胸廓出口综合征的描述性综述（三）
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. 本次学习由谢珺田副主任医师主讲。
4. Relevant Anatomy
When discussing pertinent TOS anatomy, three spaces of frequent neurovasculature compression are the scalene triangle, costoclavicular space, and subcoracoid space. Table 1 summarizes the borders and relevant contents of each space. The most medial of the three is the scalene triangle, which is bounded anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the first rib . The scalene triangle contains the trunks of the brachial plexus and the subclavian artery, while the sub-clavian vein passes beneath the anterior scalene, avoiding the compartment altogether. Structures within the scalene triangle are often compressed by anatomic variations of the scalene muscles, the presence of the scalenus minimus muscle, or osseous abnormalities such as the presence of a cervical rib .
The costoclavicular space lies between the other two spaces and is bounded anteriorly by the clavicle, posteromedially by the first rib, and posterolaterally by the scapula’s upper border . The divisions of the brachial plexus and both of the subclavian vessels traverse this compartment . Compression within this compartment may result from anatomical variation of the subclavian muscle .
Lastly, the subcoracoid space is bounded anteriorly by the pectoralis minor muscle, posteriorly by ribs 2–4, and superiorly by the coracoid process of the scapula . The subcoracoid space contains the cords of the brachial plexus, the second part of the axillary artery, and the axillary vein, and these contents may be compressed by the clavipectoral fascia or chondrocoracoidal fasciculus .
4.相关解剖
在讨论TOS相关解剖学时，神经血管常受到三个空间的压迫，是斜角肌间隙、肋锁间隙和喙突下间隙。表1总结了每个空间的边界和相关内容。这三个三角中最内侧的是斜角肌间隙，它的前面是前斜角肌，后面是中斜角肌，下面是第一肋骨。斜角肌间隙包含臂丛主干和锁骨下动脉，而锁骨下静脉穿过前斜角肌，完全避开了这个间隙。斜角肌间隙内的结构经常被斜角肌的解剖变异、小斜角肌的存在或骨异常，如颈肋的存在所压迫。
肋锁间隙位于另外两个间隙之间，前与锁骨相连，后内与第一肋骨相连，后外与肩胛骨上缘相连。臂丛的分支和锁骨下血管都穿过这个间隙。压迫可能是由于锁骨下肌的解剖变异。
最后，喙突下间隙前面是胸小肌，后面是2-4肋骨，上面是肩胛骨的喙突。喙下间隙包含臂丛神经束、腋动脉第二部分和腋静脉，这些内容物可能被锁骨胸筋膜或软骨喙状束压迫。
5. Clinical Presentation
The constellation of symptoms seen in true nTOS is caused by compression or irritation of brachial plexus nerves. Pain, paresthesia, and/or weakness in the distribution of affected nerve roots are the hallmarks of nTOS presentation . Compression of the lower plexus (C7-T1) elicits pain of the medial arm, forearm, and hand, paresthesia of the fourth and fifth digits, and hand weakness or loss of dexterity. Similarly, compression of the upper plexus (C5-C7) results in pain in the neck, shoulder, chest, and supraclavicular region, along with arm weakness and paresthesia of the first three digits . In broader terms, patients often complain of proximal pain associated with distal paresthesia or weakness. Reproduction of these symptoms aid in diagnosis and can be accomplished by certain maneuvers (discussed later) or by directly pressing on the affected brachial plexus . Chronic nTOS may also result in thenar, hypothenar, and interossei muscle weakness and atrophy . History of neck trauma should raise suspicion of nTOS, with motor vehicle accidents being the most common inciting incident, followed by stress due to repetitive movement, especially in athletes who practice overhead lifting . Additionally, as previously mentioned, disputed nTOS patients may present with similar symptoms of true nTOS, along with a variety of associated symptoms, including facial pain, visual or hearing disturbances, vertigo, tachycardia, and sleep disturbances . Occipital headaches are another common complaint, occurring in 76% of nTOS patients .
5.临床表现
在真性nTOS中所看到的一系列症状是由压缩或刺激臂丛神经引起的。受影响的神经根分布区的疼痛、感觉异常、和/或无力是nTOS典型表现的标志。压迫下神经丛(C7-T1)引起内侧手臂、前臂和手的疼痛，第四和第五指，手无力或失去灵活性。同样的，压缩上神经丛(C5-C7)导致颈、肩、胸和锁骨上区疼痛，还有手臂无力和前三个手指[34]的感觉异常。更广泛的来说,患者常抱怨近端疼痛，远端感觉异常或无力。这些症状的再现有助于诊断，可以通过特定的检查方法(稍后讨论)或直接按压受累臂丛完成。慢性nTOS也可能导致大鱼际、小鱼际和骨间肌无力萎缩。有颈部外伤史者应怀疑为nTOS，机动车事故是最常见的诱发事件，其次是重复的运动产生的压力，尤其是练习头顶举的运动员。此外,先前提到的，假性nTOS患者可能会出现类似的真性nTOS的症状，以及各种相关症状，包括面部疼痛，视觉或听觉障碍、眩晕、心动过速和睡眠障碍。枕部头痛另一种常见的主诉，出现在76%的nTOS患者。
Compression of the subclavian vein results in the characteristic symptomatology of vTOS (also called “effort thrombosis” or Paget–Schroetter syndrome), which includes upper extremity swelling, venous engorgement, cyanosis, feelings of arm heaviness, and pain . The affected extremity is often noticeably larger than the other, and complaints of pain or heaviness are exacerbated by shoulder abduction. Symptoms are typically acute in onset with the formation of a thrombus in the subclavian vein . A history of heavy overhead lifting should raise suspicion for vTOS as a chronic venous injury is commonly the inciting cause of venous stenosis followed by thrombosis, and prompt recognition of this clinical presentation can reduce the complications of Paget–Schroetter syndrome .
While aTOS presents the least frequently, it is associated with the most dangerous clinical presentation and may present with pain and weakening of the radial pulse with large arm movement, as well as pallor, weakness, and fatigue. aTOS also commonly presents with hand or upper extremity ischemia due to distal embolization . aTOS is due to clinically evident compression of the subclavian artery and is the least common form of TOS . Although rare, aTOS is the most dangerous subtype of TOS, and patients who present with critical limb ischemia are treated immediately. aTOS patients with chronic limb ischemia should be recognized and treated in an expedited fashion to reduce potentially limb- and life-threatening complications. Physical exams should aim to identify ischemia and check for a marked discrepancy in blood pressure between the two arms . Classically, aTOS is associated with pallor, pulselessness, pain/paresthesia, and poikilothermia . A palpable pulse or audible bruit may be present in the supraclavicular area if an aneurism has formed . As with the other types of TOS, aTOS may be acquired in athletes or occupational lifters. However, it is much more commonly associated with anatomic variances, with an estimated 85% chance of occurring secondary to a cervical rib .
锁骨下静脉受压导致vTOS的特征性症状(也称为静脉血栓形成或Paget Schroetter综合征)，包括上肢肿胀、静脉充血、发绀、手臂沉重感和疼痛。患肢通常明显大于另一侧，肩外展可加重了疼痛或沉重的主诉。在锁骨下静脉血栓形成时，症状通常为急性发作。由于慢性静脉损伤通常是引起静脉狭窄并发血栓形成的诱因，因此有过头举重物的患者应怀疑vTOS，及时认识这种临床表现可减少Paget-Schroetter综合征的并发症。
虽然aTOS出现的频率最低，但它常与最危险的临床表现有关，可表现为大臂运动时桡动脉搏动减弱和疼痛，苍白，无力和易疲劳。由于远端栓塞，aTOS常出现手或上肢缺血。aTOS是由于锁骨下动脉明显受压引起，是最少的TOS形式。虽然少见，但aTOS是TOS最危险的亚型。慢性肢体缺血的aTOS患者应该被快速识别和治疗，以减少潜在的肢体和危及生命的并发症。体格检查的目的是鉴别缺血，并检查两侧上肢血压有无明显差异。通常，aTOS与苍白、无脉搏、疼痛/感觉异常和体温异常有关。如果动脉瘤已形成，则在锁骨上区可触到的明显脉搏或可听到杂音。和其他类型的TOS一样，aTOS可以在运动员或职业举重运动员中发生。然而，这种情况更常与解剖变异相关，估计有85%病例继发于颈肋。