Disclosure: I have nothing to disclose

Transcription

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2 Disclosure: I have nothing to disclose

3 Pectoralis Minor Syndrome Definition Hand and arm symptoms due to Compression of Axillary neurovascular bundle by Pec Minor Muscle

4 Pectoralis Minor Syndrome Short History 1945-Wright Hyperab. Syndrome(APMS) papers on Neuro (NPMS) K.Johanson PecMinTenot-Rec NTOS (Dr. George Thomas, Seattle) Also venous obstruction--10 pts with non-thrombotic VPMS

5 Anatomy of 2 Spaces 1. Scalene triangle Above Clavicle (TOS) 2. Pectoralis minor space Below Clavicle (PMS) Neurovascular bundle Essentially same in both areas

6 3 Types of PM Syndrome 1. Neurogenic PMS > 96% Usually trauma to shoulder/scapula 2. Venous PMS 4% Non-Thrombot.Obstruction: axillary vein 3. Arterial PMS 0.0?% Rare none reported This talk will be on Neurogenic only--npms

7 Etiology Neurogenic PMS Adults--- Neck & Shoulder Trauma 1. Auto Accidents 2. Repetitive stress injury 3. Falls on floors, ice, stairs Children---Adolescents Competitive Sports-excessive shoulder motion Swimming Note: Etiology of NPMS is same as NTOS

8 Symptoms Similarities Pain Paresthesia Weakness Both NPMS & NTOS In hand and upper extremity

9 Symptoms Differences NPMS Alone NTOS Alone Pain/tender: Chest Neck & Axilla & SupClavic. Area Headache: None Occipital Headache If all Sx present think both NPMS & NTOS

10 Physical Exam PM Alone A. Pec Minor tenderness B. Axilla tenderness C. Provocative maneuvers **1. ULTT Upper Limb Tension Test Mild + (comparable to straight-leg raising) 2. Elevated arm stress test (EAST) Mild + 3.Head Rotation usually neg. 4. Head tilt usually neg. Note: When all Pos. Think NPMS & NTOS

11 Physical Exam Tenderness over pec. minor

12 ULTT

13 Elevated Arm Stress Test 90 0 AER In NPMS Mild Symptoms and Easy to Hold to 3 Minutes In NTOS Stronger Symptoms Harder to Hold

14 Head Rotation Head Tilt In NTOS Each elicits symptoms in opposite arm But in NPMS, usually negative/minimal

15 NPMS VS NTOS Physical exam NTOS Stronger Px Findings NPMS Weaker Px Findings

16 Diagnosis 1. History of neck/shouldertrauma or Sports 2. Symptoms 3. Physical Exam 4. Diagnostic tests consider other diagnoses

17 Diagnostic Tests 1. Nerve tests MABCN (MAC); EMG/NCV 2. Pectoralis Minor Muscle block 3. (Scalene Muscle block) as indicated

18 Medial Antebrachial Cutaneous Nerve (MAC) Lowest branch of brachial plexus (BP) Most sensitive branch of BP Each lab must establish normal ranges Measurements of Latency and Amplitude ---- positive responses in 40 of 41 operated patients Ref: Machanic. Ann Vasc Surg 2008;22:248-54

19 Pec Minor Muscle Block Aim needle 45 0 up 4cc 1% lidocaine Move needle often-.5cc Always aspirate 1 st

20 Pec Minor syndrome Treatment 1. Conservative--Physical Therapy 2. Surgery Pec minor tenotomy

21 Pec Minor Syndrome--Treatment Conservative Rx: Pec Minor stretching: Hands on door jams and Drop weight forward

22 Pec Minor Syndrome--Treatment Surgical treatment: Pec Minor Tenotomy 1. Incision 3-6 cm a. Transaxillary-- begin at Ant. Ax fold 1 cm above bottom of hairline.*(our preference) b. Clavipectoral groove c. Anterior--split pec major (on chest wall) 2. Divide pec minor at coracoid 3. Excise 2 cm of muscle (to avoid pec. nerves) 4. Excise bands of clavipectoral fascia *(Harmonic Scalpel)

23 Pectoralis Minor Syndrome 3 groups of patients 1. Only diagnosis (NPMS-alone) 2. With Neurogenic TOS (NPMS & NTOS) 3. Recurrent TOS (Rec NTOS)

24 Results Pectoralis Minor Tenotomy Only (primary operation) Diagnosis # Ops Good Fair Failed 1. NPMS-alone 52 90% 2% 8% 2. NPMS & NTOS 48 35% 19% 46% Total ops 100 Follow up: 1 to 2 years Ref: Ann Vasc Surg :

25 Results Pectoralis Minor Tenotomy Combined with TOS Operation Diagnosis #Ops Good Fair Failed 1. Primary Op 80 75% 12% 13% 2. Recurrent TOS 39 58% 20% 22% Total ops 119 Follow up: 1-3 years Most recurrences appear within 24 months.

26 Recurrent NTOS Reoperations # Ops Good Fair Failed Neurolysis & PMT 39 58% 20% 22% PMT Alone 65 69% 8% 23% Total Ops 104 Follow up: 1-3 years. Ref: Vasc Endovascular Surg :33-38

27 Results NPMS alone or with NTOS Washington University Dr. RW Thompson Operation #Pts Improved PMT Alone 57 75% PMT + Scal &1 st Rib % Total 200 pts. Ref: J Vasc Surg. 2013

28 BP Compression in Children Operation #Ops Good/Exc Fair Fail NPMS (PMT) 20 75% 10% 15% NTOS Op 20 70% 0 30% Total Ops 40 Ref: J Vascular & Endovascular Surg: 2013

29 Reason: Etiology: Sports Inj. In Child. (Swimming, Ball throwing, Wt. lifting) & fewer Whiplash (Neck) injuries Neurogenic BP Compression in Children PMT TOS Decompression ops 15 ops (3Failed) ops (3Fail) 5 ops (Incl 3 Failed) Conclusion: Prior to 2005 probably missed many NPMS diagnoses

30 Neurogenic BP Compression in Children Conclusions 1. Etiology Competitive sports 2. Diagnosis PMS as Major Dx

31 Pectoralis Minor Syndrome In Short Sx: 1. Pain chest, trapezius, axilla, arm 2. Paresthesia hand, any fingers 3. Similar to NTOS but few head & necksx Px: 1. Tenderness over Pec Minor & axilla 2. Positive ULTT (Upper Limb Tens. Test) Dx: 1.Pec Minor muscle block 1% Lidocaine 2. MAC Electrodiagnostic nerve test Rx: 1. PT Pec Minor stretching 2. Pec Minor tenotomy

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