Thoracic Outlet Syndrome

Vijay Bhasker Rao Blue surgery

TOS - Definition
Adson first described his maneuver in 1927 Thoracic Outlet Syndrome first coined in 1956
Upper extremity symptoms due to compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle
Etiologies include congenital bony structures, fibromuscular abnormalities, posture, certain movements, trauma Also known as Backpackers shoulder

TOS - Anatomy

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 Cervicoaxillary canal-proximal component is the costoclavicular space and distal component is axilla Costoclavicular space contains an anteromedial space with the subclavian vein and a posterolateral space or scalenous triangle which contains the subclavian artery and brachial plexus

Causes
Poor posture-line workers, cash register operators Trauma- fracture clavicle Carrying heavy loads Repetitive overhead work electricians,painters,plasterers Repetitive hyperabduction of arms- Swimmers, volleyball players, tennis players Congenital-extra rib, fibrous bands, long C7 transverse process

TOS - Epidemiology
3 to 80 cases per 1000 Ages 20-40 Women > Men (4:1) Neurogenic TOS (90%) > Venous TOS > Arterial TOS (<1%) Cervical ribs occur in < 1% of population
70% women

 It is important to know that not all patients with thoracic outlet syndrome have cervical ribs and not all patients with cervical ribs have thoracic outlet syndrome The idea of the double or multiple crush is that patients with nerve compression at one site are more likely to develop nerve compression at another site.

TOS Differential Diagnosis

Cervical disc disease Cervical facet disease Malignancies (Pancoast/local tumors, spinal cord tumors) Peripheral nerve entrapments (ulnar or median nerve) Brachial plexitis Rotator cuff injuries Fibromyalgia, muscle spasm Neurologic disorders (MS) Chest pain, angina Vasculitis Vasospastic disorder (Raynauds) Neuropathic syndromes of upper extremity
Talu, GK: Agri 17 (2005), 5-9.

COMPRESSION:
INTERSCALENE TRIANGLE(A&N) COSTOCLAVICULAR SPACE(Vein) SUBCORACOID AREA(A,V,N) PAGET-SCHROETTER SYNDROME: thrombosis of subclavian A or V secondary to unusual,repetitive /excessive exercise

TOS - Symptoms
Neurogenic TOS
Pain, paresthesia, and weakness in the hand, arm and shoulder, plus neck pain and occipital headaches
Raynauds phenomenon, hand coldness and color changes are also seen frequently in NTOS

Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.

TOS - Symptoms
Venous TOS
Swelling of the arm, plus cyanosis is strong evidence of subclavian vein obstruction Pain often present, but may be absent Arm swelling distinguishes VTOS from ATOS and NTOS

Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.

TOS - Symptoms
Arterial TOS
Digital ischemia, claudication, pallor, coldness, paresthesia and pain in the hand (but rarely in the shoulder/neck) Symptoms are a result of arterial emboli from a mural thrombus in a subclavian artery aneurysm or from thrombus forming distal to subclavian artery stenosis

Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.

TOS Physical Exam

VTOS
arm swelling cyanosis distended superficial veins over the shoulder and chest wall

NTOS
Tenderness over scalene muscles Positive provocative tests
Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.

TOS Physical Exam

Provocative tests
Adson test Neck rotation and head tilting (ear to shoulder) eliciting pain and paresthesia down the contralateral side 90AER - Abducting arms to 90 degrees in external rotation, brings on symptoms within 60 seconds Upper Limb Tension Test
Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.

Fig. Upper Limb Tension Test (ULTT). Position 1: Arms abducted to 90 with elbows extended. Position 2: Dorsiflex wrists. Position 3: Tilt head to side, ear to shoulder. Each maneuver progressively increases stretch on the brachial plexus.

 ADSONS TEST: Ask the patient to take deep inspiration with full extension of neck and ask to turn the head to the affected side.Then feel the radial pulse HALSTED: Make the patient in military position & then palpate the radial artery WRIGHT: Abduct the arm upto 180 degree &then palpate the radial artery ROOS TEST: Ask the patient to abduct the arm upto 90 degree ,then externalrotate the arm.Ask to stay in the position for sometime.symptoms may aggravate

ADSONS TEST

TOS Diagnostic Testing

Neck or chest x-ray
Detects cervical rib or elongated C7 transverse process

EMG/NCS
Normal in large majority of clinically Most common finding in NTOS is ulnar neuropathy Recent study suggests NCV abnormalities of the sensory medial antebrachial cutaneous nerve are seen in NTOS

MRI/CT Venography/venous duplex

VTOS

Arteriography
Only indicated in ATOS
Seror, O. Clin Neurophysiol 115 (2004), 2316-2322.

TOS Treatment
Conservative Management
Massage, hydrotherapy and PT Behavioral modification/avoidance of provocative activities PT to strengthen muscles of the pectoral girdle and restore normal posture Improvement: 50-90%

TOS Treatment
Definitive management
Surgical decompression of the neurovascular bundle
First rib resection Scalenectomy Subclavian artery reconstruction Cervical sympathectomy Success rate is 70% at 5 years

1st rib resection

Transaxillary approach Supraclavicular approach Infraclavicular approach Transthoracic approach Posterior approach

Complications
Surgical management of thoracic outlet syndrome is controversial is because of the complications that have been reported following surgery injury to the major blood vessels or nerves in the region of the brachial plexus stellate ganglion horners syndrome long thoracic nerve along middle scalene phrenic nerve along anterior scalene

References
Barkhordarian, S. J Hand Surg 32 (4/2007), 565-570. Demondion, X, et al. Radiographics 26 (2006), 1735-1750. Sanders RJ, et al. J Vasc Surg, 46 (2007), 601-604. Seror, O. Clin Neurophysiol 115 (2004), 2316-2322. Talu, GK: Agri 17 (2005), 5-9. Vanti C, et al. Eura Medicophys 43 (2007), 55-70.