胸廓出口综合征的描述性综述（四）

 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。

Diagnosis
As mentioned above, nTOS, vTOS, and aTOS each possess a characteristic clinical presentation based on their respective compressed structures. It is, however, important to note that there are often overlaps in symptomatology when multiple structures are compressed. Additionally, although explorative exams are invaluable in confirming the suspected diagnosis, negative results do not rule out TOS. Only a thorough history and physical exam with an emphasis on detecting neurovascular compromise, in combination with additional diagnostic tests and imaging, can accurately diagnose TOS and form an effective treatment plan.

诊断
如上所述，nTOS、vTOS和aTOS由于各自压迫的结构不同，而各有其临床特点。然而，需要注意的是，当有多个结构同时受压时，通常会有症状的叠加。此外，尽管探索性检查可以确诊可疑诊断，但阴性结果不排TOS。只有全面的病史和体格检查（以检测神经血管损害为重点），诊断性测试和影像学，能准确诊断TOS并形成一个有效的治疗方案。

The history comprises information regarding the onset, evolution, location, quality, intensity, and timing of symptoms, as well as their respective exacerbating and relieving factors. Specific questionnaires used in the workup of pain and disability, such as the McGill Pain Questionnaire or Northwick Park Neck Pain Questionnaire, may also provide invaluable insight into the patient’s symptoms and may be effective in collecting patient history.

病史包括关于发病、病情进展、位置、性质、症状的强度和时间，以及它们的恶化和缓解因素。在疼痛和功能障碍检查中使用的调查问卷，如McGill疼痛问卷或Northwick Park颈部疼痛问卷，可以对病人的症状提供非常宝贵的见解，并有效收集病史。

The physical exam is multifaceted and involves an examination of the patient’s posture, cervical alignment, and shoulder blade stability. Additional evaluation of the osseous, muscular, and nervous tissue of the thoracic outlet is usually indicated. The examination consists of careful observation, followed by palpation and various provocative maneuvers, which are discussed in the next section. Bony examination of the thoracic outlet includes the cervical and thoracic spine, first rib, and various joints of the shouldergirdle. Muscular assessment includes evaluation of strength and coordination of the scalene muscles, major and minor pectorals, trapezius, and accessory shoulder girdle muscles. Neurological examinations test the patient’s reflexes as well as sensation. Notably, loss of vibratory sense is highly suggestive of TOS, as vibration sensation is quickly lost following compression of the thoracic outlet.

体格检查是多方面的，包括检查患者的姿势、颈椎序列对齐和肩胛骨稳定性。附加评估通常指的是胸廓出口的骨、肌肉和神经组织。检查包括仔细观察，触诊和各种激发试验，这将在下一节中讨论。胸廓出口的骨骼检查包括颈胸椎、第一肋和肩胛带的各种关节。肌肉评估包括评估斜角肌，胸大肌和胸小肌，斜方肌和肩胛带辅助肌的力量和协调性。神经系统检查检测患者的反射和感觉。值得注意的是,振动觉的丧失高度提示TOS，因为胸廓出口受压后振动觉很快就会丧失。

Provocative Maneuvers
A hallmark of TOS is the reproducibility of symptoms with specific arm and shoulder movements. Three common physical exam maneuvers used to diagnose TOS include the elevated arm stress test (EAST), the upper limb tension test (ULTT), and the Adson test. These maneuvers are designed to target specific anatomic areas that are commonly implicated inTOS in order to reproduce symptoms of pain, paresthesia, or pulselessness. The maneuvers and positive results are outlined in Table 2. The EAST narrows the costoclavicular space, and subsequent hand gripping may result in pain or paresthesia in the case of nTOS and reduced radial pulse in the case of aTOS. The ULTT stretches the brachial plexus and elicits the symptoms of pain or paresthesia in the setting of TOS. Adson’s test is used to diagnose the compression of structures within the scalene triangle, which is made evident through a diminished radial pulse. Although provocative tests collectively only have an average sensitivity and specificity of 72% and 53%, respectively, they can provide considerable weight to a TOS diagnosis, especially when used in conjunction with imaging techniques.

激发试验
TOS的一个标志是特定的手臂和肩运动可重现症状。三种常用的用于诊断TOS的物理检查方法包括抬臂加压试验(EAST)、上肢张力试验(ULTT)和Adson试验。这些操作的目的是针对特定的解剖区域，重现疼痛、感觉异常或无脉搏的症状。操作和和阳性的结果列于表2。抬臂加压试验(EAST)使肋锁间隙变窄，然后紧握手，在nTOS中，可能导致疼痛或感觉异常，在aTOS中减少桡动脉搏动。上肢张力试验(ULTT)拉伸臂丛并诱发TOS产生疼痛或感觉异常。Adson试验通过桡动脉搏动减弱可诊断斜角肌间隙内结构的压迫。虽然激发试验的平均灵敏度和特异度分别为72%和53%，但仍为TOS诊断提供了相当大的权重，特别是当其与成像技术结合使用时。