TORASİK ÇIKIŞ SENDROMLU İKİ PEDİATRİK VAKA

Torasik çıkış sendromu (TÇS) brakiyal pleksus, subklaviyan arter ve/veya ven gibi nörovaskuler yapıların klavi-kula ve skalen kaslar arasında sıkışması sonucu ortaya çıkan bir hastalıktır. Çocukluk çağında çok sık görülenbir hastalık olmadığı için bu yaş grubunda tanısı kolaylıkla gözden kaçabilmektedir. Bu makalede geç pubertaldöneme kadar tanı konulamamış iki TÇS vakası sunulmuştur. Her iki vakada boyun ve omuz ağrısı, kol ve ön kol-larda ağrı ve güç kaybı gibi benzer nöropatik şikayetler ile başvurmuşlardır. Üst ekstremitelerde derin tendonrefleksleri (DTR) canlı, kas gücü 5/5, kas atrofisi veya kontraktür ve patolojik refleks saptanmamıştır. Duyu mu-ayenesinde üst ekstremitelerde C7,C8 ve T1 dermatomunda hiperaljezi gözlemlendi. X-ray/bilgisayarlı tomog-rafide (BT) servikal kosta varlığı ve doppler ultrasonografide (USG) üst ekstremite abduksiyon ve dış rotasyonuile aksiller arter kan akımı azalması gösterilerek tanı kesinleştirildi. Servikal kosta, anormal fibröz kosta varlığıve skalen üçgenin konjenital darlığı TÇS’una neden olabilecek en önemli predispozan faktörlerdir. Hastalargenellikle üst ekstremitelerde ağrı, paresteziler ve ön kol ve kollarda güçsüzlük gibi nöropatik şikayetler ile baş-vurmaktadırlar. Pozitif Tinel bulgusu, Elvey’in üst ekstremite gerim testi, Adson testi, Allen testi ve yükseltilmişkola germe testi (EAST) gibi provakatif testler ile semptomlar tetiklenebilmektedir. X-ray, BT, doppler USG veelektromiyografi (EMG) tanıya ulaşmakta kullanılan tetkiklerdir. Davranış değişiklikleri, iş alanlarında ergono-mik düzenlemeler, uygun postür eğitimleri ve gevşeme egzersizleri (abdominal solunum, yumuşak masaj, sinirkaydırma egzersizleri ve boyun ve omuz germe egzersizleri gibi) önemli konservatif tedavi yöntemleridir. En az3 ay uygulanan konservatif tedaviye rağmen semptomları gerilemeyen hastalara cerrahi tedavi yapılmaktadır.

Two Pediatric Cases with Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is characterized by compression of neurovascular structures such as brachial plexus, subclavian artery and/or vein between the clavicle and scalene muscles. Since it is not a common childhood disease, it can be easily overlooked in this age group. Herein, we report two TOS cases were left undiagnosed until late pubertal period. Both cases had similar neuropathic complaints, including neck and shoulder pain, and pain and loss of strength in the upper limb. Deep tendon reflexes (DTR) in the upper limb were brisk, muscle strength was 5/5, muscle atrophy or contracture and pathological reflexes were not found. During the sensory examination, hyperalgesia in C7, C8 and T1 dermatome in the upper limb was observed. The diagnosis was confirmed by showing the presence of the cervical rib on X-ray/computed tomography (CT) and reduced blood flow in the axillary arteries in the abduction and external rotation of the upper limb on doppler ultrasonography (USG). The presence of the cervical rib, anomalous fibrous rib, and congenital narrowing of the scalene triangle are the main predisposing factors leading to TOS. Patients typically present with neuropathic complaints such as pain, paresthesia, and loss of strength in the arm and forearm. Provocative tests including positive Tinel’s sign, the upper limb tension test of Elvey, Adson test, Allen test, and elevated arms stress test (EAST) can exacerbate symptoms. X-ray, CT, doppler USG, and electromyography are used as the diagnostic tools. Conservative treatment modalities include behavioral changes, ergonomic arrangements in the workplace, good posture training, and relaxing exercises (i.e., abdominal breathing, gentle massaging, nerve gliding exercises, and neck and shoulder stretching exercises). Surgery is indicated in patients without any symptomatic relief, despite conservative treatment for at least three months.

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