Tratamento de oclusão arterial em membro superior causada por costela cervical / Treatment of upper limb arterial occlusion caused by a cervical rib

Resumo A síndrome da costela cervical ocorre quando o triângulo intercostoescalênico é ocupado por uma costela cervical, deslocando o plexo braquial e a artéria subclávia anteriormente, o que pode gerar dor e espasmo muscular. O objetivo deste estudo é discutir sobre o diagnóstico da síndrome da costela cervical e as possibilidades de tratamento. Este desafio terapêutico descreve a condução clínica e cirúrgica de uma paciente de 37 anos com obstrução arterial em membro superior causada por costela cervical.

Abstract The cervical rib syndrome occurs when the interscalene triangle is occupied by a cervical rib, displacing the brachial plexus and the subclavian artery forward, which can cause pain and muscle spasms. The objective of this study is to discuss diagnosis of the cervical rib syndrome and treatment possibilities. This therapeutic challenge describes clinical and surgical management of a 37-year-old female patient with upper limb arterial occlusion caused by a cervical rib.

Síndrome del opérculo torácico en adolescentes: serie de casos / Thoracic outlet syndrome in adolescents: a case series

OBJETIVO: El síndrome del opérculo torácico (SOT) está causado por una compresión del plexo braquial y vasos subclavios en su paso hacia la extremidad superior. Patología típica de mujeres entre 20 y 50 años, que es infrecuente diagnosticar en niños. Presentamos nuestros resultados en el diagnóstico y tratamiento del SOT pediátrico. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes diagnosticados de SOT entre diciembre de 2017 y junio de 2018. Se analizaron variables clínicas, radiológicas, quirúrgicas y de evolución. RESULTADOS: Cinco SOT fueron diagnosticados en cuatro pacientes, uno de ellos bilateral. La edad media al diagnóstico fue de 12,5 años (7-15) y hubo una demora en el diagnóstico de 153 días (10-360). SOT venoso (3) y neurológico (2). Presentaron dolor (5/5), edema (4/5), hipoestesia (3/5), disminución de fuerza (3/5) y dolor cervical (2/5). Una paciente presentaba dolor asociado al deporte. El estudio neurofisiológico fue normal en tres casos. Dos pacientes presentaron anomalías óseas por TAC. Se realizaron tres intervenciones quirúrgicas en dos pacientes por abordaje supraclavicular realizando resección de la primera costilla anómala y escalenectomía. Una paciente rechazó la intervención y en otra se mantuvo en una actitud expectante sin reaparición de los síntomas. Seguimiento posoperatorio de 9 meses (6-12) con mejoría progresivas de los síntomas. CONCLUSIÓN: El SOT puede darse en adolescentes, siendo el dolor y edema de la extremidad superior lo más específico. Se recomienda la realización de pruebas de imagen para detectar estructuras anatómicas anómalas. El abordaje supraclavicular se presenta como una técnica segura y eficaz en la descompresión del desfiladero torácico

OBJECTIVE: Thoracic Outlet Syndrome (TOS) is caused by a compression of the brachial plexus and the subclavian vessels in their passage to the upper limb. It mostly occurs in women aged 20-50, so it is infrequent in children. We present our results in the diagnosis and management of pediatric TOS. MATERIALS AND METHODS: Retrospective study of patients diagnosed with TOS between December 2017 and June 2018. Clinical, radiological, surgical, and evolution variables were assessed. RESULTS: Five TOS were diagnosed in 4 patients - one TOS was bilateral. Mean age at diagnosis was 12.5 years (7-15), and there was a delay in diagnosis of 153 days (10-36). TOS was either venous (3) or neurogenic (2). Patients presented with pain (5/5), edema (4/5), hypoesthesia (3/5), decreased strength (3/5), and cervical pain (2/5). One patient presented with sport-related pain. Neurophysiological study was normal in three cases. Two patients presented bone anomalies at CT-scan. Three surgeries were performed in two patients using the supraclavicular approach with resection of the anomalous first rib and scalenectomy. One patient refused surgery, and another patient remained expectant without reappearance of symptoms. Postoperative follow-up was 9 months (6-12), with progressive improvement of symptoms. CONCLUSIONS: TOS may occur in adolescents in the form of upper limb pain and edema. Imaging tests are recommended to detect abnormal anatomical structures. The supraclavicular approach represents a safe and effective technique in decompressing the thoracic outlet

Costilla accesoria cervical como causa de síndrome de apertura torácica superior. Nuestra experiencia de los últimos diez años / Cervical accessory rib, as a cause of thoracic oulet syndrome (tos): our experience of the last ten years

El síndrome de apertura torácica superior por costilla cervical, es una patología no muy frecuente, ocasionada por la persistencia después del nacimiento de la última costilla cervical que debería haberse reabsorbido. La patología que origina, es comprensiva de las estructuras vecinas en especial nerviosas, pero también vasculares. Se manifiesta en pacientes jóvenes después de la adolescencia con una especial incidencia en el sexo femenino. El diagnóstico es sencillo si se piensa en esta causa como la etiológica del síndrome, con la realización de una simple radiografía de base de cuello para evidenciar su presencia, aunque es posible realizar otras complementarias. El tratamiento es la simple extirpación de la costilla que en la mayoría de las ocasiones resuelve el cuadro clínico. Se analiza en la publicación la experiencia de nuestro servicio hospitalario en los últimos diez años, analizando aspectos demográficos, diagnósticos, terapéuticos y los resultados obtenidos

The syndrome of superior thoracic opening due to cervical rib is a not very frequent pathology, caused by the persistence after birth of the last cervical rib that should have been reabsorbed. The pathology that it originates is comprehensive of neighboring structures, especially nervous, but also vascular. It manifests itself in young patients after adolescence with a special incidence in the female sex. The diagnosis is simple if we think of this cause as the etiological cause of the syndrome, with a simple neck base X-ray to show its presence, although it is possible to perform other complementary ones. Treatment is the simple removal of the rib, which in most cases resolves the clinical picture. The experience of our Hospital Vascular Service in the last ten years is analyzed in the publication, analyzing demographic, diagnostic and therapeutic aspects and the results obtained

Síndrome de la costilla deslizante. Serie de 4 casos clínicos / No disponible

Introducción: El síndrome de costilla deslizante (SCD) es una entidad poco frecuente en niños. Se cree que su causa es una debilidad en los ligamentos costales que permite una hipermovilidad de las costillas. Genera un dolor intermitente en la región baja del tórax o alta del abdomen que puede afectar a las actividades de la vida diaria o generar un dolor crónico. Material y métodos: Revisión retrospectiva de SCD entre octubre de 2012 y diciembre de 2017. Se recogió información acerca de los datos demográficos, síntomas, estudios de imagen, hallazgos intraoperatorios, material fotográfico y seguimiento a largo plazo. Resultados: Durante este periodo, 4 pacientes fueron diagnosticados de SCD. La mediana de edad al diagnóstico fue de 13 años (12-15 años) con una duración previa de los síntomas de 13 meses (12-36 meses). En 2 pacientes se asoció una dismorfia costal (DC). El diagnóstico fue clínico con confirmación ecográfica. Se realizó resección de los cartílagos afectos en 3 pacientes con un seguimiento posterior de 6 meses (3-30 meses). Actualmente se encuentran sin dolor y con un resultado estético satisfactorio. Un paciente rechazó la intervención. Conclusiones: El SCD aparece en pacientes preadolescentes que en algunos casos asocian DC. Una exploración física y ecografía enfocada son las claves para un diagnóstico certero. La resección de cartílagos es efectiva a largo plazo

Aim of the study: The slipping rib syndrome (SRS) is an unknown pathology for the pediatric surgeon due to its low incidence in children. The weakness of the costal ligaments allowing an area of rib hypermobility has been postulated recently as the main etiology. It produces an intermittent pain in the lower thorax or upper abdomen that can affect to the daily activities and can be the origin of unspecific chronic pain. Methods: A retrospective review of patients diagnosed with SRS between october 2012 and march 2017 was performed. Data of demographics, symptoms, imaging studies, surgical findings and long-term follow-up were collected. Results: During this period, 4 patients were diagnosed with SRS. Median age at diagnosis was 13 years (12-15 years) with a mean duration of symptoms of 13 months (12-36 months). In 2 patients the SRS was associated with Costal Dysmorphia (CD). The initial diagnosis was clinical with posterior ultrasound confirmation. Resection of the affected cartilages was performed in 3 patients and after a follow-up of 6 months (3-30 months), they all are painless and refer a good cosmetic result. One patient refused the intervention. Conclusions: The SRS is an infrequent cause of thoracic pain with an etiology not well understood. The awareness of this disease and its typical presentation can avoid unnecessary studies. The resection of the affected cartilages is a safe and effective treatment

Claviculectomía total como procedimiento de rescate: Reporte de un caso y revisión bibliográfica / Total claviculectomy as a rescue procedure. Case report and literature review

La seudoartrosis de clavícula es una causa infrecuente de síndrome del opérculo torácico. Se describe un caso de plexopatía braquial por seudoartrosis previamente infectada de clavícula. La paciente fue sometida a una claviculectomía total para aliviar los síntomas. Del análisis de la literatura citada, se concluye en que la claviculectomía total es una opción por considerar si se han agotado las opciones terapéuticas. Los resultados funcionales pueden ser satisfactorios cuando se la indica por infección, plexopatía o sarcoma. Nivel de Evidencia: IV

Clavicle non-union is an uncommon cause of thoracic outlet syndrome. A case of brachial plexopathy by previously infected clavicle pseudarthrosis is described. Total claviculectomy was performed for symptom relief. From literature analysis we conclude that total claviculectomy is an option to be taken into account when therapeutic options have exhausted. Functional results could be adequate when total claviculectomy is indicated in cases of infection, plexopathy or sarcoma. Level of Evidence: IV

Modified Interscalene Approach for Resection of Symptomatic Cervical Rib: Anatomic Review and Clinical Study.

BACKGROUND: Cervical ribs have been reported to be present in about 0.5% of the general population, 10% of patients with cervical rib who are symptomatic usually have neurogenic symptoms, but some have arterial symptoms. In 1861, Coote was the first to excise a cervical rib through a supraclavicular approach and relieved the symptoms of thoracic outlet syndrome. OBJECTIVE: In this study, we address the efficacy and safety of a modification to the supraclavicular approach for resection of symptomatic cervical ribs. PATIENTS AND METHODS: The surgical team in collaboration with an anatomist performed cadaveric dissections of the posterior triangle of the neck in the Department of Anatomy, Ain Shams University. A prospective study was performed of 25 patients with moderate to severe neck or upper limb pain; this pain was resistant to medical treatment for at least 6 months. Preoperative cervical radiography showed cervical ribs. Pain was assessed by using the visual analog scale. Electrophysiologic tests were performed to confirm the diagnosis. In this study, we performed a modified supraclavicular interscalene approach with resection of the symptomatic rib and without resecting either of the scalene muscles or the first thoracic rib. RESULTS: A total of 25 patients were included in this study; the mean age was 36 years (± 12 standard deviation), and the mean follow-up period was 12.3 months. All patients had moderate (28%) to severe (72%) preoperative pain. Motor deficits were present in 6 cases (24%); Sensory manifestations were present in 80%. All patients had a relief of severe pain at the first postoperative visit in the first week. There were improvements in the motor power in 5 of the 6 patients who had preoperative motor deficit. CONCLUSIONS: A modified supraclavicular interscalene approach for resection of symptomatic cervical ribs has been shown to be effective in the treatment of neuralgic pain. Compared with other approaches, it proved to be less invasive, with small transverse incision and without resection of scalenus anterior muscle.

Síndrome de la costilla deslizante. Tratamiento agresivo pero eficaz / Slipping rib syndrome. An aggressive but effective treatment

El síndrome de la costilla deslizante (SCD) es una entidad infrecuente, que exige un diagnóstico diferencial preciso incluyendo patología digestiva, cardiaca, respiratoria, infecciosa y músculo-esquelética torácica o abdominal. Se presenta el caso de dos niñas, en edad puberal, con dolor torácico incapacitante de varios meses de evolución y sin antecedente traumático. En la exploración existía un punto de dolor a la palpación de la parrilla costal y la 'maniobra del gancho' era dolorosa. Se realizó una resección de los cartílagos costales, respetando el pericondrio. La evolución tras uno y cuatro años de seguimiento, fue satisfactoria sin complicaciones y con resolución inmediata de la sintomatología. La cirugía de resección costal parece una opción muy agresiva, aunque con resultados muy satisfactorios. Un abordaje mínimamente invasivo podría ser mejor opción a considerar en el futuro (AU)

Slipping rib syndrome (SRS) is an unusual cause of recurrent chest or abdominal pain in children. The diagnosis is elusive, including gastroenterological, cardiac, respiratory, infectious and chest or abdominal muscular pathologies. Two paediatric patients were diagnosed with SRS, both of them were female teenagers with a similar clinical pattern: crippling unilateral chest pain without a traumatic event. On physical examination, all patients had reproducible pain with the 'hooking maneuver'. Surgical excision of the costal cartilages was done, preserving the perichondrium. No complications were reported. In both cases we achieve an excellent outcome after one and four years of follow-up, resolving the symptoms completely. The surgical excision of the costal cartilages seems to be an aggressive option but with an excellent outcome. A minimum invasive approach could be a better option in the future (AU)

A hand surgeon's advanced experience with thoracic outlet compression syndrome.

Although hand surgeons may often see patients with arm and hand pain, numbness and tingling in their practice, the possibility of the presence of thoracic outlet compression syndrome (TOCS) is not often considered. In our practice almost half of newly referred patients have the complaint of upper extremity pain, numbness and tingling. In approximately 50% of these patients detailed history and physical examination are suggestive of TOCS. For this reason it is quite important to recognize the possibility of the existence of this condition. Very often in the past, and occasionally today, this condition has been considered a controversial subject by numerous physicians because of the absence of objective findings in many patients. For several years it has been very well known that the objective findings are present in about 10% of patients and the remaining 90% of patients have subjective complaints. For this reason it has been one of the most commonly underrated, overlooked, and misdiagnosed conditions. During the last 22 years our experience with combined surgical approach for this condition (transaxillary first rib resection with immediate transcervical anterior and middle scalenectomy) has been quite satisfactory. During these years over 850 of these procedures were performed. Between 1989 and 2002 (13 years) 532 patients from a wide geographic area had this combined approach procedure. We were able to locate 358 of these patients for follow-up and of those only 102 responded to our questionnaire. Of the 102 who responded, 95 reported improvement of their symptoms. From 2003 to the middle of 2012, 350 patients from a wide region had this combined procedure. We sent a questionnaire to these patients and had only 57 to respond. Of those who responded, there were 19 bilateral interventions performed a few months apart, with a total of 76 procedures performed. Results based on these 76 procedures revealed 95% improvement of their symptoms. This combined approach for TOCS is the most complete intervention with high rate of improvement and low rate of recurrences.

The significance of cervical ribs in thoracic outlet syndrome.

OBJECTIVE: The purpose of this study was to review our operative experience in patients with thoracic outlet syndrome (TOS) resulting from cervical ribs causing clinical symptoms. METHODS: This study is a retrospective review of a prospectively acquired database of patients with TOS treated with first rib resection and scalenectomy with or without cervical rib resection at the Johns Hopkins Medical Institutions. RESULTS: Between October 2003 and June 2011, a total of 23 cervical rib resections were performed on 20 patients, three of whom had bilateral cervical ribs resected during separate operations. Seven patients presented with subclavian artery thrombosis. Three of seven patients had subclavian artery aneurysms and underwent cervical rib resection through a supraclavicular approach to facilitate subclavian artery bypass. Five patients presented with an ischemic upper extremity without thrombosis and underwent transaxillary first rib and cervical rib resection. Three patients presented with subclavian vein thrombosis; two of the three patients underwent balloon dilation 2 weeks postoperatively for stenosis. Additionally, five patients presented with neurogenic TOS evidenced by pain, numbness, and weakness without vascular compromise in the affected arm. Cervical ribs with bony fusion to the first rib were found in 17 of 23 cases (74%). CONCLUSIONS: Cervical ribs causing clinical symptoms are large and frequently fused to the first rib, and can result in aneurysm formation or thrombosis. In our experience, both the cervical rib and the first rib must be removed to relieve arterial compression and can usually be done through a transaxillary approach. Only patients with aneurysms needing arterial reconstruction require resection of the artery from a supraclavicular approach.

[Thoracic outlet syndrome in a child: a rare pediatric diagnosis]. / Syndrome du défilé thoraco-brachial par côte surnuméraire : un diagnostic rare en pédiatrie.

Thoracic outlet syndrome (TOS) is a rare pediatric syndrome and few cases have been reported in the literature. The authors report the case of a 10-year-old boy with generalized arm pain and neck stiffness. The angiocomputed tomography revealed the presence of a TOS caused by an additional cervical rib and stenosis of the sub-clavian artery. The resection of this rib relieved the patient of his pain during a full year following surgery. This case reminds us that children can also be affected by TOS. When a cervical rib causes TOS, a resection is often necessary.

[Surgical treatment of cervical rib syndrome].

The authors report herein the results of examination and surgical management of fifty-one patients presenting with cervical ribs. Of these, there were 33 women. Compression of the neurovascular bundle (NVB) was found to be caused by a supplementary cervical rib in twenty-three patients while in the remaining 28 patients by a rudimentary cervical rib. Twenty-two patients were found to have clinical manifestations of Raynaud's syndrome. The presence of abnormal cervical ribs was determined roentgenologically. All the patients with rudimentary cervical ribs and twelve of the 23 patients with supplementary cervical ribs were diagnosed as having bilateral abnormalities. Haemodynamics was studied by Doppler ultrasonography revealing blood flow impairments in upper-limb arteries in Edson's test in patients with supplementary cervical ribs and Raynaud's syndrome. In rudimentary cervical rib - only in the development of Raynaud's syndrome. The nervous function was studied by means of electroneuromyography (ENMG). All the patients were diagnosed as having a significant decrease in both motor and sensitive nervous conductivity of the radial and median nerves. All patients were operated on under endotracheal anaesthesia. Decompression operations were carried out in fifty-one patients, with selective thoracocervical sympathectomy performed in twelve. For treating rudimentary cervical rib, we worked out a combined method of an operative intervention. Analysing the obtained surgical outcomes showed the following: forty-four patients (86.3%) endured the operation with no complications. Intraoperative complications were noted to occur in 5.9% of patients and complications in the immediate postoperative period were observed to develop in 7.8% of patients. All the encountered complications turned out transient, easily amendable to treatment, and did not influence the final outcome of the operation. In the remote period up to 5 years positive results remained in 90.2% of the patients.

[Falconer-Weddel's costoclavicular syndrome].

Analysed herein are the findings of examination and outcomes of surgical management of fifty-eight patients (25 men and 33 women) presenting with Falconer-Weddel's costoclavicular syndrome in which the subclavian artery and vein and the brachial plexus at the thoracic outlet appear to be compressed. Of the 58 patients,five subjects were found to have a rudimentary cervical rib and three more (5.3%) patients had trophic disorders on their digits fingers: dystrophy of the nail plates, their fragility, periodically opening trophic ulcers at the digital tips and one patient presented with gangrene of the inguinal phalanx of the middle finger. Three patients had hyperemia of the face. A further four patients had roughening, hyperkeratosis of the skin of the hands, cracks. The presence of the supernumerary ribs was determined roentgenologically. Haemodynamics was studied using Doppler ultrasonography making it possible to reveal disordered blood flow in the upper-limb arteries in the physiological position assumed, in the Adson test as well as with Raynaud syndrome, which was observed in 39 patients. The function of the nerves was studied using electroneuromyography (ENMG). All patients were operated on under endotracheal anaesthesia. Decompression-medical operations were carried outperformed in all 58 patients, with the following four types of interventions being performed: transaxillary resection of the first rib combined with sympathectomy carried out in 23 patients, resection of the first rib without sympathectomy in eighteen patients, resection of the first rib via a surpraclavicular approach in four patients, scalenotomy and selective cervicothoracic sympathectomy in 13 patients.

Endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe surgical option.

BACKGROUND: Endoscopic-assisted transaxillary first rib resection is a novel approach in the management of thoracic outlet syndrome (TOS) and allows us to safely identify the neurovascular package and different structures. Our main objective is to assess the results of morbidity and mortality of the surgical treatment in TOS with this technique. METHODS: We carried out a prospective, longitudinal study with 22 surgical interventions of transaxillary first rib resection with endoscopic support in patients with TOS from January 2000 to January 2009 in a private hospital located in Puebla, Mexico. There were 16 females and six males with a mean age of 35 years. We found 16/22 (72.7%) patients with neurological symptoms and 6/22 (27.3%) with venous symptoms; 2/22 (9.09%) patients had effort thrombosis of the axillary-subclavian vein. RESULTS: Of the 22 interventions, we found fibrous bands in 8/22 patients (36.3%); 1/22 (4.5%) with type 1 cervical band and cervical rib grade II, 1/22 (4.5%) with type 2 cervical band and cervical rib grade I, 2/22 (9.09%) with band type 3, 1/22 (4.5%) with band type IV, 1/22 (4.5%) with band type V and 2/22 (9.09%) with band type VII and axillary-subclavian thrombosis. After the procedure, 20/22 (90.9%) patients showed total symptom improvement and 2/22 (9.1%) patients had mild paresthesias. There were no complications from nerve, vascular or pleural damage. CONCLUSIONS: This technique provides an ample margin of safety and improves visibility, reducing surgical complications.

Resección transaxilar de la primera costilla con apoyo endoscópico en el síndrome de salida de tórax: una opción quirúrgica segura / Endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe surgical option

Introducción: La resección transaxilar con apoyo endoscópico es una técnica quirúrgica novedosa en el manejo del síndrome de salida de tórax que permite identificar con seguridad el paquete vasculonervioso y las diferentes estructuras. Nuestro objetivo fue valorar los resultados de morbilidad y mortalidad del tratamiento quirúrgico en el síndrome de salida de tórax con esta técnica. Material y métodos: Estudio longitudinal prospectivo de 22 intervenciones quirúrgicas de resección transaxilar de la primera costilla, con apoyo endoscópico a pacientes con síndrome de salida de tórax, entre enero de 2000 y enero de 2009, en un hospital privado de la cuidad de Puebla, México. De ellos, 16 mujeres y seis hombres, con edad promedio de 35 años. Encontramos 16/22 (72.7 %) pacientes con síntomas neurológicos y 6/22 (27.3 %) con síntomas venosos; entre ellos, 2/22 (9.09 %) presentaban trombosis venosa de esfuerzo axilosubclavia. Resultados: Entre las 22 intervenciones encontramos bandas fibrosas en 8/22 pacientes (36.3 %): 1/22 (4.5 %) con una banda cervical tipo 1 y costilla cervical grado II, 1/22 (4.5 %) con banda cervical tipo 2 y costilla cervical grado I, 2/22 (9.09 %) con banda tipo 3, 1/22 (4.5 %) con banda tipo IV, 1/22 (4.5 %) con banda tipo V y 2/22 (9.09 %) con banda tipo VII y trombosis axilosubclavia. Después del procedimiento, 20/22 (90.9 %) pacientes manifestaron mejoría total y 2/22 (9.1 %), parestesias leves. No hubo complicaciones por lesiones nerviosas, vasculares o pleurales. Conclusiones: La técnica escrita provee un margen de seguridad amplio y mejora la visibilidad, disminuyendo las complicaciones quirúrgicas.

BACKGROUND: Endoscopic-assisted transaxillary first rib resection is a novel approach in the management of thoracic outlet syndrome (TOS) and allows us to safely identify the neurovascular package and different structures. Our main objective is to assess the results of morbidity and mortality of the surgical treatment in TOS with this technique. METHODS: We carried out a prospective, longitudinal study with 22 surgical interventions of transaxillary first rib resection with endoscopic support in patients with TOS from January 2000 to January 2009 in a private hospital located in Puebla, Mexico. There were 16 females and six males with a mean age of 35 years. We found 16/22 (72.7%) patients with neurological symptoms and 6/22 (27.3%) with venous symptoms; 2/22 (9.09%) patients had effort thrombosis of the axillary-subclavian vein. RESULTS: Of the 22 interventions, we found fibrous bands in 8/22 patients (36.3%); 1/22 (4.5%) with type 1 cervical band and cervical rib grade II, 1/22 (4.5%) with type 2 cervical band and cervical rib grade I, 2/22 (9.09%) with band type 3, 1/22 (4.5%) with band type IV, 1/22 (4.5%) with band type V and 2/22 (9.09%) with band type VII and axillary-subclavian thrombosis. After the procedure, 20/22 (90.9%) patients showed total symptom improvement and 2/22 (9.1%) patients had mild paresthesias. There were no complications from nerve, vascular or pleural damage. CONCLUSIONS: This technique provides an ample margin of safety and improves visibility, reducing surgical complications.

Late outcome of surgical treatment of the non-specific neurogenic thoracic outlet syndrome.

OBJECTIVE: Despite the relatively high incidence of the thoracic outlet syndrome, diagnostic criteria, role of surgery and optimal operative approach remain controversial. The main goal of the current study is to determine the long-term outcome of operative treatment of a series of patients with non-specific neurogenic thoracic outlet syndrome. METHODS: A retrospective study of a consecutive group of patients with thoracic outlet syndrome was carried out. The indications for surgery relied on clinical examination. Patients with diffuse pain were excluded. In all cases, the supraclavicular approach was used. Main outcome measures were neurological status and subjective complains. RESULTS: Nineteen patients have been operated over a period of 5 years. Total number of surgeries was 23. Pain and paresthesia on exertion were the leading symptoms in all cases. The causes of thoracic outlet syndrome were fibromuscular compression in 43.5%, cervical rib alone or in combination with a fibromuscular component in 30.4% and the first rib in 26.1%. The average follow-up was 36.3 months. In 91.7%, improvement of at least 50% was observed; 20.8% of the patients were completely symptom-free, and in 25%, the improvement was 90%. Recovery of the pre-operative motor weakness was recorded in 66.6%. The mortality and the permanent morbidity rates of the procedure were 0%. DISCUSSION: Operative decompression of the brachial plexus via the supraclavicular approach in patients with non-specific neurogenic thoracic outlet syndrome is a safe procedure that leads to a significant neurological improvement and amelioration of complains. The indication for surgery should be based chiefly on the neurological and clinical findings.

Thoracic outlet syndrome associated with a large cervical rib.

This case illustrates the anatomic impact of a large cervical rib as an etiology for thoracic outlet syndrome. Current management remains predicated on astute diagnosis, multidisciplinary therapy including, physical therapy, scalene muscle blockade, and surgical decompression in appropriate cases.

[Unusual reason for unilateral (corrected) Raynaud's phenomenon with intensification when the arms are elevated]. / Einseitiges Raynaud-Phänomen mit Verstärkung bei Elevation des Arms.

Thoracic outlet syndrome (TOS) is a broad term for compression of the neurovascular structures in the area of the 1. rib and the clavicle. The cause can be either fibrous bands, cervical ribs, anomalous muscles or posttraumatic changes as well as tumors. Symptoms depend on the affected structure, in most cases (up to 97% of TOS patients) neurologic symptoms are present. In case of an arterial compression, for example due to a cervical rib like in our case, embolism of the arm and finger arteries can occur. For mild or moderate symptoms a conservative approach with physiotherapy can be helpful. For severe cases surgical resection of the compressing structure and the first rib is necessary. In our case, the cervical and first rib were excised after an initial lysis therapy. Furthermore, the aneurysm of the subclavian artery was excised.