Cervical edge – congenital anomaly at which one or several additional edges departing from the lower cervical vertebras come to light (usually – VII). Often proceeds asymptomatically. As a rule, for the first time demonstrates at adult patients, it can be shown by the pains, sensitivity violations, hypostasis, cyanosis, a cold snap of an extremity and other symptoms caused by disorders of blood supply and an innervation on the party of defeat. It is diagnosed on the basis of complaints, the yielded external survey and results of a X-ray analysis. Treatment – physical therapy, rest, novokainovy blockade. At inefficiency the operational resection of an additional edge is shown.
Cervical edge (tservikalny edge) – rather widespread malformation. It is found in 0,5% of the population and in 6% of patients with vertebrogenny diseases, it is more often diagnosed for women (according to various data, in 70-85% of cases). The first description of this pathology was made by the French anatomist Shede in 1740. The most known classical research in this sphere is the monograph of the Russian anatomist V. L. Gruber. Additional edges can be single or multiple, settle down with one or from two parties. Almost at 85% of patients bilateral defeat is defined. Extent of development of tservikalny edges significantly varies – from the rudiments which are slightly supporting limits of a cross shoot to the created bone structures connecting to a breast or the I edge. The clinical manifestations caused by a compression of a subclavial artery and a nervous texture come to light approximately at 10% of total number of patients, usually for the first time arise after achievement of majority.
Reasons of a cervical edge
Violation of processes of pre-natal development is the cause of anomaly. In the beginning 29 couples of rudiments of edges are formed of a sclerolanguid mesenchyma. Continue to develop in the subsequent 12 pairs of edges which depart from the I-XII chest vertebras, and the others are gradually reduced. At violation of the return development additional edges appear. The reduction of rudiments occurs from top to down therefore in clinical practice the additional edges departing from VII are usually observed is more rare – from VI and V cervical vertebras. The factors provoking are definitely not established.
Rather large tservikalny edge changes relationship between anatomical structures of a neck. Clinical value has influence of a rudiment on an arrangement of a humeral texture and a subclavial artery. In the presence of not completely created edge or a fibrous tyazh the vessel and a nervous texture are displaced kpered, at more expressed anomaly settle down over additional bone structure. Sometimes points of fixing of forward and average ladder muscles change – they are attached not in the area I of an edge, and to cervical or to both edges. In a zone of defeat multiple fibrous tyazh can come to light.
Everything listed creates favorable conditions for squeezing of a neurovascular bunch. At the physical activity which is especially connected with change of provision of a zone of a humeral belt (for example, at procrastination of a hand from top to bottom), the additional edge presses on a vessel or nerves, there is a compression syndrome. On the basis of observations it is established that completely created edges provoke the vascular frustration which are partially created more often become the reason of neurologic violations. Usually both components are combined among themselves in various proportions.
Allocate true and false, full and incomplete tservikalny edges. The true edge is jointed with a cross shoot of the corresponding vertebra a usual joint, false is fixed to a shoot sinostozy or sindesmozy. The full edge on the appearance reminds a usual edge, is attached to a breast or the I edge. Incomplete represents a rudimentary fragment which end is not attached or connected to anything to the I edge by means of a fibrous tyazh. Gruber's classification is made taking into account extent of development of bone structures, includes four types of cervical edges:
- I – there is a small rudiment which length does not exceed length of a cross shoot.
- II – the edge is longer than a cross shoot, but is shorter than bone part I of an edge.
- III – a little underdeveloped rudimentary edge fixed by a soyedinitelnotkanny tyazh to the I edge or (more rare) to a breast comes to light.
- By IV – the full-fledged bone structure reminding a usual edge, which is jointed directly with a breast is defined.
Symptoms of a cervical edge
In the absence of a compression syndrome there are no complaints. Sometimes deformation over a clavicle comes to light, at a palpation dense opukholevidny education is defined. Multiple tservikalny edges are shown by the typical appearance including a reinforced neck in the form of a cone and the lowered shoulders which look as continuation of a neck. The asymmetry of nadplechiya which is a consequence of uneven development of additional edges or unilateral defeat is quite often noted.
The most widespread complaint at a sdavleniye of a neurovascular bunch the pain syndrome arising or amplifying after physical activity at the movements of a neck and head, raising of a hand, lowering is considered . The morbidity zone usually corresponds to area of an innervation of an elbow nerve, spread of pain on a proximal part of an extremity, a nadplechya, the head is sometimes noted. The pain syndrome is often combined with decrease, increase or lack of sensitivity in zones of an innervation of beam and elbow nerves. Involvement of a median nerve is observed seldom. The cold snap, the increased perspiration and the pallor of an extremity caused by violation of vegetative regulation of a vascular tone can come to light.
At a sdavleniye of a subclavial artery patients note essential restrictions when performing certain movements, for example, heavy lifting, driving of the car etc. At external survey puffiness and cyanosis of an extremity is found, pulse on a beam artery is weakened or is not defined. Raising of a chin and turn of the head in the sick party on a breath is followed by weakening of a pulse wave and pressure decrease on the affected hand. At a number of patients the syndrome of a ladder muscle comes to light.
In hard cases trophic frustration develop, extremity gangrene is possible. Because of a sdavleniye of an arterial trunk in its wall there are changes increasing risk of formation of blood clots and formation of aneurism of a subclavial artery. At untimely carrying out operation residual disorders of sensitivity can be noted. Pathology causes restriction of physical activity, impossibility to be engaged in certain kinds of activity that can become the reason of the compelled change of a profession.
Diagnosis usually does not cause difficulties, is carried out by the traumatologist or the orthopedist. Assessment of degree of a compression of an arterial trunk and nerves of a humeral texture, definition of optimum tactics of treatment are made by the neurologist and the vascular surgeon. The plan of inspection includes the following objective and tool techniques:
- Poll, survey. The doctor specifies time of emergence and dynamics of development of symptoms (at their existence). At survey deformation quite often is found, at a palpation one or several edges can be defined. At a sdavleniye of a vessel and nerves neurologic frustration, blood circulation violations are observed. Special tests at which the patient holds the position narrowing space between edges and a clavicle are carried out. In the presence of a tservikalny edge the symptoms demonstrating passing violation of blood supply of an extremity become result of tests.
- Backbone X-ray analysis. Appoint a radiological research of the lower cervical and top chest vertebras, areas . In pictures the additional edges of various length which are quite often reminding the increased cross shoots are visible. The relation of additional edges to a breast and the I edge is estimated, existence or lack of bone growths is defined. On the basis of roentgenograms the differentiation of cervical edges from ekzostoz, neoplaziya of nearby bone structures is made.
- Angiography. Carrying out a traditional X-ray contrast research or the MR-angiography of a subclavial artery is possible. During the diagnostic procedure features of an arrangement of a vessel, extent of its narrowing are established. In the presence of aneurism spindle-shaped expansion of disteel departments of an artery is looked through.
Differential diagnostics of tservikalny edges is performed with a radikulomiyelopatiya, osteochondrosis of cervical department of a backbone, neuralgia, a tunnel syndrome, pains at hernia of an intervertebral disk, new growths of a humeral nervous texture. At suspicion on a neoplasia of the patient direct to consultation to the oncologist.
Treatment of cervical edges
Medical tactics is defined by the available symptomatology. In the absence of manifestations treatment is not required. In spite of the fact that early removal of an additional edge provides the best effect in the remote period in comparison with the operation performed at a stage of the developed clinical changes, the preventive resection is not carried out because of low probability of emergence of symptoms and high injury of intervention. Conservative therapy is shown to patients with a syndrome of a ladder muscle. Provide to the struck zone rest by imposing of a collar of Shants and an immobilization of a hand with a soft bandage. Apply vasodilating medicines, a medicinal electrophoresis with lidazy and anesthetics, make novokainovy blockade. Recommend to abstain from the loadings provoking emergence or strengthening of symptoms.
At the expressed compression syndrome effect of conservative therapy doubtful. When progressing a disease and long refusal of radical treatment irreversible degenerate changes in fabrics of a nervous texture, an artery wall can develop. The resection of an edge or excision of muscular structures is recommended. surgery is carried out with use of one of the following techniques:
- Edge resection forward access. It is carried out in position of the patient on a back through a horizontal section in supraclavicular area (Voskresensky's section). Superficially located muscles cut, vessels tie up, allocate nerves and a subclavial artery and take aside. The cervical edge is deleted in parts, using Lyuer's nippers.
- Edge resection back access. It is made in position of the patient on a stomach with use of paravertebralny access (Kimbarovsky's way). Includes stratification of muscles and a resection of cross shoots of cervical vertebras. After receiving access to a rudimentary edge it is held a kostoderzhatel, allocated from soft fabrics and deleted.
- Resection of a forward ladder muscle. It is carried out from forward supraclavicular access. Provides cutting off of a muscle at a point of an attachment and removal of its lower part. Solderings between nerves and an artery cut, in an interval stack fragments of fatty tissue for prevention of scarring. The full edge is partially rezetsirut together with other educations (for example, fibrous tyazha) squeezing a neurovascular bunch.
At the IV type of pathology the resection is carried out sometimes through an ugloobrazny section which horizontal part passes parallel to a clavicle, and vertical settles down in the field of edge of a deltoid muscle. The main stages of surgical intervention the same, as when using forward access. In the postoperative period in all cases carry out an immobilization, apply antibiotics and anesthetics, appoint massage, physiotherapeutic procedures, LFK.
Forecast and prevention
At unsharply expressed symptomatology, adequate conservative treatment and observance of the mode of physical activities reduction or disappearance of clinical manifestations is noted. At the developed clinical picture the forecast is defined by expressiveness of degenerate changes of nerves and walls of a subclavial artery. Timely carrying out operation allows to liquidate a compression, to completely restore blood supply, to eliminate neurologic violations. At a degeneration of a nervous texture and change of a vascular wall the residual phenomena can be observed (weakness of an extremity, disorder of sensitivity and so forth). Preventive measures are not developed because of the congenital nature of pathology and lack of exact data on the reasons of its development.