the size of thenar muscle atrophy. When the pressure is mainly dry for the shoulder abduction, elbow flexion weakness, decreased muscle strength, often accompanied by shoulder and neck pain and discomfort, but the passive normal. Subclavian artery compression can occur when the limbs get cold, pale and with numbness and weakness. When the subclavian vein compression limb swelling, hand and forearm can be bruising. Sympathetic nerve fiber compression, in addition to upper limb pain, but also often Raynaud's phenomenon, manifested as limb pale, cyanosis, and also showed his hands were sweating a lot. In addition, there are some TOS patients stimulated precordium, neck and shoulder discomfort as the main performance. 1. Medical history and symptoms (1) Past medical history: the majority of patients had a long history of health search the neck and shoulder pain and neck disease or frozen as a treatment has long been admitted to a number of misdiagnosed cases in which nearly half were misdiagnosed as cervical spondylosis and 2 / 5 patients were misdiagnosed as frozen shoulder and shoulder the impact of disease. (2) The main symptoms: The disease mainly for neck and shoulder pain and discomfort may be unable to shoulder and elbow radiation health search affected limb, the patient put to sleep how uncomfortable limb may be associated with dizziness, tinnitus embolism. first visit time: about 30% of cases in the incidence of a health clinic within a year to search for half of the patients in 1 to 2 years and 20% of patients attending more than 2 years of diagnosis. body disease: multiple non-dominant hand, accounted for 2 / Clinical features: acute onset of health accounted for 55% of chronic disease accounts for about 45% of the search. Zhui nature of pain: are closely related with the position, 95% of patients were intermittent seizures. Other symptoms: Almost all patients had abnormal neck, shoulder, back, about half of discomfort associated with pain
Thoracic outlet syndrome pain. In addition almost 95% of cases put to sleep was not comfortable with how limb accompanied by a small number of patients unable to be held on the shoulders of tinnitus, dizziness and elbow powerlessness. 2. Checks and signs checks should be carefully observed shape, the symmetry of the shoulders, and posture health search whether upper limb muscular atrophy, carefully check the neck, shoulder health search whether there is tenderness, check the feeling of the upper extremity strength and muscular tension and the case of ulnar and radial artery pulse, conventional tests do AdsonWrightRoos health search. The s found that almost all cases, the midpoint of the posterior margin of sternocleidomastoid muscle tenderness, and another half in the upper corner of the inside of the shoulder blade area and upper arm deltoid tenderness lateral hypoesthesia accounted for more than 80% Zhui, of which 15% insensitive to health associated with the medial forearm and another half of the cases of muscle weakness search, mainly supraspinatus, infraspinatus deltoid and biceps muscle, and muscle atrophy appears healthy sign search 3. special test (1) Adson test : 15% ~ 20% positive (2) Roos test: positive rate and the former is similar. (3) Wright test Zhui: 80% of patients with positive results. Surgery treatment indications: for 1 to 3 months after non-surgical treatment no improvement or even increased symptoms, ruler of God
Thoracic outlet syndrome, thoracic outlet by the conduction velocity by less than 60m / s were; subclavian angiography showed stenosis of arteries and veins were obstructed; local pain or symptoms of venous compression were significant. Operation principle: lifting of the neurovascular bundles of bone scissors-like compression to be amputated 1 rib length and the discharge of the oppression of factors, so that down the brachial plexus and subclavian artery without teratogenic complications. Surgical methods: (a) axillary ways: general anesthesia or epidural anesthesia, recumbency position, limb elevation 45 , lifting the lower edge of upper limb after axillary rib level 3 for 6 ~ 7cm long transverse incision; in between the anatomy of pectoralis major and latissimus dorsi muscle to the chest, separated from the bottom up in the axillary fascia, the top edge of the ribs in the first one to see the neurovascular bundle; lifting the upper left neurovascular bundle 1 rib, cut off the angle before muscle, rib and periosteum removal of 1, front-end to the rib cartilage, back to the transverse process, of surgery of brachial plexus compression check whether the bone stump; this procedure less trauma, less bleeding, but the exposure is poor, could easily lead to 1 rib resection is not complete. (B) parascapular ways: lateral position under general anesthesia, limb up. Incision starting from the high side shoulder blade area, under the direction along the shoulder blade around the inside to the axilla. Cut off the latissimus dorsi, rhomboid muscle and the serratus anterior muscle. Stretch out the shoulder blades up, cut off the middle scalene muscle fibers, revealing 1 ribs. After the removal of paragraph 2 of the ribs, to increase exposure while 1 2 rib intercostal nerve from decompression. Cervical vertebra thoracic scoliosis or round the top of the gap also play the role of chest expansion. Scalene and cut off 1 1 rib length, while the skeletal abnormalities such as cervical ribs, abnormal vertebral transverse process is too long and should be removed fiber wrap, etc., the larger the incision, the time of surgery to stop bleeding should be carefully After the machine to prevent hematoma of adhesion. This incision can be cut 1 rib satisfaction and discharge of the oppressed factors for reoperation patients. The disadvantage is the larger trauma, bleeding more. There is damage caused by complications of pleural pneumothorax, brachial plexus traction caused by intraoperative or postoperative hematoma arm numbness infection. After about 90% of the cases the symptoms disappear. (C) removal of aneurysms: subclavian artery aneurysm in a difficult to reach the site, revealing more difficult. Incision should be based on etiology, tumor size and location may be. In general, the subclavian artery the second, three aneurysms can be exposed through the supraclavicular transverse incision; but the first part of the aneurysm, must be added as a separate incision or incision, or unable to get a good proximal control . Median sternotomy is required for the right split incision. After the left lateral chest may be 4 3 intercostal intercostal incision or chest. Department of the number of cases of surgical chest incision to the neck. The law will bend the neck down turn in the medial incision, the sternal manubrium to 2 and then turned to the lateral intercostal plane, split sternal manubrium to the second intercostal space plane, by the rib into the chest. Often have to then cut off the middle of the clavicle, the entire organization turn out to expose the aneurysm and the proximal and distal arteries. Aneurysm resection, reconstruction of an effort. Easy to use as artificial blood vessels or saphenous vein can be, pay attention to retain the vertebral artery; as it has been subject to implicate the tumor can be cut off after the replantation; such as proof of preoperative imaging mainly contralateral vertebral artery, the ipsilateral vertebral artery without weight. Dougherty and other 1 case reported in 1995, surgery, removal of the first subclavian artery aneurysm, the distal artery and left common carotid artery for end to side anastomosis, eliminating the application of the graft, the effect is good. The Department's and that the acromioclavicular rich collateral circulation, aneurysm ligation and excision alone without additional reconstruction, or cause serious consequences. Proposed for the subclavian artery aneurysm, reconstruction is only a secondary pursuit of the concept. This only for reference.
Thoracic Outlet Syndrome General Statistics by groups of cases, simple ligation of subclavian artery aneurysm near the tumor, remote persons, 75% of the patients had no circulation, 25% of patients have "limp (claudication)" performance, meaning there is upper limb dysfunction . Surgery in 3 cases, 1 case for the proximal and distal arterial ligation, cut the tumor, capsule suture opening branches, not for reconstruction. There was no lack of performance of any artery. Postoperative complications: 1. Wound oozing; 2. Pneumothorax; 3. Chyle leakage and the lymphatic fluid; 4. After cervical instability; conservative treatment for early onset of symptoms were mild and the method are: conservative treatment, such as Patients with mild symptoms, no symptoms of nerve injury can be treated conservatively. The goal is to increase the space at the thoracic outlet and restore the balance of neck and shoulder muscles. First described the disease and for patients with life coaching to eliminate symptoms of anxiety to avoid the deterioration of the action to do so (such as discreet or arm on the move, etc.); followed by training to be corrected by the patient's poor body posture (such as avoiding prolonged desk with a rubber band hanging limbs, etc.), bad posture can improve the lock ribs and brachial plexus relaxation space to expand; Finally, it should be to strengthen the muscles around the shoulder girdle
Thoracic outlet syndrome training to improve muscle endurance. In addition, while application of heat therapy, oral neurotrophic drugs, neck pain point Bureau of letters and other methods. Most patients with symptoms after conservative treatment could be improved. Landry et al reported that 78% of patients return to work after conservative treatment, and surgical treatment no significant difference. Therefore, most scholars advocate of conservative treatment of patients with early TOS, but Novotny and so that the longer the conservative treatment, many patients do not have time or do not have good treatment, therefore, the TOS should be early surgery once the diagnosis. TOS symptoms if surgery can not stand too serious failure of conservative treatment conservative treatment or surgery can release. The surgical methods included resection of cervical rib, first rib resection, resection of the former in scalene, scalenus resection with rib resection. Path has been axillary surgery, supraclavicular, infraclavicular, transthoracic or incision, according to the doctor's habit of choice. Christian and so that when the removal of cervical rib on the way through the clavicle, because the more convenient way. The first rib resection may be taken by the axillary approach, and the patient recovered quickly with few complications. The effects of various surgical methods are controversial, Roos introduced in 1966 by the axillary first rib resection is the most widely used surgical methods. But Mackinnon, etc. tend to use by the supraclavicular approach, since not only facilitate the release scalenus, and when the first rib resection can be clearly exposed and C8T1 lower trunk of brachial plexus nerve roots, to be effectively protected, too long The C7 transverse process can also be easily removed. And Ernesto is satisfied that the axillary or supraclavicular first rib resection is often not completely removed the first rib, so they designed a new surgical path, in the axillary approach by the joint shoulder blades on the basis of a small incision, can prevent thoracic outlet injury, other important structures, complete resection of first rib also. Chen Desong so beautiful from the perspective of the design of the root of the neck stripes and a small incision along the neck, the length of not more than 5cm. Can be smoothly cut through the incision before the small scalene, the same surgical procedure to achieve the requirements, and the appearance of the patients was small. However, in the small incision for resection of cervical rib or first rib is very difficult. Despite the small vascular TOS, but most require surgical release. TOS venous thrombosis can be partially based thrombectomy, early removal of the first rib, anterior scalene muscle and the rib lock ligament, after no long-term anticoagulation. Arterial TOS should be removed the first rib, the occurrence of thrombosis or aneurysm formation of viable artery bypass grafting. To have the burning neuropathic pain, may jointly sympathectomy. Since surgery is only lifting the nerves of the neck muscle imbalance scapular region no improvement, so most patients need to line the shoulder girdle muscle strength exercises, scapular neck area in order to restore muscle balance. Most of the patients after surgery release can achieve good results. Sanders reed the TOS and so the effect of surgical treatment of patients that scalene resection, resection of the first rib by the axillary, supraclavicular first rib resection similar effect, early up to 90%, 15 years later there are still 65% of patients maintained a good effect. Fulford et al reported 61 patients treated by surgery were followed up for 6 months after treatment 91.5% improvement of symptoms, of which 61.5% the symptoms disappeared completely. 74% after 4 years follow-up symptoms, of which 58% of the symptoms disappear. Many factors affect results of operations. Axelrod and other 24 170 patients are summarized for patients with symptoms of brachial plexus compression led to surgical treatment, he found that severely depressed, unmarried, high school education were less concerned with the operation fails, and results of operations and duration of symptoms, preoperative examination results, Age, sex and type of work has nothing to do. Psychological and socio-economic characteristics may also affect the success rate of surgery. Because
Thoracic surgical treatment of this line should select the appropriate cases. Despite the small vascular TOS, but most require surgical release. TOS venous thrombosis can be partially based thrombectomy, early removal of the first rib, anterior scalene muscle and the rib lock ligament, after no long-term anticoagulation. Arterial TOS should be removed the first rib, the occurrence of thrombosis or aneurysm formation of viable artery bypass grafting. To have the burning neuropathic pain, may jointly sympathectomy. Since surgery is only lifting the nerves of the neck muscle imbalance scapular region no improvement, so most patients need to line the shoulder girdle muscle strength exercises, scapular neck area in order to restore muscle balance. Most of the patients after surgery release can achieve good results. Sanders reed the TOS and so the effect of surgical treatment of patients that scalene resection, resection of the first rib by the axillary, supraclavicular first rib resection similar effect, early up to 90%, 15 years later there are still 65% of patients maintained a good the effect of hydrocortisone treatment of thoracic outlet syndrome Use: Left or right supraclavicular fossa tenderness by injection of 1% procaine injectiml 5ml partial hydrogenation of intramuscular cortisone; week 1, 3 to 5 times for a course; history of local muscle strain effects are obvious. Care and psychological care of patients, longer duration, and antecedent surgery misdiagnosis or poor outcome of conservative treatment, therefore, inevitable that patients with fear, tension, anxiety and other emotions, or after surgery and concerns. Therefore, before surgery for the patient's condition, the need for an operation, risks, possible complications, and prognosis of the recovery process, and awake the purposes of discomfort caused by body position, to be patiently explained to obtain the trust and with, so that patients with a positive attitude to surgery and postoperative treatment. Noteworthy is that after 2 days of symptoms in patients with apparent ease, enhance muscle strength, sensory recovery. However, as a result of surgical trauma response, postoperative local edema, swelling of the organization is on the nerves and blood vessels leads to repression, in the 3-7 days after surgery before symptoms reappear or increase, generally only gradually after 2 weeks edema subsided, the symptoms gradually ease. Thus the trauma reaction stage, surgery patients doubt, anxiety, negative emotions. In addition, about 30% of patients with different postoperative adjuvant therapy needed, such as the partial closure, physical therapy, shoulder muscle exercise and other physical therapy and cervical traction. So once again after the onset of symptoms to patients repeatedly stated the reasons for, and fully mobilize the initiative of its own initiative, with the smooth progress of the entire treatment process was extremely important. Rehabilitation care after brachial plexus compression pressure based on the performance of the different parts of the symptoms varies. Such as the oppression of the brachial plexus mainly for shoulder abduction and elbow flexion dysfunction, mainly under the oppression of the brachial plexus is not for the finger flexion, and shoulder, elbow and wrist joints were normal, brachial plexus compression performance of the whole upper limb was flaccid paralysis, loss of function joint initiative activities. Nerve muscle tissue not only dominated the movement, but also the role of muscle tissue nutritious. Therefore, after nerve compression caused by different degree of dominance, said muscle atrophy, so that weakness, if the persistence of oppression, the muscles eventually lose their contractile function fibrosis. Patients with thoracic outlet syndrome usually longer course, accompanied by upper limb muscle atrophy. In addition to surgery to release pressure factor, but want to restore muscle strength needed for postoperative functional exercise. Postoperative functional exercise should be based on different parts of the brachial plexus compression set different training programs, guidance of limb function in patients early after exercise, the present claim can be carried out after 2 days. Conditions may in the gradual rehabilitation under the guidance of teachers. Resistive exercise training is to accelerate muscle recovery, promote the recovery of limb function in an effective way. Such as the oppression of the upper arm from the shoulder to the training of outreach on the move and the main function of elbow flexion, brachial plexus major training under the oppression of the finger flexion, adduction, abduction, and refers to the palm and so on, need to strengthen the whole brachial plexus nerve compression, elbow flexion and extension and wrist dorsiflexion and palmar flexion activities recurrent postoperative symptoms in some patients, may aid physical therapy such as electrical therapy, ultrasonic therapy. You can also use anti-inflammatory agents, muscle relaxant agents improve symptoms in order to achieve accelerated local tissue blood circulation, dredge the meridians, relieve pain and restore muscle strength of purpose. Prevention to avoid the heavy stuff with the shoulder, because it will oppress the clavicle, and increase the pressure on exports in the chest. Can also do some simple exercises to the shoulder muscles strong. Here are four exercises each day to do each exercise 10 times, repeat twice. 1. In the corner of the stretch: Stand in the corner, about a foot or so away, hands on both sides of the wall. By the body to the corner, feeling the neck with stretch so far, adhere to 5 seconds. 2. Neck stretch: left hand on the back of his head, his right hand on the back. To the left shoulder with his left hand by the head, pulling the right side of the neck with a sense of ending, adhere to 5 seconds. Practice hands again in the opposite direction. 3. Shoulder joint training: shrug, and then backward, downward, to do a similar arc of shoulder motion. 4. Neck contraction: Gravitropism straight nose in the air to keep the jaw position, adhere to 5 seconds.


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