RU2243717C1 - Method for diagnosing the cases of superior thorax aperture syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out ultrasonic scanning examination of subclavian artery over its whole extent in physiological arm position with arterial blood pressure being measured in the middle one third of the arm. Next, when applying compression tests, blood circulation parameters variations are recorded in distal segment of the subclavian artery with arterial blood pressure being concurrently measured. Three degrees of superior thorax aperture syndrome severity are diagnosed depending on reduction of linear blood circulation velocity and arterial blood pressure compared to their initial values. Mild one takes place when linear blood circulation velocity reduction reaches 40% and arterial blood pressure 20% of initial level, moderate one when linear blood circulation velocity reduction reaches 70% and arterial blood pressure 50% and heavy one when linear blood circulation velocity reduction is greater than 70% of initial level and arterial blood pressure is greater than 50% to the extent of no blood circulation manifestation being observed in the subclavian artery.

EFFECT: high accuracy of diagnosis.

Description

The invention relates to medicine, namely to vascular surgery. Until recently, that is, before the widespread introduction into practice of ultrasonic duplex scanning, the diagnosis of diseases included in the syndrome of the upper thoracic aperture (hereinafter referred to as SVGA) was based in the vast majority of cases on the use of clinical compression tests (Rusa, Lange, Togoerello, Adson, etc. .), which are quite subjective.

The most reliable and informative method for diagnosing SVGA is angiography, but this method is invasive and cannot be used in all cases of suspected SVGA.

Ultrasound dopplerography is the most optimal method for studying patients with CVA, since it is non-invasive, allows you to objectively evaluate the results of compression tests, as well as to judge the degree of compression of the neurovascular bundle, which, together with clinical manifestations, allows you to isolate the severity of CVA and differentially approach the choice of treatment method.

Prototype

Closest to the proposed is the method described by Vardanyan A.V. (Ph.D. thesis on the topic: “Clinic, diagnosis and indications for surgical treatment of neurovascular bundle compression syndrome at the exit from the chest”. Moscow, 1990, pp. 51-53). This method is taken as a prototype. It includes a study of the linear blood flow velocity (hereinafter - LSC) and blood pressure (hereinafter - HELL) in the subclavian, axillary, brachial, ulnar and radial arteries at rest and LSC in the radial artery with 3 functional tests: abduction, hyperabduction and in position “Military posture”. When the blood flow changed to collateral or disappeared, dynamic compression of the subclavian artery was confirmed. The disadvantage of this method is that only the compression of the subclavian artery is confirmed on the basis of changes in blood flow in the radial artery without determining the specific form and severity of the course of SVGA.

The purpose of the invention

The aim of the invention is the development of a method for ultrasound examination of the subclavian artery in patients with uncomplicated form of IAD at rest and during compression tests, which allows to evaluate the nature and degree of circulatory disorders in the upper extremities for an accurate diagnosis.

SUMMARY OF THE INVENTION

The proposed method for the diagnosis of SVGA is as follows.

Ultrasonic duplex scanning with color Doppler mapping (CDL) is carried out by a linear sensor with a frequency of 7.5 MHz in the position of the patient sitting with the normal physiological position of the hands. Blood flow is studied throughout, i.e. on the radial, ulnar, brachial, axillary arteries. The state of the vessel is assessed in B-mode (clearance, diameter, wall), in color mapping mode and Doppler mode (determining the nature of blood flow and characterization of speed indicators). Then, the middle and distal segments of the subclavian artery with all the above characteristics and with the simultaneous measurement of blood pressure on the shoulder are purposefully examined.

A method for the diagnosis of upper thoracic aperture syndrome, which consists in conducting an ultrasound examination, characterized in that they conduct an ultrasound examination of the subclavian artery in its distal segment (lumen, diameter, wall thickness, blood flow and LSC) with measuring blood pressure in the middle third of the shoulder with the physiological position of the arm and at the same time carry out compression tests to determine the specific nosological unit that is part of the SVGA, and the severity of the disease.

Further, the blood flow through the subclavian artery with the same localization of the sensor and the same parameters is estimated during compression tests:

1) a test with abduction and hyperabduction indicates a syndrome of the pectoralis minor muscle;

2) Lange test - characteristic of the scalenus syndrome;

3) a test with lowering and retraction of the hands back, when closing the hands on the lower back to the “lock” - for the presence of costal-clavicular syndrome.

Ultrasonic signs of compression of the subclavian artery can occur with cervical rib syndrome already with a slight abduction of the arm (it all depends on the length of the rib, its location in the tissues, attachment location), which together with the radiography data (the presence of additional ribs) allows you to make a diagnosis.

Based on the data obtained by ultrasound, three degrees of severity of the SVGA can be distinguished:

1. Easy - decrease in BFV to 40% and blood pressure to 20% of the initial level while maintaining the main character of blood flow. In the absence of clinical manifestations and painful subjective sensations, such indicators can be regarded as normal options.

2. Medium - decrease in BFV to 70% and blood pressure to 50% of the initial values with the closure of the spectral window and a change in the nature of blood flow to the main-changed one.

3. Severe - a decrease in BFV of more than 70% and blood pressure of more than 50% of the initial up to a complete absence of blood flow through the subclavian artery (PKA).

An example of a specific implementation of the method:

Patient Magomedova R. (medical history 12/0558), 26 years old, was admitted to the vascular surgery department of the Republican Clinical Hospital in Makhachkala with complaints of weakness, pain in the right hand, a cold feeling, numbness in the right hand, aggravated by a raised arm. The patient considers himself about 2 years old, was previously treated by a neurologist with a diagnosis of osteochondrosis of the cervicothoracic spine. Objectively: the general condition is satisfactory, the skin and visible mucous pink, peripheral lymph nodes are not enlarged. Asthenic physique. In the lungs, vesicular breathing is carried out in all fields, NPV - 18 beats / min. Heart sounds are clear, rhythmic, heart rate - 74 beats / min. HELL 110/70 mm Hg The abdomen is soft, painless, active motility, the liver and spleen are not enlarged.

Local status: both upper limbs are relatively equal in length and volume, there are no skin trophic disturbances, no edema.

The pulsation on the radial arteries at rest is distinct on both sides during abduction and hyperabduction of the hands is determined. During the Lange test, the pulsation is determined on the left, on the right - it disappears, the Rus test is positive - the fingers turn pale, get colder, paresthesias appear.

In laboratory studies, there are no pathological changes.

Ultrasound dopplerography with duplex scanning and color mapping of blood flow was prescribed:

On the right - 1) at rest, LSC by PKA 48 cm / sec, the main blood flow; 2) with the abduction of the arm LSC 32 cm / sec, the main blood flow; 3) during the Lange test, LSC decreases to 11 cm / sec, the nature of the blood flow is trunk-altered; 4) with the lowered and retracted arm LSK 43 cm / sec, the main blood flow.

On the left, respectively: 1) 53 cm / sec; 2) 43 cm / sec; 3) 52 cm / sec; 4) 48 cm / sec.

The nature of the blood flow remained trunk.

Systolic blood pressure on the right in the initial position of 110 mm Hg, with a sample of Lange - 40 mm Hg

The diagnosis was made: SVGA, right-angus syndrome, neurovascular form, uncomplicated variant, severe course.

10.10.01 in a planned manner an operation was performed - a right-angle scan.

The postoperative course is smooth, there is a regression of symptoms.

When the control ultrasound scan for 10 days LSC on the right at rest 42 cm / sec, during the test Lange - 35 cm / sec while maintaining the main nature of the blood flow.

The histological conclusion: the final stage of chronic productive myositis.

The patient was discharged in satisfactory condition. When viewed after three months, there is no data for a relapse of the disease.

Features distinguishing from the prototype:

1. In the physiological position of the arm, blood flow is examined throughout (as in the prototype), but when conducting compression tests, changes in blood flow parameters are recorded in the distal segment of the PCA (ie, immediately after the compression site), in contrast to the prototype, where indicators are measured blood flow velocity in the radial artery.

2. According to the prototype method, only the fact of dynamic compression of the PCA is confirmed without indicating the possible level of compression and, accordingly, the specific nosological unit that is part of the CSGA. According to the proposed invention as a method of changing the characteristics of blood flow during certain compression tests, it is possible to make a specific diagnosis and differentially approach the choice of the method of operation, namely:

a) a test with abduction and hyperabduction - indicates a syndrome of the pectoralis minor muscle;

b) Lange test - characteristic of the scalenus syndrome;

c) a test with lowering and retraction of the hands back, when closing the hands on the lower back to the “lock” - for the presence of costal-clavicular syndrome.

2) The prototype does not provide guidance on determining the severity of the SVGA based on ultrasound data. In the proposed diagnostic method, three severity levels of SVGA are distinguished, which helps in choosing a conservative or surgical method of treatment, namely: mild with a decrease in BFV to 40% and blood pressure up to 20% of the initial level, while maintaining the main character of blood flow, medium with a decrease in BFB to 70% and blood pressure up to 50% and a change in the nature of blood flow to a trunk, severe with a decrease in BFV of more than 70% and blood pressure more than 50% of the initial up to a complete absence of blood flow in the subclavian artery.

Usefulness of the offer

This method of diagnosing SVGA examined 30 patients. Proposed as an invention, the method has improved the quality of diagnosis of this group of diseases, the method has confirmed its information content, made it possible to differentially approach the choice of treatment method. As a result of treatment, the compression was removed in all patients, after the operation, the pulsation on the radial arteries did not disappear during the compression tests; during the control of ultrasound, the increase in LSC during compression was recorded two or more times compared to the initial level.

Claims (1)

A method for diagnosing the severity of upper thoracic aperture syndrome (UGA), including ultrasound examination (ultrasound) of the subclavian artery (PKA), measuring blood pressure (BP) and conducting compression tests, characterized in that the initial ultrasound examination of the PKA is carried out throughout its physiological position hands with blood pressure measurement in the middle third of the shoulder, then, when performing compression tests, changes in blood flow parameters are recorded in the distal segment of the PCA with simultaneous measurement of blood pressure and depending on the degree lowering the linear velocity of blood flow (LSC) and blood pressure compared to their initial level, three degrees of severity of the SVGA are diagnosed: mild - with a decrease in BFV to 40% and blood pressure to 20% of the initial level, medium - with a decrease in BFV to 70% and blood pressure to 50% and severe - with a decrease in BFV of more than 70% and blood pressure more than 50% of the initial up to a complete absence of blood flow in the PCA.