106. FEASIBILITY OF ENDOSCOPIC EXPLORATION OF THE CERVICOBRACHIAL OUTLET

Abstract

Purpose of the study: The cervicobrachial outlet syndrome is an anatomic and clinical entity related to intermittent or permanent compression of the brachial plexus trunks, and/or the subclavian artery and vein as they pass through six successive spaces in the thoracic cervicobrachial outlet, including the intercostoscalenic space. The purpose of this work was to evaluate the feasibility of endoscopic exploration of the infra-clavicular portion of the outlet and the options for therapeutic interscalenic release.

Material and methods: Cadaver study of 12 shoulders: 3 male, 3 female.

1. dissection of the supra and infra-clavicular region (n=3) to identify zones of potential impingement and determine the structures constituting the outlet;

2. dissections (n=2) centred on the different zones considered as potential endoscopic portals;

3. endoscopies (n=2) via a supra-lateral clavicular approach followed by dissection;

4. endoscopies (n=2) via a supra-lateral clavicular approach followed by dissection with insertion of landmarks then a new endoscopy;

5. Endoscopies (n=3) via a supra-lateral clavicular approach to achieve intercalenic release followed by control dissection.

Results: The medial and lateral clavicular approaches identified two zones of less risk considering the proximity of the neck vessels and the phrenic and suprascapular nerves. A first, it was difficult to localize the brachial plexus endoscopically. This was achieved after dissection and insertion of landmarks. Five endoscopic procedures had to be performed to localize the plexus and starte the interscalenic release. Minute identification of the entry points for the trocars, as a perfect orientation of the instruments was necessary to achieve the procedure. The control dissections did not identify any vessel or nerve injury.

Discussion: Few data in the literature examine the question of endoscopic interscalenic release. Unlike Krishnan and Pinzer, we found that endoscopic exploration of the outlet at possible, but difficult, procedure. Use of an arthropump remains to be evaluated because of the distension and impregnation of the tissues. Insufflations with CO2 might be an alternative.

Conclusion: To our knowledge, a supra-clavicular approach for endoscopic exploration of the brachial plexus has not been described. Exploration of the outlet via this approach might be a less invasive procedure than conventional surgery. Complementary research is necessary to evaluate the morbidity of the different techniques.