Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland.
Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland.
Ann Thorac Surg. 2020 Sep;110(3):1043-1049. doi: 10.1016/j.athoracsur.2019.12.059. Epub 2020 Feb 8.
When conservative therapy for thoracic outlet syndrome fails, scalenectomy with or without first-rib resection (FRR) is the treatment of choice. We measured pressure in the costoclavicular space before and after FRR at time of neurogenic thoracic outlet syndrome release to evaluate whether FRR is required to completely decompress the costoclavicular space.
Using a supraclavicular exposure for anterior-middle scalenectomy with FRR, costoclavicular space pressures were measured using a balloon catheter with the patient's arm in neutral anatomic position, secondarily, the arm abducted and externally rotated. Pressures were recorded in both arm positions before scalenectomy, after scalenectomy, and after FRR. Paired Student's t test was used to compare differences in group means for paired samples. Patient-reported outcomes were reported using the Derkash classification and quick disabilities of the arm, shoulder, and hand (qDASH) questionnaire.
Fifteen patients (16 cases) surgically treated for neurogenic thoracic outlet syndrome were included in this retrospective study. There was no significant difference in pressure change between arm positions before scalenectomy (161.56 ± 71.65 mm Hg difference) or after scalenectomy (148.5 ± 80.24 mm Hg difference). There was a significant difference in pressure change between post-scalenectomy and post-FRR arm positions; mean pressure change between arm positions after FRR was 50.56 ± 40.28 mm Hg. Mean postoperative qDASH score was 20 ± 23.2. All patients reported improvement in symptoms and functional status.
Supraclavicular first rib resection for management of neurogenic thoracic outlet syndrome can be safely performed with favorable outcomes. The pressure increase in the costoclavicular space caused by arm abduction and external rotation was significantly reduced only after FRR, raising concerns about potential incomplete costoclavicular space decompression with scalenectomy alone for neurogenic thoracic outlet syndrome management.
当保守治疗胸廓出口综合征失败时，前中斜角肌切除术加或不加第一肋骨切除术（FRR）是首选治疗方法。我们在神经源性胸廓出口综合征松解时测量 FRR 前后肋锁空间的压力，以评估 FRR 是否需要完全减压肋锁空间。
采用锁骨上入路行前中斜角肌切除术加 FRR，在患者手臂处于中立解剖位、其次外展和外旋时，使用球囊导管测量肋锁空间压力。在斜角肌切除术前、切除后和 FRR 后记录臂位压力。使用配对学生 t 检验比较配对样本组均值的差异。使用 Derkash 分类和快速上肢、肩部和手部残疾（qDASH）问卷报告患者报告的结果。
本回顾性研究纳入了 15 例（16 例）接受神经源性胸廓出口综合征手术治疗的患者。斜角肌切除术前和切除后手臂位置之间的压力变化无显著差异（161.56±71.65mmHg 差值）或切除后（148.5±80.24mmHg 差值）。斜角肌切除术后和 FRR 后手臂位置之间的压力变化有显著差异；FRR 后手臂位置之间的平均压力变化为 50.56±40.28mmHg。术后平均 qDASH 评分为 20±23.2。所有患者报告症状和功能状态均有改善。
锁骨上第一肋骨切除术治疗神经源性胸廓出口综合征可安全进行，且结果良好。仅 FRR 后，因手臂外展和外旋引起的肋锁空间压力增加明显降低，这引发了对神经源性胸廓出口综合征管理中单独行斜角肌切除术可能不完全减压肋锁空间的担忧。
