Division of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
Division of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
J Vasc Surg. 2018 Oct;68(4):1143-1149. doi: 10.1016/j.jvs.2018.01.057. Epub 2018 Apr 25.
The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach.
We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report.
Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit).
This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.
在存在颈肋的情况下，经锁骨下入路行胸廓出口减压术具有减少臂丛神经及其相关神经操作的优势。这可能会降低围手术期并发症（如神经损伤）的发生率。我们的目的是报告一系列通过经锁骨下入路治疗胸廓出口综合征（TOS）和颈肋患者的最新数据。
我们对连续接受手术治疗 TOS 且存在颈肋的患者的前瞻性数据库进行了回顾性研究。本报告的基础是症状、术前评估、手术细节、并发症和术后结果。
1997 年至 2016 年期间，共有 818 例患者接受了 1154 次 TOS 手术，其中 873 例接受了肋骨切除术。在这些患者中，56 例患者接受了 70 例第一和颈肋切除术。颈肋根据血管外科学会的报告标准进行分类：25 例为 1 类，17 例为 2 类，5 例为 3 类，23 例为 4 类。临床表现包括神经源性 TOS49 例，动脉性 TOS7 例。手术时间平均为 141 分钟，失血量为 47 毫升，平均住院时间为 2 天。未发现臂丛神经、胸长神经或胸背神经损伤。1 例患者出现部分膈神经功能障碍，随后恢复。无血肿、淋巴漏或早期再住院发生。平均随访时间为 591 天。术后 52 例（92.8%）患者完全缓解或症状轻微。最后一次随访时，4 例（7.1%）患者仍有明显残留症状，需要进一步评估或疼痛管理。躯体疼痛评分从术前的 6.9 分降至末次就诊时的 1.3 分。采用缩短的上肢残疾问卷（DASH）评分进行标准化评估表明，从术前的 60.4 分改善至末次就诊时的 31.3 分。
本系列经锁骨下入路颈肋和第一肋切除术的临床结果良好，发病率低。颈肋的存在、斜角肌肌间沟阻滞的阳性反应以及电诊断检查的异常是手术的可靠指征。TOS 患者存在颈肋表明，在进行第一和颈肋切除术后，有极好的改善潜力。
