Nassr Ahmad, Larson Annalise Noelle, Crane Benjamin, Hammerberg Kim W, Sturm Peter F, Mardjetko Steven M
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 5905, USA.
J Pediatr Orthop. 2009 Jan-Feb;29(1):31-4. doi: 10.1097/BPO.0b013e318192198a.
An innovative treatment for thoracic insufficiency syndrome involves a vertical expansion of the chest wall through a horizontal chest wall osteotomy maintained by a distraction device (vertical expandable prosthetic titanium rib or VEPTR). Upper-extremity neurovascular dysfunction has been reported after expansion. The purposes of this study are to identify potential etiologies for compression of the brachial plexus after expansion thoracoplasty and to suggest strategies to reduce the incidence of this complication.
A simulated VEPTR procedure was performed on 8 fresh cadaveric specimens. Manometric measurements were taken in the 3 anatomic regions of the thoracic outlet after thoracotomy and rib distraction were performed. Confirmation of the location of compression was performed by placing barium-impregnated putty along the course of the brachial plexus and evaluating the effect of expansion using video fluoroscopy. A midclavicular osteotomy was then performed and video fluoroscopy repeated.
A 20% increase in pressure was seen in the costoclavicular region of the thoracic outlet after expansion. Constriction of the midclavicular region of the thoracic outlet between the first rib and clavicle was confirmed using the putty model. Midclavicular osteotomy alleviated this region of compression.
Expansion thoracoplasty with the VEPTR procedure causes increased pressure in the costoclavicular region of the thoracic outlet. A midclavicular osteotomy may be one method to alleviate thoracic outlet narrowing after VEPTR procedure, although the short- and long-term effects of this is procedure is not known.
Our model supports an iatrogenic thoracic outlet syndrome caused by expansion thoracoplasty. Based on our data as well as a review of the literature, we recommend intraoperative neurologic monitoring of the ipsilateral upper extremity during the VEPTR procedure.
一种治疗胸廓发育不全综合征的创新方法是通过使用撑开装置（垂直可扩张人工钛肋或VEPTR）维持的水平胸壁截骨术来实现胸壁的垂直扩展。有报道称在扩展后出现上肢神经血管功能障碍。本研究的目的是确定胸廓成形术后臂丛神经受压的潜在病因，并提出降低该并发症发生率的策略。
对8个新鲜尸体标本进行模拟VEPTR手术。在开胸和肋骨撑开后，在胸廓出口的3个解剖区域进行压力测量。通过沿臂丛神经走行放置钡剂浸渍的油灰并使用视频荧光透视评估扩展效果来确定压迫位置。然后进行锁骨中段截骨术并重复视频荧光透视。
扩展后胸廓出口的肋锁区域压力增加了20%。使用油灰模型证实了胸廓出口锁骨中段区域在第一肋骨和锁骨之间的狭窄。锁骨中段截骨术减轻了该区域的压迫。
采用VEPTR手术的胸廓成形术会导致胸廓出口肋锁区域压力增加。锁骨中段截骨术可能是减轻VEPTR手术后胸廓出口狭窄的一种方法，尽管该手术的短期和长期效果尚不清楚。
我们的模型支持胸廓成形术导致的医源性胸廓出口综合征。基于我们的数据以及文献回顾，我们建议在VEPTR手术期间对同侧上肢进行术中神经监测。
