【原】胸廓出口综合征的描述性综述（六）

 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。

Surgical Management
Although 60–70% of nTOS cases can be improved with conservative management, some patients still require decompressive surgery. Surgical management of TOS is typically considered after the patient has failed a trial of 4–6 weeks of conservative therapy and presents with worsening symptoms. As mentioned above, refractory cases of vTOS and aTOS also always require surgical management as a majority of cases are due to structural abnormalities with resultant subclavian artery stenosis with or without mural thrombus. More than half of patients with refractory nTOS and aTOS can be relieved by complete first rib resection and anterior scalenectomy (FRRS). The first rib is classically removed via either a transaxillary, supraclavicular, or infraclavicular approach. Although each approach has produced positive outcomes, the transaxillary approach is preferred to the clavicular counterparts in the setting of nTOS due to its rapid and easy exposure of the compressed structures, reducing the risk of injury. However, the supraclavicular approach is more advantageous in the setting of aTOS, as it allows for easier resection of the first rib, cervical ribs, and other fibromuscular structures which may be compromising the subclavian artery. Additionally, the subclavian artery is often compromised by extensive arterial injury or stenosis in aTOS, and an important advantage of the supraclavicular approach is the ability to address surgically indicated procedures on the subclavian artery. Surgical resections are usually very effective, with significant improvement found in approximately 90% of patients. Surgical patients also reported experiencing greater average levels of improvement than those who only underwent conservative therapy.

手术治疗
虽然60-70%的nTOS病例可以通过保守治疗得到改善，但一些患者仍然需要减压手术。4-6周的保守治疗无效且出现症状加重的患者，通常考虑TOS的手术治疗。如上所述，难治性vTOS和aTOS的病例总是需要手术治疗，因为大多数病例是由于结构异常，导致锁骨下动脉狭窄，伴有或无附壁血栓。超过一半的难治性nTOS和aTOS患者可以通过完全的第一次肋骨切除术和斜角肌切除术(FRRS)来缓解。第一根肋骨切除术通常有三种入路，腋窝、锁骨上或锁骨下。虽然每种方法都有效，但对于nTOS，腋窝入路优于锁骨入路，因为此入路快速，且容易暴露压迫结构，降低了损伤风险。然而，锁骨上入路在aTOS的治疗中效果更佳，因为它可以更容易地切除第一肋骨、颈肋和其他可能压迫锁骨下动脉的纤维肌肉组织。此外，aTOS中锁骨下动脉常常受到广泛的动脉损伤或狭窄，锁骨上入路的一个重要优势是能够在锁骨下动脉上进行手术操作。手术切除通常非常有效，约90%的患者有显著改善。接受外科手术的患者的平均改善程度高于单纯保守治疗的患者。

aTOS is commonly attributed to bony abnormalities such as the presence of a large cervical rib, which may fuse with the first rib and cause subclavian artery compression, resulting in subsequent thrombosis, embolism, and vascular compromise. Surgical management of aTOS consists of three general steps: Firstly, the source of arterial compression is removed. Although FRRS is most commonly performed, it is currently unclear as to whether first rib resection or scalenectomy is more vital for effective aTOS treatment. The first rib is often removed to prevent aTOS recurrence as it is a common fibromuscular anchor point, many of which cause compression of the subclavian artery. However, some authors argue that scalenectomy alone produces similar results utilizing a less invasive procedure, with a lower risk of injury, morbidity, and improved patient recovery times. The superiority of either approach remains unclear, and a majority of aTOS patients do well post-FRRS. The second step of aTOS management involves inspection of the subclavian artery for damage due to arterial degeneration, dilation, or aneurysm. If compromised, the artery is repaired with a saphenous vein graft, synthetic prosthesis, or bypass grafting. The final consideration in aTOS management involves blood flow restoration in the form of vascular reconstruction. Patients may also require additional embolectomy in concert with vascular reconstruction if there is distal embolization .

aTOS通常归因于骨的结构异常，如一根大的颈肋的存在，它可能与第一肋融合并导致锁骨下动脉压迫，导致继发的血栓形成、栓塞和血管损害。aTOS的手术操作包括三个步骤：首先，去除压迫动脉的结构。虽然FRRS手术最常见，但目前尚不清楚第一肋切除术或斜角肌切除术在有效的aTOS治疗中是否更加重要。第一肋通常被切除，防止aTOS的复发，因为它是一个常见的纤维肌肉的锚定点，其中许多会导致锁骨下动脉的压迫。然而，一些作者认为，采用更微创的单纯斜角肌切除术可以产生类似的结果，且损伤风险更低、复发少和恢复时间短。这两种方法的优势性尚不清楚，大多数aTOS患者在FRRS后表现良好。aTOS手术的第二步包括检查锁骨下动脉是否存在因动脉变性、扩张或动脉瘤造成的损伤。如果动脉受损，可以采用隐静脉移植、人工假肢或旁路移植修复。aTOS手术的最后考虑因素是以血管重建形式的血流重建。如果存在远端栓塞，患者可能还需要进行额外的栓塞清除和血管重建。

Current first-line treatment in acute vTOS include thrombolytic therapy and early decompression with FRRS and subclavius tendon division. Following initial treatment, venography is often used to evaluate the need for venoplasty. Interestingly, recent studies have suggested that thrombolytic therapy may not reduce the likelihood that a patient will require venoplasty, and thus may not be effective in first-line treatment of vTOS. Surgical decompression is also indicated in patients presenting with chronic vTOS, along with preoperative thrombolysis and postoperative anticoagulation to maintain venous patency. Occasionally, vTOS patients will also present with symptoms of intermittent obstruction without accompanying occlusion of the subclavian vein and only require surgical decompression. Rib resections carry an inherent risk of neurovascular injury due to poor visualization and incomplete resection. The use of robotically assisted endoscopic cameras allows for improved visualization of the first rib and the neurovascular bundle, although it is unclear whether this procedure is correlated with stronger symptomatic and postoperative outcomes. Other studies have discussed the advantages of minimally invasive surgical approaches to symptomatic TOS; robotically assisted transthoracic cervical rib resections are associated with improved postoperative wound healing, decreased neurologic complications, and cosmetically favorable scar formation.

目前急性vTOS的一线治疗包括溶栓治疗和早期用FRRS和锁骨下肌腱切开减压。在早期治疗，静脉造影术通常被用于评估静脉成形术的必要性。有趣的是，最近的研究表明，溶栓治疗可能不会降低患者需要静脉成形术的可能性，因此溶栓治疗在vTOS的一线治疗中可能无效。外科减压推荐用于慢性vTOS患者，同时应用术前溶栓和术后抗凝以维持静脉通畅。偶尔，vTOS患者也会出现间歇性阻塞的症状，而不伴有锁骨下静脉的阻塞，只需要手术减压。肋骨切除术，，由于视野暴露不良和肋骨部分切除，具有神经血管损伤的风险。使用机器人辅助的内窥镜技术可以改善第一肋和神经血管束的可视化，尽管尚不清楚该手术是否与严重的术后症状相关。其他研究讨论了微创手术治疗症状性TOS的优势；机器人辅助经胸颈肋切除术与改善术后伤口愈合、减少神经并发症和疤痕更加美观有关。

Conclusions
TOS stems from compression of the neurovasculature in the thoracic outlet and can be subdivided into nTOS, vTOS, and aTOS based on the relevant compromised structures and corresponding clinical presentations. The most common cause of TOS is neck trauma, which can arise due to whiplash injuries sustained during a motor vehicle collision. Other populations with increased risk of TOS include athletes who frequently perform overhead movements, patients with tumors or cysts surrounding the thoracic outlet, and those born with anatomic variations such as a cervical or anomalous first ribs. Diagnostic criteria for TOS remain controversial, and a thorough history combined with subsequent provocative maneuvers, radiographic imaging, and vascular studies are helpful in elucidating TOS and rule out other differential diagnoses. Early recognition and appropriate treatment are paramount for patient recovery, although this is often difficult due to nonspecific symptoms at initial presentation. First-line therapy is conservative, and most often consists of a combination of physical therapy and pharmacological management. Injection therapy may also be considered if symptoms are due to muscular compression. Surgical intervention is considered only after the patient has failed conservative therapy, although it may be considered earlier if patients present with worsening aTOS or vTOS.

结论
TOS源于胸廓出口神经血管系统的压缩，根据相关的受压结构和相应的临床表现，可细分为nTOS、vTOS和aTOS。TOS最常见的原因是颈部创伤，这可能是由于机动车碰撞中的鞭打伤害造成的。其他患TOS的高风险人群包括经常进行头顶运动的运动员，胸廓出口周围有肿瘤或囊肿的患者，以及先天性解剖变异的人群，如颈肋或异常的第一肋骨。TOS的诊断标准仍然有争议，全面的病史采集结合激发试验、影像检查和血管血管有助于明确TOS，排除其他鉴别诊断。早期识别和适当的治疗对患者的恢复是至关重要的，尽管在疾病初期阶段由于非特异性症状而诊断困难。一线治疗是保守治疗，通常物理治疗结合药物治疗。如果症状起源于肌肉压迫，也可以考虑注射治疗。只有在患者保守治疗失败后才考虑手术干预，如果患者出现aTOS或vTOS恶化，可以提前考虑手术干预。