| 2 women with acute anterior poliomyelitis affecting the upper limb girdles in early childhood later developed thoracic outlet syndromes, 1 of them bilaterally. It is thought that the poliomyelitis was a contributory factor in each case by allowing undue descent of the shoulder girdles, although cervical ribs were also present in the second case. This association had not been recorded previously. Both patients obtained substantial relief from anterior scalenotomy, indicating that previous involvement of the shoulder girdle by poliomyelitis does not negate the efficacy of this operative procedure. ( info) |
| Nine cases of microemboli of arterial origin to the upper extremity are reported. The source of emboli in five of these cases was in the subclavian artery compressed by osseous anomalies in the thoracic outlet. Three aneurysms, one in a subclavian vein graft and two traumatic false aneurysms in the hand, were also noted to be the sources of distal emboli. One unproved case of emboli from an atherosclerotic plaque of the subclavian artery is also reported. Chronicity of symptoms and delay in operation are often noted and lead to difficulties in surgical management. The compressing osseous structures causing the vascular lesion in the thoracic outlet syndrome must be resected, along with removal of the source of emboli. Cervicodorsal sympathectomy is often needed in cases of extensive thrombosis and/or long-standing ischemia. embolectomy is usually a futile procedure when the main arterial trunk contains old, organized thrombus. Differential diagnostic problems between collagen vascular disease, vasculitis, vasospastic disease, and microembolic disease in cases of unilateral Raynaud's phenomenon are pointed out. ( info) |
| Thirty-one patients with thoracic outlet syndrome have been studied in detail in the neurological and vascular clinics at this hospital. The patients were classified on the basis of their presenting symptoms into four groups--predominantly vascular, neurological, combined vascular and neurological, and pain and paraesthesiae alone. The majority of patients had radiological abnormalities and all had structural lesions in the superior thoracic aperture seen at operation. All operations were carried out through a standard supraclavicular approach, enabling the compressive structures to be visualized. This would not have been the case had the commoner trans-axillary approach for first rib resection been followed and in fact none of the operations included removal of the first rib. The results of operation were evident in our patients with a marked relief in their vascular symptoms, their pain and paraesthesiae and a slight but definite improvement in muscle bulk and power. ( info) |
14/21. Staging of arterial complications of cervical rib: guidelines for surgical management. subclavian artery compression by a cervical rib is an uncommon but potentially disabling condition. A series of 12 patients with 15 arterial lesions is reviewed and a staging system proposed to provide guidelines for managing patients with this condition. Stage I lesions have only arterial stenosis and minor poststenotic dilatation and are managed by thoracic outlet decompression, usually consisting of cervical rib resection. Stage II lesions have intrinsic arterial damage usually with subclavian aneurysm formation and require rib resection, aneurysmectomy, and arterial reconstruction. Stage III lesions present with distal thromboembolic complications and require thrombectomy or embolectomy in addition to thoracic outlet decompression and arterial reconstruction. The anatomic and pathophysiologic bases of the syndrome are reviewed and clinical and angiographic examples of each stage are presented. ( info) |
15/21. Isolated fracture of a cervical rib: a case report. A case of isolated fracture of a cervical rib in a young woman is presented. The mechanism of injury was direct blunt trauma. Histological examination showed changes compatible with a previous fracture of the cervical rib. literature concerning the incidence, complications and removal of these ribs is reviewed. Closely associated with this anomaly is the thoracic outlet syndrome, a differential diagnosis of which is given. ( info) |
16/21. The scalenus medius band and the seventh cervical transverse process. A case is reported of compression of the lowest trunk of the brachial plexus by a fibrous scalenus medius band. The band, when present, connects the transverse process of the seventh cervical vertebra, to the first rib. Its presence may on occasions be inferred from the abnormal shape of the seventh cervical transverse process. Similar case reports are reviewed. A study of the length and shape of the transverse process in symptoms-free patients was contrasted with the appearance in a patient with a scalenus medius band and symptoms of brachial neuritis. It is concluded that the shape rather than the length of the process is the clue to the diagnosis. ( info) |
17/21. cervical rib syndrome: a neurosurgical experience with a series of 38 cases. A series of 38 patients with thoracic outlet syndrome caused by a cervical rib is reviewed after a postoperative follow-up period of 3 to 24 years. The outcome of the operation (anterior scalenotomy and partial to subtotal removal of the cervical rib) is not considered wholly satisfactory; three causes for this were identified: excessive duration of symptoms (mean almost 6 years), insufficient patient work-up and inadequacy of the incomplete removal of the cervical rib. In the presence of a cervical rib, other possible causes of compression of the neurovascular supply to the upper limb should always be considered. ( info) |
| thoracic outlet syndrome is the causative factor in less than 5% of patients with upper extremity ischemia. Congenital bony abnormalities (cervical rib) are most often responsible for the arterial complications of this syndrome. This article presents the case report of a patient who presented with ischemia of an upper extremity caused by embolization from subclavian artery stenosis and an aneurysm secondary to cervical rib. The treatment plan included excision of the cervical rib, repair of the subclavian artery aneurysm and a bypass graft which achieved a satisfactory outcome. ( info) |
19/21. Distal arterial reconstruction using Esmarch's bandage technique to salvage upper extremity function in thoracic outlet syndrome caused by cervical ribs: a report of two cases. We present herein the cases of two patients with thoracic outlet syndrome (TOS) who required arterial reconstruction due to gangrene of the fingers and/or hand. In both patients, the cervical ribs had produced intimal injury of the subclavian arteries, and the successive distal arterial embolism brought about severe ischemia of the affected upper extremity. To treat the TOS, the cervical ribs were resected through a supraclavicular incision. In the first patient, arterial reconstruction was performed from the subclavian artery to the radial collateral artery, a branch of the deep brachial artery, which resulted in minimizing amputation of the gangrenous hand. In the second patient, resection and direct anastomosis of the injured subclavian artery were performed, and bypass surgery from a brachial artery to an interosseous artery was carried out, preserving finger function. Reversed saphenous vein grafts were utilized and Esmarch's bandage technique was applied as a substitute for a vascular clamp in both patients. Following these case reports, we discuss the technique of performing distal bypass in the upper extremities and comment on the usefulness of Esmarch's bandage technique for preserving upper extremity function. ( info) |
20/21. Cervical ribs: a cause of distal and cerebral embolism. The thoracic outlet syndrome occurs when the neurovascular structures are compressed as they traverse the thoracic outlet. Degenerative changes can occur in the subclavian artery and the vessel may become a source of embolism with the risk of acute or chronic upper limb ischaemia. Rarely, distal thromboembolism in the thoracic outlet syndrome may be associated with retrograde flow when there is the added risk of cerebral thromboembolism. ( info) |