【原】胸廓出口综合征的描述性综述（五）

 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。

Imaging and Additional Diagnostic Tests
Although the combination of patient history and detailed physical exam often induce strong clinical suspicion of TOS, imaging is often necessary to confirm both the subtype and exact anatomical site of compression. Plain chest radiographs play a significant role in the diagnosis of all three types of TOS and serve as good initial tests, especially if the clinical presentation is vague. Chest X-rays are also useful in identifying bony abnormalities associated with TOS, including cervical ribs, first rib anomalies, focal bone lesions, and congenital malformations. CT and MRI also play definitive roles in diagnosing TOS subtypes by providing a more detailed survey of the anatomy.

影像学检查
虽然结合病史和详细的体格检查常常引起临床上对TOS的强烈怀疑，影像学检查通常需要证实这两种亚型以及压迫的确切解剖位置。胸部平片起着重要的作用。在所有三种TOS类型的诊断中，都可以作为很好的初始测试，特别是如果临床表现不明确。胸部x光片在鉴别骨骼方面也很有用。与TOS相关的异常，包括颈肋骨、第一肋骨异常、局灶性骨病变和先天性畸形。CT和MRI也起决定性作用，对TOS亚型的诊断可提供更详细的解剖学评估。

In the setting of nTOS, imaging modalities are invaluable in ruling out differential diagnoses such as cervical disc disease, brachial neuritis, or carpal tunnel syndrome. nTOS may also be diagnosed with test injections, electromyography, and nerve conduction studies. However, electromyography and nerve conduction studies are often used in conjunction with other diagnostic tests to rule out other etiologies of neuropathic pain and are rarely utilized alone due to frequent negative, nonspecific, and intermittent findings.

在nTOS中，影像检查在排除鉴别诊断如颈椎间盘疾病、臂神经炎或腕管综合征方面是十分重要的。也可通过注射试验、肌电图和神经传导检查确诊。然而，肌电图和神经传导研究经常与其他检查结合使用，以排除其他病因的神经性疼痛，很少单独使用，由于其频繁的阴性结果、非特异性和间歇性。

Regarding vTOS and aTOS, duplex ultrasound (DUS) is used to detect subclavian vessel aneurysm, as it is readily available, noninvasive, and can be used during dynamic maneuvers. If surgery is not indicated, DUSs may be repeated every six months in asymptomatic aTOS patients for continual monitoring. Venography is considered a mainstay of vTOS diagnosis, and may be combined with intravascular ultrasound to evaluate external vessel compression in vTOS patients with a negative DUS. CT and MR angiography and venography are reliable diagnostic tools that can also identify dynamic changes with positioning and have been deemed appropriate in the diagnosis of aTOS and vTOS by the American College of Radiology. See Table 3 for a summary of imaging studies.

多普勒超声(DUS)，由于其易获得、无创的、可动态评估，常用于检测vTOS和aTOS中锁骨下血管动脉瘤。如果未进行手术，无症状aTOS患者可每6个月重复一次，以持续监测。静脉造影术被认为是vTOS诊断的支柱，并可与血管内超声相结合，以评估超声检查阴性的vTOS患者的外部血管压缩情况。CT和MR血管造影和静脉造影是可靠的诊断工具，也可以识别动态变化，并被美国放射学学院认为适用于诊断aTOS和vTOS。影像学研究总结详见表3。

 Conservative Management
Appropriate TOS treatment accounts for factors including disease subtype and etiology as well as severity and duration of symptoms. In the absence of significant vascular compromise, muscle atrophy, or general disability, first-line therapy is most often conservative and comprised of a combination of rest, education, activity modification, physical therapy, and NSAIDs. Due to the multifactorial nature of TOS, specific management regimens are selected depending on the patient’s underlying etiology. If the patient’s condition is refractory to a trial of 4–6 months of conservative management, more invasive therapies such as surgery are often considered.

保守治疗
适当的TOS治疗包括疾病亚型和病因学以及症状的严重程度和持续时间等多种因素。在没有明显的血管损伤、肌肉萎缩或功能障碍的情况下，一线治疗通常是保守治疗，包括休息、教育、活动方式改变、物理治疗和非甾体抗炎药的联合组成。由于TOS的多因素性质，可以根据患者的潜在病因学选择具体的治疗方案。如果4-6个月的保守治疗疗效不佳，手术治疗等侵入性治疗通常被采用。

Injection Therapy
As previously discussed, structures within the scalene triangle may be compressed by the anterior and middle scalene muscles or the presence of the scalenus minimus muscle. Symptomatic patients with this etiology who fail standard conservative therapy may benefit from nonsurgical muscular decompression through injection of botulinum toxin (BTX-A), trigger point injections, steroids, or anesthetics.

注射治疗
如前所述，斜角肌间隙的结构可以被前斜角肌和中斜角肌或小斜角肌的存在而压迫。此类患者，如果保守治疗失败，可以通过非手术方式的肌肉减压来获得疗效，入注射肉毒杆菌毒素(BTX-A)，触发点注射，类固醇或局麻药.

BTX-A is a neurotoxin that has been historically used to treat pathologic pain due to excessive muscle contraction. BTX-A exerts its effect by inhibiting the release of acetylcholine from presynaptic nerve terminals . BTX-A may also play a role in directly reducing pain sensation; although this mechanism of action is unclear, studies have shown that it may involve inhibiting the release of nociceptive neuropeptides, including substance P and calcitonin gene-related peptide (CGRP) . What is certain is that it reduces the muscular tension pain.

BTX-A是一种神经毒素，历史上一直用于治疗因肌肉过度收缩而产生的病理性疼痛。BTX-A通过抑制突触前神经末梢释放乙酰胆碱发挥作用。BTX-A也可直接减轻痛感;虽然这种作用机制尚不清楚，但已有研究表明表明可能与抑制伤害性神经肽的释放有关，包括P物质和降钙素基因相关肽(CGRP)。有什么是确定的减轻肌肉紧张性疼痛呢？