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1. It refers compression of subclavian vessels and brachial plexus at the superior aperture of the thorax. 2. The symptoms can be neurologic or( and ) vascular. 3. The pain may be atypical and predominant in the chest wall and parascapular area, simulating angina pectoris.
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4. Diagnosis of nerve compression can be determining the ulnar nerve conduction velocity( UNCV ). 5. Physiotherapy to improve posture, strengthen shoulder girdle, and stretch neck muscle is used initially. 6. Surgery includes extirpation the first rib, usually through transaxillary approach.
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A. ANATOMIC CONSIDERATIONS
A-0 The subclavian vessels and brachial plexus transverse the cervicoaxillary canal into the arm. The outer border of the first rib divides the canal into a proximal and a distal division. The proximal division is composed of the scalene triangle and the space bounded by the clavicle and the first rib( costoclavicular space ).
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A. ANATOMIC CONSIDERATIONS
4. The proximal division is the most critical for neurovascular compression. It is bounded superiorly by the clavicle and the subclavius muscle; inferiorly by the first rib; anteromedially by the sternum, clavipectal fascia and the costocoracoid ligament; and posterolaterally the scalenus media muscle and the long thoracic nerve.
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A. ANATOMIC CONSIDERATIONS
5. The axilla, which is the outer division of the cervicoaxillary canal is bounded with pectoralis minor muscle, the coracoid process, and the head of humerus.
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C. DIAGNOSIS
1. PE, history, radiographs of chest and cervical spine, neuroloical consultation, EMG and UNCV. 2. Pulmonary, esophageal and chest wall causes must be ruled out.
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C-2 Angiography
1. Bruits in the supra- or infraclavicular spaces suggests stenosis, and absence of pulse denotes total occlusion. 2. Retro- or antegrade arteriograms of the subclavian and brachial arterial systems are indicated. 3. Phlebograph is indicated in patients of venous stenosis or obstruction.
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D. THERAPY
1. Physiotherapy is performed before surgery. 2. Physiotherapy includes heat massage, active neck exercise, scalenus anticus muscle stretching, strengthening of the upper trapezius muscle, and posture instrusion. 3. Most patients with a UNCV above 60 m/sec improve with phsiotherapy. 4. Most patients with a UNCV below 60 m/sec must undergo surgery with resection of the first rib and correction of other bony deformities.
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D. THERAPY
5. Roos et al. suggested resection of the first rib, and a cervical rib when present, is best performed through the transaxillary approach, with decompression of 7th and 8th cervical and 1st thoracic root. 6. The anterior supraclavicular, infraclavicular and posterior approach were ever reported. 7. Posterior approach is especially important because 80% of patients are females.
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D-2 Results
1. The results of first rib resection is good in 85%, fair in 10% and poor in 5%. 2. Uniform improvement of symptoms is usually in patients of primarily vascular compression. 3. There are 2 groups of patients, who have neural compression.
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D-2 Results
4. The 1st group includes patients with ulnar neuralgia and diminution of radial pulse. 95% of this group are improved after first rib resection. 5. The 2nd group includes patients with atypical pain distribution with or without pulse change in compression tests. Although many patients can improve after first rib resection, the fair and poor results may mostly occur in the group.
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D-2 Results
6. No hospital mortality is related directly to the procedure. 7. Morbidity includes pneumothorax, hematoma and infection.
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E. PAGET-SCHROETTER SYNDROME
1. It refers effort thrombosis of the axillarysubclavian vein inducing by excessive or unusual use of the arm in addition to one or more compressive elements. 2. It is usually seen in professional athletes, Linotype operators, painters and beauticians. 3. Anticoagulants and conservative exercise can be used to treat it.
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E. PAGET-SCHROETTER SYNDROME
4. First rib resection is indicated for patients with recurrent disease when returning to work. 5. Bypass with veins and other conduits has limited application.
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