Introduction: Cervico-thoraco-brachial outlet syndrome is a rare condition, affecting 1% of the population. It results from the compression of the vasculo-nervous structures, most often by the presence of a cervical rib or fibrous tissue. The place and importance of surgery remains debated by these authors who advocate conservative treatment. Patients and methods: This was a retrospective descriptive study of five patients with cervico-thoraco-brachial crossing syndrome treated in the Thoracic and Cardiovascular Surgery Department of National University Hospital Center of Fann in Senegal from January 1, 2006 to December 31, 2020, over a period of 15 years. Results: Five patients, aged on average 33 years (extreme 18 and 50 years), were operated on. The predominance was female (1 man and 4 women). The symptoms were neurological in all patients, with upper limb claudication (3 cases), cervico-brachialgia and paresthesias (5 cases). The right side was the most affected with 3 patients. Right supraclavicular swelling was noted in two patients. The Adson test was positive in 4 patients. No vascular manifestations were observed. The average duration of symptoms before the intervention was 4 years (Extremes: 1 and 5 years). Imaging revealed: a cervical rib in 3 patients. This was bilateral in 2 patients; and right unilateral in 1 patient. In the two other cases, it was an apophysomegaly of the 7th cervical vertebra and a fibrous dysplasia of the first left rib. The electromyogram performed in the 3 patients confirmed a C6 C7 C8 (1 case) and C6 C7 (2 cases) plexopathy. The preferred surgical approach was supraclavicular. For fibrous dysplasia of the first rib, a double sus and subclavicular approach was made. Compression was due to a cervical rib (3 cases), dysplasia of the first rib (1 case) and apophysomegaly (1 case). There was fibrous tissue (2 cases) and the anterior scalene muscle (1 case). Medical treatment and physiotherapy were instituted in all patients. This allowed us to have generally satisfactory results after an average follow-up of 8 years (2 – 15 years). Conclusion: cervico-thoraco-brachial crossing syndrome is rare. The most common anatomical modifications are the presence of a cervical rib or fibrous tissue. Surgery combined with physiotherapy improves the quality of life of patients. A more exhaustive multicenter study would allow a better evaluation of the syndrome.
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The cervico-thoraco-brachial crossing syndrome (CTBCS) is the set of clinical manifestations resulting from the compression of the nervous and / or vascular structures during their passage at the level of the thoraco-brachial passage
Compression is linked to changes in the cervical outlet and / or the presence of a cervical rib. Compression generally comes from the presence of a cervical rib, abnormal scalene fascicles or fibromuscular abnormalities
Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am 1995; 20: 542-8.
[6]
Chang KZ, Likes K, Davis K et al. The importance of the cervical ribs in thoracic outlet syndrome. J Vasc Surg 2013; 57: 771-775.
[3-6]
.
We distinguish: the complete cervical ribs, attached to the sternal manubrium by a cartilage individualized or confused with that of the first rib; incomplete cervical ribs, which may have a free end which floats in the supraclavicular hollow or be extended forward by a fibrous bunch which attaches to the first rib; Cervical pseudo-ribs are C7 processes extended by a solid fibrous cord and often associated with a cervical rib
[5]
Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am 1995; 20: 542-8.
[6]
Chang KZ, Likes K, Davis K et al. The importance of the cervical ribs in thoracic outlet syndrome. J Vasc Surg 2013; 57: 771-775.
[7]
Benzon HT, Rodes ME, Chekka K, et al. Scalene muscle injections for neurogenic thoracic outlet syndrome: case series. Pain Pract 2011; 12: 66-70.
[5-7].
The diagnosis is clinical based on neurological manifestations (pain, paresthesias and paresis of the neck, upper limb, chest wall and interscapulo-thoracic region) and/or vascular (more or less marked signs of limb ischemia thoracic: (pain and paresthesia, edema, reduction or abolition of pulse, heaviness, coldness and cyanosis) The cervicothoracic x-ray and CT scan highlight the anatomical abnormalities
Chang KZ, Likes K, Davis K et al. The importance of the cervical ribs in thoracic outlet syndrome. J Vasc Surg 2013; 57: 771-775.
[7]
Benzon HT, Rodes ME, Chekka K, et al. Scalene muscle injections for neurogenic thoracic outlet syndrome: case series. Pain Pract 2011; 12: 66-70.
[8]
Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309.
[9]
Chang K, Graf E, Davis K et al. Spectrum of presentation of thoracic outlet syndrome in adolescents. Arch Surg 2011; 146: 1383-1387.
[1, 6-9]
.
The aim of surgical treatment is to decompress the vascular-nervous bundle at the level of the thoraco-brachial process. The results are always punctuated by pain and sequelae paresthesias
[10]
Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
[11]
Orlando MS, Likes KC, Mirza S, et al. A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. J Am Coll Surg 2015; 220: 934-9.
[12]
Glass C, Dugan M, Gillespie D, et al. Costoclavicular venous decompression in patients with threatened arteriovenous hemodialysis access. Ann Vasc Surg 2011; 25: 640-5.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[14]
Caputo FJ, Wittenberg AM, Vemuri C, et al. Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations. J Vasc Surg 2013; 57: 149-57.
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[10-15]
. Thus, the recent use of physiotherapy has made it possible to improve the symptoms relegating surgery to the background
[16]
Sällström J, Celegin Z. Physiotherapy in patients with thoracic outlet syndrome. Vasa 1983; 12: 257-61.
[17]
Aligne C, Barral X. Rehabilitation of patients with thoracic outlet syndrome. Ann Vasc Surg 1992; 6: 381-9.
[18]
Novak CB. Physical therapy management of musicians with thoracic outlet syndrome. J Hand Ther 1992; 5: 73-9.
[16-18]
.
The aim of our work is to evaluate the results of surgical treatment of cervico-thoraco-brachial crossing syndrome. We will analyze these results in light of the literature.
2. Patients and Method
This was a retrospective study of five patients operated on for cervico-thoraco-brachial crossing syndrome between January 2004 and December 2021 in the Thoracic and Cardiovascular Surgery department in the National University Hospital Center of Fann in Senegal.. only patients operated on for cervico-thoraco-brachial crossing syndrome and followed in the department were included.
Pre- and post-operative pain was assessed using the visual analog scale (VAS), as well as whether symptoms recurred or not. The parameters studied were: sociodemographic characteristics, history, clinical signs and radiological lesions (radiography and chest CT), electromyography results, surgical treatment, evolution. The degree of patient satisfaction rated on a scale of 1 to 10 as for the VAS. The patients were classified into three groups. The result was fair if the score was less than 4. It was good if the score was between 5 and 8. A score above 8 was considered an excellent result. The analysis was descriptive. Quantitative variables were expressed by means and limits.
3. Results
Five patients, aged on average 33 years (extreme 18 and 50 years), were operated on. The majority was female (1 man and 4 women). The symptomatology was neurological in all patients marked by cervico-thoraco-brachial pain; paresthesias. Upper limb claudication was noted in 3 patients. The average duration of symptoms before the intervention was 4 years (Extremes: 1 and 5 years). The right side was the most affected with 3 patients. Right supraclavicular swelling was noted in two patients. The Adson test was positive in 4 patients. No vascular manifestations were observed.
Imaging revealed a cervical rib in 4 patients. This was bilateral in 3 patients; and right unilateral in 1 patient. In the last case, it was fibrous dysplasia of the first left rib. The Electromyogram (EMG) performed in the 4 patients with cervical ribs confirmed C6 C7 C8 (1 case) and C6 C7 (1 case) plexopathy. The EMG was normal in the other two patients. EMG was not indicated in the last patient with fibrous dysplasia of the left first rib. Table 1 summarizes the diagnostic aspects of the patients.
Table 1. Diagnostic aspects according to patients. Diagnostic aspects according to patients. Diagnostic aspects according to patients.
Patients
Sex
Age years
Clinical Data
Para-clinical data
Diagnosis retained
Functional
General
Physical
X-ray
Scanner
EMG
1
W
30
-Right cervvico-brachialgia
-right upper limb lameness
- Paresthesias
-Since 1 year
General condition preserved
-ADSON (+)
Bilateral cervical rib
-Bilateral cervical rib.
-Synostosis with the first right rib.
-Risk block narrowing the costoclavicular process to 6 mm on the right compared to 16 mm on the left.
Plexopathy C6, C7, C8 on the right
Right root compression by a cervical rib
Gruber type 3
2
W
45
-Left cervvico-brachialgia
-right upper limb lameness
- Paresthesias
-Since 5 years
General condition preserved
-Painful left supraclavicular mass
-ADSON (+)
Bilateral cervical rib
-Bilateral cervical rib
Plexopathy C6 and C7 on the left with radicular pain
Left root compression by a cervical rib
Gruber type 3
3
W
18
-Right cervvico-brachialgia
-right upper limb lameness
-Since 5 years
General condition preserved
-Right supraclavicular mass
-ADSON (+)
Bilateral cervical rib
Bilateral cervical rib without vascular lesion
Not done
Right radicular syndrome by a cervical rib
Gruber type 3
4
W
29
Right cervvico-brachialgia
Paresthesias of the 4th and 5th fingers
Since 4 years
General condition preserved
ADSON (+)
C7 apophyso-megaly
C7 apophyso-megaly
Normal
C7 apophyso-megaly
With right root compression.
Gruber type 3
5
M
50
-Left cervvicobrachialgia.
-Since 4 years
Paresthesias
General condition preserved
no mass.
ADSON (-)
Fibrous dysplasia of the 1st left rib.
Fibrous dysplasia of the 1st left rib.
Not indicated
Fibrous dysplasia of the 1st left rib.
C = Cervical rib; EMG = Electrmyogram; W = Women; M = Male.
Patients with a cervical rib were operated on via a supraclavicular approach. For fibrous dysplasia of the first rib, a double sus and subclavicular approach was made.
Exploration revealed compression of the brachial plexus by the cervical rib (once). In two cases, the compression was due to fibrous tissue stretched from the end of the cervical rib to the first rib. In one case, it was a compression by an extension of a fibrous tissue of the anterior scalene. In one patient (5th case), there was agenesis of the anterior scalene.
Figure 1. Surgical specimen for fibrous dysplasia of the first rib.
In one patient, the procedure was a resection of the cervical rib and the extending fibrous tissue (figure 1); or the 1st rib (4 cases). A partial anterior scalenectomy was associated in one patient.
There was a right pleural rupture which progressed well after 72 hours with chest drainage. The average length of hospitalization was 3 days (range: 2 and 5 days). Postoperative pain management was based on injectable paracetamol associated or not with tramadol. The postoperative course was simple.
After an average follow-up time of 8 years (range: 1 year – 17 years), one patient presented with residual pain relieved by analgesics. It was classified as a good result. In 2 patients, pain with residual paresthesia was noted at 2 months and 3 months postoperatively respectively. The EMG confirmed C7 C6 and C8 C7 C6 plexopathy. Analgesic treatment and vitamin B1 associated with motor physiotherapy were instituted with a disappearance of the pain after 6 months and 8 months respectively. They were classified as good results. Another patient who had undergone a previous scalenectomy had intermittent, persistent residual pain that was bearable under paracetamol combined with codeine or with oral tramadol. The latter was classified as fair. The last patient had no postoperative pain. His result was excellent. Table 2 illustrates the therapeutic and evolutionary aspects of the patients.
Table 2. Therapeutic and evolving aspects according to the patients.
Patients
Surgical Data
Evolution and results
Post-operative treatment
Results
Way
Exploration
Gestures
Duration of hospitalization
Evolution
EMG
1
Right supraclavicular
Right cervical rib compressing the right brachiocervical plexus
Resection of the right cervical rib.
2 Days
Fatigability at Y3
Brachial paresthesia at Y10
Residual pain
Axonopathy C6, C7, C8 on the right
Vitamin B
Motor physiotherapy
Good
2
Left supraclavicular
Left cervical rib + fibrous tissue attaching to C1 and compressing the right brachiocervical plexus + right pleural rupture
Resection of fibrous tissue and left cervical rib + pleural drainage
Days
Left antebrachial monoparesis at Y17
Residual pain
C8 and D1 axonopathy on the left.
Sensory axonal neuropathy of the left ulnar nerve with C8 and D1 radicular pain on the left
Vitamin B
Motor physiotherapy
Analgesics
Good
Paresthesias at A3
EMG shows a clear improvement in previous sensory and motor amplitudes
3
Right supraclavicular
Right cervical rib + fibrous termination of the anterior scalene on C1 compressing the right brachiocervical plexus
Right cervical rib resection + partial anterior scalenectomy.
Days
M2: regression of symptomsM5: pain after long work
Y1: normal examination
Y2: intermittent neurological symptoms
Y11: Cervico-brachialgia and anesthesia of the right shoulder stump
Normal
Vitamin B
Motor physiotherapy
Analgesics
Fair
4
Right supraclavicular
Right cervical rib with fibrosis sheathing nerve threads of the brachial plexus
Cervical rib resection.
4 Days
None at Y2
Not done
Vitamin B
Motor physiotherapy
Corticotherapy
Analgesics and Anti-inflammatories
Good
5
Left supra and subclavicular
Fibrous dysplasia of the left 1st rib compressing the right brachiocervical plexus
Resection of the 1st left rib.
Days
None at Y1
Not done
Analgesics
Excellent
C = Cervical rib; D = Dorsal rib; EMG = Electromyogram; Y = Year.
4. Discussion
The cervico-thoraco-brachial crossing syndrome has been the subject of publications and research for a long time but remains a rare condition
Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am 1995; 20: 542-8.
[6]
Chang KZ, Likes K, Davis K et al. The importance of the cervical ribs in thoracic outlet syndrome. J Vasc Surg 2013; 57: 771-775.
[7]
Benzon HT, Rodes ME, Chekka K, et al. Scalene muscle injections for neurogenic thoracic outlet syndrome: case series. Pain Pract 2011; 12: 66-70.
[8]
Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309.
[4-8]
. This rarity, proven by the short series found in the literature, is confirmed by the small size of our series. In his 2013 publication, Sané AD et al
[19]
Sané AD et al. Cervical rib - about 2 observations and review of the literature. Journal Africain de Chirurgie 2013; 2(3): 163-167.
[19]
found only 2 cases in Senegal. The anatomical anomalies and variations of the cervico-thoraco-brachial region are the causes of the symptoms of the cervico-thoraco-brachial crossing syndrome, the management of which gives rise to numerous controversies
[20]
Carlier A, Ronsmans C, Brilmaker J, Hayderi L EL. The cervico-thoracobrachial crossing syndrome: a heavy anatomical heredity. e-memoirs of the National Academy of Surgery 2008; 7 (3): 49-55.
[21]
Hooper TL, Denton J, McGalliard MK et al. Thoracic outlet syndrome: a controversial clinical condition. Part 1: Anatomy and clinical examination/diagnosis. Manip manuel J Ther 2010; 18: 74-83.
[20, 21]
.
The female predominance has been noted by several authors
[9]
Chang K, Graf E, Davis K et al. Spectrum of presentation of thoracic outlet syndrome in adolescents. Arch Surg 2011; 146: 1383-1387.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[20]
Carlier A, Ronsmans C, Brilmaker J, Hayderi L EL. The cervico-thoracobrachial crossing syndrome: a heavy anatomical heredity. e-memoirs of the National Academy of Surgery 2008; 7 (3): 49-55.
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[9, 13, 20, 22]
, which corroborates our results. Neurological forms are more the prerogative of women while vascular forms affect both men and women
[9]
Chang K, Graf E, Davis K et al. Spectrum of presentation of thoracic outlet syndrome in adolescents. Arch Surg 2011; 146: 1383-1387.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[9, 13]
. In our series, all our patients presented neurological forms consistent with the female predominance described in the literature.
Hug U, Jung FJ, Guggenheim M, Wedler V, Burg D, Künzi W. "True Neurologic Thoracic Outlet Syndrome". Handchir Mikrochir Plast Chir. 2006 Feb; 38(1): 42-5.
[1-3, 23]
.
The cervical rib is bilateral and symptomatic in 8-50% according to the authors
[6]
Chang KZ, Likes K, Davis K et al. The importance of the cervical ribs in thoracic outlet syndrome. J Vasc Surg 2013; 57: 771-775.
[24]
Ruber W. Ueber die halsrippen des menschen vergleichend-anatomischen remerkungen. Mem Acad imper St Petersburg. 1869; 13(2): 26.
[6, 24]
. We observed the presence of bilateral cervical rib in 3 patients. It was unilateral right in one patient. Other anomalies outside the cervical rib can be the cause of the cervico-thoraco-brachial crossing syndrome, as is the case with pseudarthrosis of the first rib reported by Borrelly J et al
[25]
Borrelly J, Merle M, Hubert J, Grosdidier G, Wack B. [Compression of the brachial plexus by a pseudarthrosis of the 1st rib]. Ann Chir Main 1984; 3: 266-8.
[25]
. These rare etiologies responsible for the neurological forms of cervico-thoraco-brachial crossing syndrome described in the literature were also found in our short series. This is the case in our 5th patient. Fibrous dysplasia of the first rib has not been found in the literature as a cause of cervico-thoraco-brachial crossing syndrome.
The neurological symptoms were dominated in all our patients by paresthesia. There was intermittent claudication in the 2 patients. Compression of the lower trunk of the brachial plexus is responsible for sensory and motor disorders in the ulnar territory
[8]
Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309.
[10]
Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
[8, 10]
. In crude forms, the Adson test can highlight the existence of nervous irritability
. This was the case in all our patients with a cervical rib. It was negative in the 5th patient.
Table 3. Gruber’s classification
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[22]
.
Type
Description
Gruber 1
Slight increase in the cervical vertebra not extending beyond the transverse processes.
Gruber 2
Cervical rib protrusion beyond transverse processes with free or floating end
Gruber 3
Projection of the cervical rib beyond the transverse processes reaching the cartilage of the 1st rib by a ligament
Gruber 4
Formation of a neo-articulation between the cervical rib, costal cartilage and sternum
Standard radiography made it possible to make the diagnosis in all cases and place them in the Gruber classification: Table 3
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[22]
. Our 4 patients with a cervical rib were classified as Gruber type 3 (Table 3). Other complementary examinations such as the cervicothoracic scan carried out in all our patients made it possible to look for associated vascular and bony abnormalities. The correlation between radiological signs and clinical manifestations is difficult to establish as reported by all authors
Hug U, Jung FJ, Guggenheim M, Wedler V, Burg D, Künzi W. "True Neurologic Thoracic Outlet Syndrome". Handchir Mikrochir Plast Chir. 2006 Feb; 38(1): 42-5.
[24]
Ruber W. Ueber die halsrippen des menschen vergleichend-anatomischen remerkungen. Mem Acad imper St Petersburg. 1869; 13(2): 26.
[25]
Borrelly J, Merle M, Hubert J, Grosdidier G, Wack B. [Compression of the brachial plexus by a pseudarthrosis of the 1st rib]. Ann Chir Main 1984; 3: 266-8.
[1, 3, 23-25]
and this was confirmed in our series.
All our patients had undergone surgery associated with functional motor rehabilitation and medical treatment based on vitamins, non-steroidal anti-inflammatory drugs and analgesics. For several years, this surgical treatment has sparked controversy among certain authors due to new conservative approaches in the management of cervico-thoraco-brachial crossing syndrome
[16]
Sällström J, Celegin Z. Physiotherapy in patients with thoracic outlet syndrome. Vasa 1983; 12: 257-61.
[17]
Aligne C, Barral X. Rehabilitation of patients with thoracic outlet syndrome. Ann Vasc Surg 1992; 6: 381-9.
[18]
Novak CB. Physical therapy management of musicians with thoracic outlet syndrome. J Hand Ther 1992; 5: 73-9.
[24]
Ruber W. Ueber die halsrippen des menschen vergleichend-anatomischen remerkungen. Mem Acad imper St Petersburg. 1869; 13(2): 26.
[16-18, 24]
. These new approaches consist of different functional rehabilitation protocols finding some indications in certain cases of cervico-thoraco-brachial crossing syndrome. These protocols were only effective in the absence of anatomical lesions responsible for the conflict with the vascular-nervous structures of the cervicothoracic region. This was not the case in any of our patients. The indications for surgery have been well elucidated in the literature
[21]
Hooper TL, Denton J, McGalliard MK et al. Thoracic outlet syndrome: a controversial clinical condition. Part 1: Anatomy and clinical examination/diagnosis. Manip manuel J Ther 2010; 18: 74-83.
[26]
Merle M, Borrelly J, Felten P. When and how to operate on neurogenic cervico-thoraco-brachial parade syndromes? About 358 interventions. In: Allieu Y, editor. The clavicle-scapular girdle. Montpellier: Sauramps; 2010. p. 289-310.
[21, 26]
.
Surgical resection of the cervical rib remains the standard treatment. The first approaches were Ross's axillary approach
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[27]
Merle M, Borrelly J. [Treatment of the neurologic forms of the thoracic outlet syndrome using the Ross approach]. Chirurgie 1987; 113: 188-94.
[15, 27]
. It has the advantage of being esthetic and less painful. Recognized as a major cause of vascular and nervous complications with a high recurrence rate, it was abandoned especially since it did not allow optimal control over the vascular and nervous elements at the time of the surgical procedure
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[27]
Merle M, Borrelly J. [Treatment of the neurologic forms of the thoracic outlet syndrome using the Ross approach]. Chirurgie 1987; 113: 188-94.
[28]
Merle M, Borrelly J. Complications of cervico-thoraco-axillary surgery. e-memories of the National Academy of Surgery 2002; 1 (3): 23-28.
[22, 27, 28]
. Thus, it is currently reserved for vascular forms of cervico-thoraco-brachial crossing syndrome
[2]
MERCIER CI, HOUEL F, DAVID G. Vascular syndromes of the thoracobrachial crossing. Cahier Med. 1979; 5(3): 161-77.
[12]
Glass C, Dugan M, Gillespie D, et al. Costoclavicular venous decompression in patients with threatened arteriovenous hemodialysis access. Ann Vasc Surg 2011; 25: 640-5.
[27]
Merle M, Borrelly J. [Treatment of the neurologic forms of the thoracic outlet syndrome using the Ross approach]. Chirurgie 1987; 113: 188-94.
[2, 12, 27]
. The new recommendations suggest the supraclavicular route which respects the insertion of the anterior scalene and the 1st side. It is currently the most used by surgeons. It allows total disinsertion of the cervical rib, resection of the middle scalene and other ligamentous, aponeurotic and muscular structures as needed
[8]
Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[24]
Ruber W. Ueber die halsrippen des menschen vergleichend-anatomischen remerkungen. Mem Acad imper St Petersburg. 1869; 13(2): 26.
[8, 13, 22, 24]
.
All our patients were operated on via the supraclavicular route. It allowed for a complete resection of the cervical rib (4 patients). In fibrous dysplasia of the first rib, it was associated with a complementary subclavicular approach for resection of the sternal end of the first rib. Rib resection was associated with partial anterior scalenectomy in one patient because of the close relationship between the anterior scalene and the brachial plexus.
Scalenectomy allowed complete release of brachial plexus compression
[28]
Merle M, Borrelly J. Complications of cervico-thoraco-axillary surgery. e-memories of the National Academy of Surgery 2002; 1 (3): 23-28.
[28]
. A deltopectoral or subclavicular approach could be carried out for the exploration of the clavipectoral process in order to section the aponeurosis of the subclavicular muscle and / or the coracoclavicular and coraco-costal ligaments if necessary
Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[1, 8, 13]
. Most often, scalenectomy concerns the middle scalene in order to prevent lateral migration of the vascular-nervous bundle which can be compressed between the clavicle and the first rib
[28]
Merle M, Borrelly J. Complications of cervico-thoraco-axillary surgery. e-memories of the National Academy of Surgery 2002; 1 (3): 23-28.
[28]
.
The most common operative incident in the literature is pleural rupture, which progresses well with chest drainage
[29]
Borrelly J, Merle R. New surgical therapeutic approach to neurogenic syndromes of the thoraco-cervico-axillary process. “Peace at the first coast” About a homogeneous and continuous series of 104 cases (July 2010-May 2013). Thoracic and Cardiovascular Surgery 2014; 18(3): 143-148.
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[29, 30]
. This is the case in one of our patients. Furthermore, it allowed better drainage of the supraclavicular cavity reducing the risk of postoperative pain
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[30]
. The immediate postoperative course was marked by complete remission of pain and paresthesias. Healing was achieved 15 days postoperatively. Before 2 months postoperatively, we noted a complete remission of the symptoms in all our patients. This was found among several authors
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[29]
Borrelly J, Merle R. New surgical therapeutic approach to neurogenic syndromes of the thoraco-cervico-axillary process. “Peace at the first coast” About a homogeneous and continuous series of 104 cases (July 2010-May 2013). Thoracic and Cardiovascular Surgery 2014; 18(3): 143-148.
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[15, 29-30]
. On the other hand, in 3 patients, we noted the recurrence of symptoms such as paresthesia of the upper limb from 2 months after the intervention. This could be explained by irritation of the brachial plexus or incomplete resection of the anterior scalene during surgery
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[19]
Sané AD et al. Cervical rib - about 2 observations and review of the literature. Journal Africain de Chirurgie 2013; 2(3): 163-167.
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[15, 19, 30]
which was not the case in our series. This recurrence has been reported in the literature, some authors of which proposed medical treatment associated with physiotherapy.
This rehabilitation, if systematically indicated after surgery, could risk aggravating the lesions if it was too violent
[10]
Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[10, 13, 22]
. Indeed, exercises should never trigger or increase pain during or after sessions. The indication for functional motor rehabilitation was aimed at patients who presented painful manifestations that were more or less bothersome on a functional level
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[23]
Hug U, Jung FJ, Guggenheim M, Wedler V, Burg D, Künzi W. "True Neurologic Thoracic Outlet Syndrome". Handchir Mikrochir Plast Chir. 2006 Feb; 38(1): 42-5.
[24]
Ruber W. Ueber die halsrippen des menschen vergleichend-anatomischen remerkungen. Mem Acad imper St Petersburg. 1869; 13(2): 26.
[13, 22-24]
. All our patients benefited from rehabilitation for three months with two to three sessions per week. Satisfaction was noted in all patients. The symptoms persisted after 2 years in one patient but were controlled by analgesics. The regularity of rehabilitation sessions favored success and regression of symptoms
[10]
Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
[29]
Borrelly J, Merle R. New surgical therapeutic approach to neurogenic syndromes of the thoraco-cervico-axillary process. “Peace at the first coast” About a homogeneous and continuous series of 104 cases (July 2010-May 2013). Thoracic and Cardiovascular Surgery 2014; 18(3): 143-148.
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[10, 29, 30].
The evaluation of the degree of satisfaction with surgery in our patients was made by residents using a visual scale as recommended by the authors
[10]
Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[10, 15]
. It was generally satisfactory for 4 patients, 3 of whom were classified “good” and one classified “excellent”. The fair result was mentioned in the patient with residual pain after a follow-up of 2 years. Our results confirm, after an average follow-up of 8 years, the improvement in the quality of life after surgery of patients suffering from cervico-thoraco-brachial crossing syndrome
[10]
Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[31]
Degeorges R, Reynaud C, Becquemin JP. Surgery for thoracic outlet syndrome: long-term functional results. Ann Vasc Surg 2004; 18: 558-565.
[10, 15, 30, 31]
.
5. Conclusion
The cervical rib is no longer an isolated clinical entity. It is rather part of the cervico-thoraco-brachial crossing syndrome “thoracic outlet syndrome”. The management of symptomatic cases requires multidisciplinary involvement. However, cervical rib resection is most often associated with an anterior scalenectomy. It made it possible to avoid resection of the first rib, which is a cumbersome procedure with serious complications. Resection of the first rib is only justified in cases of proven anatomical anomaly of the latter. Primary surgery in the management of cervico-thoraco-brachial crossing syndrome offers the best results and remains standard treatment. Surgery associated with rehabilitation is increasingly gaining a place of choice in the therapeutic arsenal of this pathology but recurrences are always possible, motivating long-term follow-up of patients.
Abbreviations
C
Cervical Rib
CTBCS
Cervico-Thoraco-Brachial Crossing Syndrome
D
Dorsal Rib
EMG
Electromyogram
M
Male
VAS
Visual Analog Scale
W
Women
Y
Year
Author Contributions
Kondo Bignandi: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing
Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am 1995; 20: 542-8.
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Chang KZ, Likes K, Davis K et al. The importance of the cervical ribs in thoracic outlet syndrome. J Vasc Surg 2013; 57: 771-775.
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Benzon HT, Rodes ME, Chekka K, et al. Scalene muscle injections for neurogenic thoracic outlet syndrome: case series. Pain Pract 2011; 12: 66-70.
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Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309.
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Chang K, Graf E, Davis K et al. Spectrum of presentation of thoracic outlet syndrome in adolescents. Arch Surg 2011; 146: 1383-1387.
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Rochlin DH, Gilson MM, Likes KC, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013; 57: 436-43.
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Orlando MS, Likes KC, Mirza S, et al. A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. J Am Coll Surg 2015; 220: 934-9.
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Glass C, Dugan M, Gillespie D, et al. Costoclavicular venous decompression in patients with threatened arteriovenous hemodialysis access. Ann Vasc Surg 2011; 25: 640-5.
[13]
Lugo J, Tanious A, Armstrong P, et al. Clinical research. Ann Vasc Surg 2015; 29: 1073-7.
[14]
Caputo FJ, Wittenberg AM, Vemuri C, et al. Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations. J Vasc Surg 2013; 57: 149-57.
[15]
Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves the patient's quality of life. J Vasc Surg 2009; 49: 630-637.
[16]
Sällström J, Celegin Z. Physiotherapy in patients with thoracic outlet syndrome. Vasa 1983; 12: 257-61.
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Aligne C, Barral X. Rehabilitation of patients with thoracic outlet syndrome. Ann Vasc Surg 1992; 6: 381-9.
[18]
Novak CB. Physical therapy management of musicians with thoracic outlet syndrome. J Hand Ther 1992; 5: 73-9.
[19]
Sané AD et al. Cervical rib - about 2 observations and review of the literature. Journal Africain de Chirurgie 2013; 2(3): 163-167.
[20]
Carlier A, Ronsmans C, Brilmaker J, Hayderi L EL. The cervico-thoracobrachial crossing syndrome: a heavy anatomical heredity. e-memoirs of the National Academy of Surgery 2008; 7 (3): 49-55.
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Hooper TL, Denton J, McGalliard MK et al. Thoracic outlet syndrome: a controversial clinical condition. Part 1: Anatomy and clinical examination/diagnosis. Manip manuel J Ther 2010; 18: 74-83.
[22]
Roos DB. New concepts of thoracic outlet syndrome which explain etiology, symptoms, diagnosis and treatment. Vasc Surg 1979; 13: 313-21.
[23]
Hug U, Jung FJ, Guggenheim M, Wedler V, Burg D, Künzi W. "True Neurologic Thoracic Outlet Syndrome". Handchir Mikrochir Plast Chir. 2006 Feb; 38(1): 42-5.
[24]
Ruber W. Ueber die halsrippen des menschen vergleichend-anatomischen remerkungen. Mem Acad imper St Petersburg. 1869; 13(2): 26.
[25]
Borrelly J, Merle M, Hubert J, Grosdidier G, Wack B. [Compression of the brachial plexus by a pseudarthrosis of the 1st rib]. Ann Chir Main 1984; 3: 266-8.
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Merle M, Borrelly J, Felten P. When and how to operate on neurogenic cervico-thoraco-brachial parade syndromes? About 358 interventions. In: Allieu Y, editor. The clavicle-scapular girdle. Montpellier: Sauramps; 2010. p. 289-310.
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Merle M, Borrelly J. [Treatment of the neurologic forms of the thoracic outlet syndrome using the Ross approach]. Chirurgie 1987; 113: 188-94.
[28]
Merle M, Borrelly J. Complications of cervico-thoraco-axillary surgery. e-memories of the National Academy of Surgery 2002; 1 (3): 23-28.
[29]
Borrelly J, Merle R. New surgical therapeutic approach to neurogenic syndromes of the thoraco-cervico-axillary process. “Peace at the first coast” About a homogeneous and continuous series of 104 cases (July 2010-May 2013). Thoracic and Cardiovascular Surgery 2014; 18(3): 143-148.
[30]
Chang DC, Lidor AO, Matsen SL, Freischlag JA. Complications reported in hospital following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg 2007; 21: 564-570.
[31]
Degeorges R, Reynaud C, Becquemin JP. Surgery for thoracic outlet syndrome: long-term functional results. Ann Vasc Surg 2004; 18: 558-565.
Bignandi, K., Diatta, S., Diop, M. S., Diagne, P. A., Ba, P. O., et al. (2024). Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal. International Journal of Cardiovascular and Thoracic Surgery, 10(5), 62-68. https://doi.org/10.11648/j.ijcts.20241005.11
Bignandi, K.; Diatta, S.; Diop, M. S.; Diagne, P. A.; Ba, P. O., et al. Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal. Int. J. Cardiovasc. Thorac. Surg.2024, 10(5), 62-68. doi: 10.11648/j.ijcts.20241005.11
Bignandi K, Diatta S, Diop MS, Diagne PA, Ba PO, et al. Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal. Int J Cardiovasc Thorac Surg. 2024;10(5):62-68. doi: 10.11648/j.ijcts.20241005.11
@article{10.11648/j.ijcts.20241005.11,
author = {Kondo Bignandi and Souleymane Diatta and Moussa Seck Diop and Pape Amath Diagne and Pape Ousmane Ba and Gabriel Amadou Ciss},
title = {Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal},
journal = {International Journal of Cardiovascular and Thoracic Surgery},
volume = {10},
number = {5},
pages = {62-68},
doi = {10.11648/j.ijcts.20241005.11},
url = {https://doi.org/10.11648/j.ijcts.20241005.11},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijcts.20241005.11},
abstract = {Introduction: Cervico-thoraco-brachial outlet syndrome is a rare condition, affecting 1% of the population. It results from the compression of the vasculo-nervous structures, most often by the presence of a cervical rib or fibrous tissue. The place and importance of surgery remains debated by these authors who advocate conservative treatment. Patients and methods: This was a retrospective descriptive study of five patients with cervico-thoraco-brachial crossing syndrome treated in the Thoracic and Cardiovascular Surgery Department of National University Hospital Center of Fann in Senegal from January 1, 2006 to December 31, 2020, over a period of 15 years. Results: Five patients, aged on average 33 years (extreme 18 and 50 years), were operated on. The predominance was female (1 man and 4 women). The symptoms were neurological in all patients, with upper limb claudication (3 cases), cervico-brachialgia and paresthesias (5 cases). The right side was the most affected with 3 patients. Right supraclavicular swelling was noted in two patients. The Adson test was positive in 4 patients. No vascular manifestations were observed. The average duration of symptoms before the intervention was 4 years (Extremes: 1 and 5 years). Imaging revealed: a cervical rib in 3 patients. This was bilateral in 2 patients; and right unilateral in 1 patient. In the two other cases, it was an apophysomegaly of the 7th cervical vertebra and a fibrous dysplasia of the first left rib. The electromyogram performed in the 3 patients confirmed a C6 C7 C8 (1 case) and C6 C7 (2 cases) plexopathy. The preferred surgical approach was supraclavicular. For fibrous dysplasia of the first rib, a double sus and subclavicular approach was made. Compression was due to a cervical rib (3 cases), dysplasia of the first rib (1 case) and apophysomegaly (1 case). There was fibrous tissue (2 cases) and the anterior scalene muscle (1 case). Medical treatment and physiotherapy were instituted in all patients. This allowed us to have generally satisfactory results after an average follow-up of 8 years (2 – 15 years). Conclusion: cervico-thoraco-brachial crossing syndrome is rare. The most common anatomical modifications are the presence of a cervical rib or fibrous tissue. Surgery combined with physiotherapy improves the quality of life of patients. A more exhaustive multicenter study would allow a better evaluation of the syndrome.},
year = {2024}
}
TY - JOUR
T1 - Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal
AU - Kondo Bignandi
AU - Souleymane Diatta
AU - Moussa Seck Diop
AU - Pape Amath Diagne
AU - Pape Ousmane Ba
AU - Gabriel Amadou Ciss
Y1 - 2024/12/30
PY - 2024
N1 - https://doi.org/10.11648/j.ijcts.20241005.11
DO - 10.11648/j.ijcts.20241005.11
T2 - International Journal of Cardiovascular and Thoracic Surgery
JF - International Journal of Cardiovascular and Thoracic Surgery
JO - International Journal of Cardiovascular and Thoracic Surgery
SP - 62
EP - 68
PB - Science Publishing Group
SN - 2575-4882
UR - https://doi.org/10.11648/j.ijcts.20241005.11
AB - Introduction: Cervico-thoraco-brachial outlet syndrome is a rare condition, affecting 1% of the population. It results from the compression of the vasculo-nervous structures, most often by the presence of a cervical rib or fibrous tissue. The place and importance of surgery remains debated by these authors who advocate conservative treatment. Patients and methods: This was a retrospective descriptive study of five patients with cervico-thoraco-brachial crossing syndrome treated in the Thoracic and Cardiovascular Surgery Department of National University Hospital Center of Fann in Senegal from January 1, 2006 to December 31, 2020, over a period of 15 years. Results: Five patients, aged on average 33 years (extreme 18 and 50 years), were operated on. The predominance was female (1 man and 4 women). The symptoms were neurological in all patients, with upper limb claudication (3 cases), cervico-brachialgia and paresthesias (5 cases). The right side was the most affected with 3 patients. Right supraclavicular swelling was noted in two patients. The Adson test was positive in 4 patients. No vascular manifestations were observed. The average duration of symptoms before the intervention was 4 years (Extremes: 1 and 5 years). Imaging revealed: a cervical rib in 3 patients. This was bilateral in 2 patients; and right unilateral in 1 patient. In the two other cases, it was an apophysomegaly of the 7th cervical vertebra and a fibrous dysplasia of the first left rib. The electromyogram performed in the 3 patients confirmed a C6 C7 C8 (1 case) and C6 C7 (2 cases) plexopathy. The preferred surgical approach was supraclavicular. For fibrous dysplasia of the first rib, a double sus and subclavicular approach was made. Compression was due to a cervical rib (3 cases), dysplasia of the first rib (1 case) and apophysomegaly (1 case). There was fibrous tissue (2 cases) and the anterior scalene muscle (1 case). Medical treatment and physiotherapy were instituted in all patients. This allowed us to have generally satisfactory results after an average follow-up of 8 years (2 – 15 years). Conclusion: cervico-thoraco-brachial crossing syndrome is rare. The most common anatomical modifications are the presence of a cervical rib or fibrous tissue. Surgery combined with physiotherapy improves the quality of life of patients. A more exhaustive multicenter study would allow a better evaluation of the syndrome.
VL - 10
IS - 5
ER -
Bignandi, K., Diatta, S., Diop, M. S., Diagne, P. A., Ba, P. O., et al. (2024). Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal. International Journal of Cardiovascular and Thoracic Surgery, 10(5), 62-68. https://doi.org/10.11648/j.ijcts.20241005.11
Bignandi, K.; Diatta, S.; Diop, M. S.; Diagne, P. A.; Ba, P. O., et al. Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal. Int. J. Cardiovasc. Thorac. Surg.2024, 10(5), 62-68. doi: 10.11648/j.ijcts.20241005.11
Bignandi K, Diatta S, Diop MS, Diagne PA, Ba PO, et al. Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal. Int J Cardiovasc Thorac Surg. 2024;10(5):62-68. doi: 10.11648/j.ijcts.20241005.11
@article{10.11648/j.ijcts.20241005.11,
author = {Kondo Bignandi and Souleymane Diatta and Moussa Seck Diop and Pape Amath Diagne and Pape Ousmane Ba and Gabriel Amadou Ciss},
title = {Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal},
journal = {International Journal of Cardiovascular and Thoracic Surgery},
volume = {10},
number = {5},
pages = {62-68},
doi = {10.11648/j.ijcts.20241005.11},
url = {https://doi.org/10.11648/j.ijcts.20241005.11},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijcts.20241005.11},
abstract = {Introduction: Cervico-thoraco-brachial outlet syndrome is a rare condition, affecting 1% of the population. It results from the compression of the vasculo-nervous structures, most often by the presence of a cervical rib or fibrous tissue. The place and importance of surgery remains debated by these authors who advocate conservative treatment. Patients and methods: This was a retrospective descriptive study of five patients with cervico-thoraco-brachial crossing syndrome treated in the Thoracic and Cardiovascular Surgery Department of National University Hospital Center of Fann in Senegal from January 1, 2006 to December 31, 2020, over a period of 15 years. Results: Five patients, aged on average 33 years (extreme 18 and 50 years), were operated on. The predominance was female (1 man and 4 women). The symptoms were neurological in all patients, with upper limb claudication (3 cases), cervico-brachialgia and paresthesias (5 cases). The right side was the most affected with 3 patients. Right supraclavicular swelling was noted in two patients. The Adson test was positive in 4 patients. No vascular manifestations were observed. The average duration of symptoms before the intervention was 4 years (Extremes: 1 and 5 years). Imaging revealed: a cervical rib in 3 patients. This was bilateral in 2 patients; and right unilateral in 1 patient. In the two other cases, it was an apophysomegaly of the 7th cervical vertebra and a fibrous dysplasia of the first left rib. The electromyogram performed in the 3 patients confirmed a C6 C7 C8 (1 case) and C6 C7 (2 cases) plexopathy. The preferred surgical approach was supraclavicular. For fibrous dysplasia of the first rib, a double sus and subclavicular approach was made. Compression was due to a cervical rib (3 cases), dysplasia of the first rib (1 case) and apophysomegaly (1 case). There was fibrous tissue (2 cases) and the anterior scalene muscle (1 case). Medical treatment and physiotherapy were instituted in all patients. This allowed us to have generally satisfactory results after an average follow-up of 8 years (2 – 15 years). Conclusion: cervico-thoraco-brachial crossing syndrome is rare. The most common anatomical modifications are the presence of a cervical rib or fibrous tissue. Surgery combined with physiotherapy improves the quality of life of patients. A more exhaustive multicenter study would allow a better evaluation of the syndrome.},
year = {2024}
}
TY - JOUR
T1 - Cervico-Thoraco-Brachial Crossing Syndrome: Results of Surgery in 5 Cases Operated on in the Thoracic and Cardiovascular Surgery Department in Senegal
AU - Kondo Bignandi
AU - Souleymane Diatta
AU - Moussa Seck Diop
AU - Pape Amath Diagne
AU - Pape Ousmane Ba
AU - Gabriel Amadou Ciss
Y1 - 2024/12/30
PY - 2024
N1 - https://doi.org/10.11648/j.ijcts.20241005.11
DO - 10.11648/j.ijcts.20241005.11
T2 - International Journal of Cardiovascular and Thoracic Surgery
JF - International Journal of Cardiovascular and Thoracic Surgery
JO - International Journal of Cardiovascular and Thoracic Surgery
SP - 62
EP - 68
PB - Science Publishing Group
SN - 2575-4882
UR - https://doi.org/10.11648/j.ijcts.20241005.11
AB - Introduction: Cervico-thoraco-brachial outlet syndrome is a rare condition, affecting 1% of the population. It results from the compression of the vasculo-nervous structures, most often by the presence of a cervical rib or fibrous tissue. The place and importance of surgery remains debated by these authors who advocate conservative treatment. Patients and methods: This was a retrospective descriptive study of five patients with cervico-thoraco-brachial crossing syndrome treated in the Thoracic and Cardiovascular Surgery Department of National University Hospital Center of Fann in Senegal from January 1, 2006 to December 31, 2020, over a period of 15 years. Results: Five patients, aged on average 33 years (extreme 18 and 50 years), were operated on. The predominance was female (1 man and 4 women). The symptoms were neurological in all patients, with upper limb claudication (3 cases), cervico-brachialgia and paresthesias (5 cases). The right side was the most affected with 3 patients. Right supraclavicular swelling was noted in two patients. The Adson test was positive in 4 patients. No vascular manifestations were observed. The average duration of symptoms before the intervention was 4 years (Extremes: 1 and 5 years). Imaging revealed: a cervical rib in 3 patients. This was bilateral in 2 patients; and right unilateral in 1 patient. In the two other cases, it was an apophysomegaly of the 7th cervical vertebra and a fibrous dysplasia of the first left rib. The electromyogram performed in the 3 patients confirmed a C6 C7 C8 (1 case) and C6 C7 (2 cases) plexopathy. The preferred surgical approach was supraclavicular. For fibrous dysplasia of the first rib, a double sus and subclavicular approach was made. Compression was due to a cervical rib (3 cases), dysplasia of the first rib (1 case) and apophysomegaly (1 case). There was fibrous tissue (2 cases) and the anterior scalene muscle (1 case). Medical treatment and physiotherapy were instituted in all patients. This allowed us to have generally satisfactory results after an average follow-up of 8 years (2 – 15 years). Conclusion: cervico-thoraco-brachial crossing syndrome is rare. The most common anatomical modifications are the presence of a cervical rib or fibrous tissue. Surgery combined with physiotherapy improves the quality of life of patients. A more exhaustive multicenter study would allow a better evaluation of the syndrome.
VL - 10
IS - 5
ER -
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