upper dry thoracic outlet syndrome
Introduction
Introduction to upper trunk thoracic outlet syndrome Anatomically, the upper trunk is located between the anterior and middle scalene muscles, without the basis of the compression, while the cervical 5 and 6 nerve roots are crossed at the intervertebral foramen. Wraparound is the basis of compression, so the authors referred to the upper dry thoracic outlet syndrome as the neck 5,6 nerve root compression. In the past, it was thought that the upper thoracic outlet syndrome was rare, accounting for only 4% to 10% of the thoracic outlet syndrome. In fact, the disease is very common in clinic. The main reason is to misclassify this type of thoracic outlet syndrome into cervical spondylotic radiculopathy. Both lesions are compressed by nerve roots, and the compression sites differ only by a few millimeters to one or two centimeters, which is clinically difficult to identify. With the in-depth study of neck and shoulder pain, it has been found that the neck 5 and 6 nerve root compression can not only exist independently, but also can be combined with cervical 5, 6 and cervical 5, 6 spinal cord compression cervical spondylosis, or combined with the next dry Type thoracic outlet syndrome. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: tinnitus
Cause
The cause of upper trunk thoracic outlet syndrome
Cause:
It is because the cervical 5,6 nerve roots are crossed before the intervertebral foramen, and the middle scalene tendon is surrounded by the initial fibers.
Prevention
Upper trunk thoracic outlet syndrome prevention
Avoid using heavy shoulders, as this will force the collarbone and increase the pressure on the chest outlet. You can also do some simple exercises to make your shoulder muscles strong.
Here are four exercises, each of which is done 10 times a day and repeated twice.
1. Stretch in the corner: Stand in the corner, about a foot or so, with your hands on two walls. The body leans against the corner and feels that the neck is pulled for 5 seconds.
2. Neck stretching: Place your left hand on the back of your head and your right hand on the back. Use your left hand to lean your head to the left, and the right neck has a pulling feel for 5 seconds. Change hands and practice in the opposite direction.
3. Shoulder joint activity training: shrug the shoulder, then move backwards and downwards, similar to the shoulder joint to make a circular motion.
4. Neck contraction: Hold your head straight to the ground and keep the squat position for 5 seconds.
Complication
Upper dry thoracic outlet syndrome complications Complications, tinnitus
Dizziness, tinnitus and other symptoms.
Symptom
Upper dry thoracic outlet syndrome symptoms Common symptoms shoulder pain muscle atrophy dizziness tinnitus fatigue dizziness
1. History and symptoms:
(1) Past history: Most patients have a long history of neck and shoulder pain, and as a treatment for neck and shoulder disease or frozen shoulder, the author has treated a group of long-term misdiagnosed cases, of which nearly half were misdiagnosed as cervical spondylosis. Another 2/5 patients were misdiagnosed as periarthritis of shoulder and shoulder joint.
(2) The main symptoms: the main manifestations of this disease are neck and shoulder pain and discomfort, can be radiated to the shoulder and elbow, the limb is weak, how to put the patient's limb when sleeping is not comfortable, may be accompanied by dizziness, tinnitus and other symptoms.
1 First consultation time: About 30% of the cases are diagnosed within 1 year of onset, half of the patients are diagnosed in 1 to 2 years, and 20% of patients are diagnosed in more than 2 years.
2 diseased limbs: more than non-dominant hands, accounting for more than 2/3.
3 characteristics of the disease: acute cases accounted for 55%, chronic disease accounted for about 45%.
4 Pain properties: both are closely related to body position, 95% of patients have intermittent attacks.
5 other symptoms: almost all cases have neck, shoulder, back abnormalities, discomfort, about half with pain, in addition, almost 95% of cases when sleeping, feel how the limb is uncomfortable, accompanied by shoulders With a powerlessness, a small number of patients may have tinnitus, dizziness and elbow weakness.
2. Examination and physical signs: The body shape, posture, symmetry of the shoulders and muscle atrophy of the upper limbs of the affected side should be carefully observed during the examination. Carefully check the neck, whether there is tenderness on the shoulder, check the muscle strength of the upper limbs, muscle tension, and feeling. And the situation of the ulnar artery pulsation, routine Adson, Wright, Roos test.
The authors found that almost all cases had tenderness at the midpoint of the posterior margin of the sternocleidomastoid muscle, and half of them had tenderness on the medial aspect of the medial scapula, and more than 80% of the deltoid and upper arm sensation decreased, of which 15% were accompanied. The medial side of the forearm was dull, and in the other half, the muscle strength was weakened, mainly the supraspinatus, the infraspinatus, the deltoid and the biceps, and the muscle atrophy.
3. Special test:
(1) Adson test: 15% to 20% positive.
(2) Roos test: The positive rate is similar to the former.
(3) Wright test: 80% of patients had a positive result.
Examine
Examination of upper dry thoracic outlet syndrome
1. Electromyography: only a few patients have positive consequences, 15% of patients with deltoid muscle, supraspinatus muscle, infraspinatus muscle, biceps muscle is a simple phase, less than 10% of cases on the EMG as a triangle Muscle, supraspinatus and infraspinatus muscle have fibrillation potential.
2. Radiological examination: The cervical X-ray plain film shows obvious hyperplastic changes of the cervical vertebrae and intervertebral space stenosis, the former accounted for about 70%, the latter accounted for 50%; in addition, about one-third of the cases showed cervical curvature disappeared. , straightening and transverse process is too long; another 10% of cases may have neck ribs and vertebral body frontal bone hyperplasia is a beak-like.
3. MRI examination: About one-third of cases have a posterior bulging sign of the intervertebral disc, but most cases can be seen without abnormalities.
4. Diagnostic treatment:
(1) Neck pain point closure: Clinically, a mixture of 2 ml of triamcinolone acetate and 0.5 ml of bupivacaine is used to make the neck pain point closed, and the corresponding transverse needle is inserted into the pain point, and the bone tissue is returned. When the blood is slowly pushed into the drug, the patient is stood up for 1 minute after the tender point is injected, and the deltoid muscle strength is checked again. At this time, all the patients feel that the injection side limb is easier than before the injection, and the shoulder abductor muscle strength is obviously increased, which is resistant. Resistance, 80% of the cases of bilateral muscle strength is basically symmetrical, for a small number of patients with bilateral neck and shoulder pain, can also be closed bilaterally, the weak side of the muscle is closed, most of them are better than the stronger side The muscle strength of the elbow flexor muscle was slightly weakened, and the muscle strength of the elbow flexor muscle was also significantly increased after the closure. The sensation was improved to 3 to 4 minutes after partial closure of the sensory limb of the affected limb. In addition, the sensory side of the forearm decreased. It also recovered or improved significantly. Others such as the loss of the lateral lateral sensation or the loss of the upper limbs were significantly improved after closure.
(2) cervical traction test: the examiner holds the patient's lower jaw with one hand, and gradually pulls up the patient's occipital part with one hand, and continuously pulls up for 1 minute with the force of 5~10kgf. At this time, the neck and shoulders of the patient are relaxed as much as possible; or 5kgf The strength of the cervical spine traction for 10min, immediately after traction examination, the shoulder abduction strength of all patients increased, the sense of decline also improved, but the effect can only be maintained for 1 ~ 2h.
Diagnosis
Diagnosis and identification of upper trunk thoracic outlet syndrome
diagnosis
For soreness, fatigue and muscle atrophy in the neck, shoulders and upper limbs, one of the following conditions should consider the possibility of the disease:
1. Shoulder muscle atrophy, shoulder abductor muscle weakness, lateral and upper arm lateral changes.
2. The inner feel of the forearm changes significantly.
3. The subclavian artery or vein has signs of compression.
4. The cervical vertebrae can be seen in the cervical rib or the seventh cervical vertebrae is too long.
5. EMG examination indicates that the conduction velocity of the branches on the stem is slowed down.
6. Exclude other diseases such as cervical spondylosis.
Differential diagnosis
Mainly differentiated from cervical 5,6 nerve root type cervical spondylosis, the author routinely used 0.5% bupivacaine 2ml plus triamcinolone acetonide 2ml, in the lateral neck tenderness point (usually at the midpoint of the posterior margin of the sternocleidomastoid muscle) Thoracentesis of the cervical vertebrae, re-infusion without blood, slowly injected, if the patient's sensory muscle strength improved significantly or completely returned to normal after 1 min, it can be confirmed that the neck 5,6 nerve root compression is outside the intervertebral foramen, is muscular , rather than bony, it must be noted that spinal cord compression cervical spondylosis can also be accompanied by extravertebral nerve compression, such as can be diagnosed before surgery, in the cervical spondylosis surgery before the cut, the middle oblique The starting fibers of the horn muscles at the 5,6 nerve roots of the neck may avoid the pain and discomfort of the neck after surgery.
