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SINDROMUL DE APERTURA TORACICA

23. Definiţie

Apertura toracică
– se întinde de la coloana cervicala şi mediastin până la marginea inferioară a
micului pectoral

– include trei compartimente: triunghiul interscalenic. Spaţiul costo-clavicular şi


spaţiul retropectoral (pectoralul mic)

Sindromul de apertură toracică = compresia dinamică astructurilor nervoaase, arteriale


şi /sau venoase care traverseazuă aceste compartimente.

Clasificare – SAT neurologic


- SAT vascular
– venos - produs prin obstructia venei subclavii cu sau fara tromboză.
Simptomul principal este edemul , însoţit frecvenmt de cianoză şi
durerer, uneori şi de parestezii. Flebografia este singura metodă
sigură de dg.
Ztratamentul are trei obiective : să indepărteze trombul, să
îndepărtezeze compresia externă, să îndepărteze compresia internă
(29)
- arterial

28. Este mai frecvent la femei


Cel mai frecvent între 20-50 ani

23. Diagnosticul
Clinic – mai ales dacă simptomele sunt ereproduse la diferite manevre, inclusiv ridicarea
braţului
Laborator
Rxgrafie coloana cervicală
CT angiografie cu manevre posturale
RM cu manevre posturale – manevra dee electie pentru SAT cu manifestări neurologice

US – mod B şi color - utile mai ales în cazurile de elelemte clinice de SAT, dar cu
rezultat negativ la CT sau RM . Uneori permite şi analiza plexului brahial

13. Manifestările clinice ale SAT:


 tromboză venoasă axilara şi subclavie
 stenoză de venă subclavie cu edem iontermitent al braţului
 claudicaţie de membru superior
 tablou de embolie acută arterială
 hiperhidroza unilaterala (24)

Coasta cervical 3 / 17 pts

Tratament:
 Tromboliza la cei cu TVP şi cu embolii
 Decompresie chirurgicală – la toţi
 Endarterectomie arterială 1 caz
 Rezectie de anevrism arterial 1 caz

12. Evaluarea aperturii toracice prin duplex color – modificarea fluxului în artera
şi vena subclavie în timpul hiperabducţiei.
Pe artera – compresie semnificativa = dublarea vitezei sistolice maxime sau disparitia
semnlaului la abductie
Pe vena – compresie se4mnificativă = dispariţie totala a fluxului sau dispariţia
modulaţiilor respiratorii în hiperabducţie
20 voluntari – compresie asimptomatica arterială 20% si venoasă 10%.
16 pacienti cu suspiciune clinică de sindrom de apertură toracică
7 = tromboză venă subclavie,
6 = compresie de venă subclavie la hiperabducţie, 3 aveau şi compresie
arterială

Duplex – sensibilitate 92%, specificitate 95%

17. Anomalii asociate cu sindromul de apertura toracică

- sindromul scalenus anticus


- compresie prin scxalenul mediu
- coasta I rudimentară
- benzi de tesut fibros în fosa supraclaviculară
- artere mari care comprimă plexul brahial
- Hiperttrofia de scalen (22.)
- Hemangiom coasta 1 (25)

19. US in dg sindr de apertura toracică


- accelerare a fluxului, preocluzie şi ocluzie a asrtereei subclavii la abducţie
- flux diminuat pe a axilară
- reapariţia fluxului la încetarea abducţiei

21. power Doppler

20. teste de provocare (PDF)

Table 1. Examination maneuvers, original description, reliability analyses and validity


testing.

Test Original Description Reliability Studies Validity Studies

Viikari-Juntura (6) 1987 Viikari-Juntura et al (7) 1989


Spurling’s/Neck Passive lateral flexion, & compression of head. Seated position. Kappa = Seated position. Sensitivity:
Compression Test Positive test is reproduction of radicular 0.40-0.77 40-60%
symptoms distant from neck. Proportion Specific Specificity: 92-100%
Agreement = 0.47-0.80

Active abduction of symptomatic arm, placing Viikari-Juntura (6) 1987 Viikari-Juntura et al (7) 1989
Shoulder patient’s hand on head. Positive test is relief or Seated position. Kappa = Seated position. Sensitivity:
Abduction (Relief) reduction of ipsilateral cervical radicular 0.21-0.40 43-50%
Sign symptoms. Proportion Specific Specificity: 80-100%
Agreement =0.57-0.67

Viikari-Juntura (6) 1987 Viikari-Juntura et al (7) 1989


Examiner grasps patient’s head under occiput Supine position. 10-15 Kg Supine position. 10-15 Kg
Neck Distraction and chin and applies axial traction force. traction force applied. Kappa traction force applied.
Test Positive test is relief or reduction of cervical = 0.50 Sensitivity: 40-43%
radicular symptoms. Proportion Specific Specificity: 100%
Agreement =0.71

Passive anterior cervical flexion. Positive test Uchihara et al (4) 1994


L’hermitte’s Sign is presence of “electric-like sensations” down Not reported. Sensitivity: < 28%
spine or extremities. Specificity: “high”

Glaser et al (33) 2000


Passive snapping flexion of middle finger Sensitivity: 58%
distal phalanx. Positive test is flexion- Specificity: 78%
Hoffman’s Sign adduction of ipsilateral thumb and index Not reported. Positive Predictive Value:
finger. 62%
Negative Predictive Value
75%

Inspiration, chin elevation, and head rotation


Adson’s Test to affected side. Positive test is alteration or Not reported. Not reported.
obliteration of radial pulse.

VI. Adson’s Test In 1927, Adson and Coffey (34) de-scribed a technique to assess for
evidence of circulatory symptoms caused by the presence of a cervical rib. “Diminution
in volume of the radial pulse is common; the pulse can be decreased or obliterated by
having the patient elevate the chin or ro-tate the head to the affected side while in-spiring
air. This was felt to be due to “con-striction of the subclavian artery or vein, obstruction
of the radial and ulnar arter-ies by emboli at the site of constriction, or possibly by
disturbance of the sympathet-ic innervation.” They believed that this evidence of
circulatory disturbance war-ranted consideration for surgical resec-tion of the cervical
rib. However, later in the same article, in discussing the cause of the various symptoms in
patients with cervical ribs, Adson and Coffey (34) de-scribed the test somewhat
differently. “Clinically, we were able to demonstrate the influence of the scalenus anticus
muscle by having the patient elevate the chin and extend the neck or rotate the head to the
affected side while taking a deep inspiration: this produces paresthesia over the
distribution of the brachial plexus and, frequently, obliteration of the pulse at the wrist on
the affected side.” Adson (35) further elaborated on this test and called it “The Vascular
Test” in an article published after his death in 1951. “The test consists of having the
patient take a long breath, elevate his chin and turn it to the affected side. This is done as
the patient is seated upright, with his arms resting on his knees. An alteration or
obliteration of the radial pulse or change in blood pressure is a pathognomonic sign of the
presence of a cervical rib or the scalenus anticus syndrome.” Adson (35) stated in this
article that if the Vascular Test is positive, scalenot-omy is indicated. He believed the test
to indicate subclavian artery compres-sion. “If the subclavian artery has been
compressed, there is a strong probabili-ty that the brachial plexus also is irritat-ed or
compressed whenever the scalenus anticus muscle is placed on tension, since the artery is
being displaced posteriorly against trunks of the plexus.” He attribut-ed the vascular and
neurologic symptoms to a hypertrophied scalene anticus muscle often but not always in
the presence of a cervical rib. He further stated, “Little has been accomplished by
scalenotomy unless the Vascular Test gives a positive result.” His conclusions were
based on personal observation of operative findings. These conclusions were further
supported by his retrospective review of all 169 patients treated by the neurosurgical staff
at the Mayo Clinic from January 1925 to August 1951 with scalenotomy. Of these
patients, 75 had scalenotomy without resection of cervical ribs, 30 had scalenotomy and
par-tial rib resection, and 64 had scalenoto-my performed in the absence of cervical ribs.
The operative findings revealed, “In all cases in which the result of the vascular test was
positive, the scalene anticus mus-cle produced a compression of the subcla-vian artery on
each inspiration.” Eighty-one to ninety percent of all patients had complete relief or
“great improvement” in symptoms following surgery. Adson’s test is currently described
in the following manner (4): “The patient’s head is rotated to face the tested shoulder.
The patient then extends the head while the examiner laterally rotates and extends the
patient’s shoulder. The examiner locates the radial pulse, and the patient is instructed to
take a deep breath and hold it. A disappearance of the pulse is indicative of a positive
test.” The interexaminer reliability and validity of Adson’s test have not been further
reported in the literature.

Unii autori sustin căraspunsul la testul Adson este un element de predicţie a raspunsului
la trtatament (26) – un test pozi8tiv este mai frecvent asociat cu un raspuns favorabil .

27. Angiografia unui pacient cu sindrom de AT - imagini