胸廓出口综合征的描述性综述（二）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Masocatto NO, Da-Matta T, Prozzo TG, Couto WJ, Porfirio G. Thoracic outlet syndrome: a narrative review. Síndrome do desfiladeiro torácico: uma revisão narrativa. Rev Col Bras Cir. 2019;46(5):e20192243. Published 2019 Dec 20. 本次学习由王珺楠副主任医师主讲。

2. Epidemiology 

The epidemiology of TOS is not fifirmly established, likely due to a lack of agreement regarding universal diagnostic criteria . The existing data suggest an average incidence of TOS between 3 to 80 cases per 1000 people, typically affecting adolescents to middle-aged adults, especially females between the ages of 20 and 50 . As mentioned above, TOS is usually subclassifified into nTOS, vTOS, and aTOS. nTOS arises from compression of the brachial plexus and comprises the majority of TOS cases, making up for 95% of all diagnosed cases. vTOS and aTOS stem from compression of the subclavian vessels and comprise roughly 4% and 1% of TOS cases, respectively .

nTOS can be subdivided into true or disputed nTOS, and is categorized as true nTOS with the presence of objective diagnostic abnormalities . True nTOS presents very rarely and is classically a unilateral condition in female patients, while disputed nTOS makes up for 95–99% of all nTOS cases, is often bilateral, and does not feature a classic syndromic vignette as the other types of TOS do . Although disputed nTOS may present with upper extremity symptoms similar to true nTOS, it is also often associated with other diffuse symptoms such as facial pain, visual or hearing disturbances, vertigo, tachycardia, and sleep disturbances .

2.流行病学

TOS的流行病学尚未确定，可能是由于缺乏统一的诊断标准。现有数据显示TOS的平均发病率为3-80/1000，常发生在青少年到中年人，特别是20- 50岁的女性。正如上面提到的,TOS通常分为nTOS、vTOS和aTOS。nTOS源自臂丛神经的压迫，占TOS的绝大多数，占确诊病例的95%。vTOS和aTOS都来自锁骨下血管受压,分别占TOS病例的4%和1%。

nTOS可以分为真性nTOS和假性nTOS，假性nTOS为真性nTOS同时伴有客观诊断异常。真性nTOS很少，表现为典型的女性患者的单侧症状，而假性nTOS构成了95-99%的nTOS病例，通常是双侧的，不像其他类型的TOS那样有典型的症状。尽管假性nTOS可能会出现上肢症状类似于真性nTOS，也常与其他弥漫性症状伴随出现如面部疼痛、视觉或听觉障碍、眩晕、心动过速、还有睡眠障碍。

As mentioned above, vascular TOS may be subdivided into vTOS and aTOS, depending on the compromised structures on presentation. vTOS is often associated with repetitive upper extremity activity and is seen in active young males, with symptoms presenting in the dominant arm . Typical symptoms of vTOS include cyanosis in the distal arm, as well as stiffness and tension in the superfificial veins of the upper extremity . In comparison, aTOS does not follow a gender distribution and is instead often linked to young adults with the presence of certain congenital anomalies such a cervical rib . While aTOS presents the least frequently, it is associated with the most dangerous clinical presentation and usually presents with pain and weakening of the radial pulse with large arm movement, as well as pallor, weakness, and fatigue .

As mentioned above, there exists a lack of data regarding the epidemiology and pathology of TOS due to its inconsistent diagnosis. In 2016, the Society for Vascular Surgery released an executive summary regarding new reporting standards for TOS . This document aims to unify terminology used to describe TOS and the diagnostic workup process, as well as improve overall reporting standards in an effort to gather clinical evidence to defifine better TOS treatment options.

如上所述，血管型TOS可细分为vTOS和aTOS，具体取决于受压的结构。vTOS通常与重复的上肢活动有关，见于活跃的年轻男性，症状多表现在优势臂。vTOS的典型症状包括上肢远端发绀，以及上肢浅静脉的僵硬和张力。而aTOS无明显性别分布差异，而是常与有某些先天性异常的年轻人相关，如颈肋。虽然aTOS发生率最低，但它与最危险的临床表现相关，通常表现为疼痛和手臂大范围活动时桡动脉搏动减弱，以及苍白、无力和疲劳。

如上所述，由于诊断标准不一致，缺乏关于TOS的流行病学和病理学。2016年，血管外科学会发布了一份关于TOS新报告标准的执行摘要。这文件旨在统一描述和诊断检查TOS中的术语，并改善整体报告标准，以努力收集临床资料以确定更好的TOS治疗方案。

3. Etiology 

There are many potential causes of TOS, ranging from congenital anomalies to repetitive motion injuries, all of which result in compression of the neurovascular bundle traversing the thoracic outlet. Nearly 70% of cases are related to soft tissue etiologies (such as scalene hypertrophy, regional tumors, or a muscular variation such as the scalenusJ. Clin. Med. 2021, 10, 962 3 of 13 minimus muscle), with the remaining 30% related to bone abnormalities such as cervical ribs or joint injury with resulting malunion .

Additionally, TOS etiologies may be divided into traumatic and nontraumatic causes. A majority of nTOS cases are preceded by neck trauma due to either acute neck hyperextension or midshaft clavicular fracture sustained during motor vehicle accidents . Additionally, fifibrosis due to wound healing from acute trauma has also been reported to occasionally compress the neurovasculature, resulting in secondary nTOS . As mentioned previously, muscular hypertrophy can predispose to TOS as well and is an example of a nontraumatic etiology. Chronic poor posture may also result in shortening of the scalene and pectoral muscles and constrict the thoracic outlet . Both nTOS and vTOS are occasionally reported in young athletes due to injury from repetitive overhead motions with hypertrophy and fifibrosis of the anterior scalene and pectoralis minor muscles . Other nontraumatic causes such as the presence of regional tumors and cysts may invade the thoracic outlet and compress the neurovasculature . Cervical ribs are commonly found in aTOS cases, although they are rare and typically asymptomatic in the general population .

3.病因

TOS的潜在原因有很多，从先天性异常到重复性运动损伤，所有这些都会导致穿过胸腔出口的神经血管束受到压迫。近70%的病例与软组织病因有关(如斜角肌肥大、局部肿瘤或肌肉变异如最小斜角肌)。其余30%与骨异常有关，如颈肋或关节损伤导致骨不愈合。

此外，TOS病因可分为创伤性和非创伤性。大多数nTOS患者在发病前都是由于急性颈部过伸或机动车事故中发生锁骨中段骨折导致的颈部创伤。此外，也有报道称，急性创伤愈合引起的纤维化偶尔会压迫神经血管系统，导致继发性nTOS。正如前面所提到的，肌肉肥大也容易诱发TOS，而且是非创伤性病因学的一个例子。慢性姿势不良也可能导致斜角肌和胸肌缩短，并收缩胸廓出口。在年轻运动员中，由于反复的头顶运动损伤伴有前斜角肌和胸小肌肥大和纤维化，偶尔有nTOS和vTOS的报道。其他非创伤性原因，如局部肿瘤和囊肿的存在，可侵犯胸椎出口并压迫神经血管系统。颈肋在aTOS病例中很常见，但在一般人群中很少见且典型无症状。