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  1. 1. THORACIC OUTLET SYNDROME Dr. N.K. CHOUDHARY 2/3/2023 Parul Institute of Medical Sciences and Research 1
  2. 2. Definition • Thoracic outlet syndrome (TOS)- a collection of symptoms brought about by abnormal compression of the neurovascular bundle by bony, ligamentous or muscular structers in the narrow space between clavicle and 1st rib –the thoracic outlet.
  3. 3. Boundaries of TO • posteriorly: T1 vertebral body • laterally: first rib and costal cartilage • anteriorly: manubrium sterni
  4. 4. ANATOMY Interscalene triangle - Inferiorly : 1st rib - Ant : scaleneus anterior - Post : scaleneus medius. Costoclavicular space - Ant : clavicle, subclavius muscle - Post medial: 1st rib - Post lateral: superior - border of scapula
  5. 5. contents • viscera – thymus – trachea – oesophagus – lung apices • vessels, nerves and lymphatics – common carotid arteries – confluences of internal jugular and subclavian veins – phrenic nerves – vagus nerves – recurrent laryngeal nerves – thoracic duct • prevertebral fascia • muscles – sternocleidomastoid muscle – anterior and middle scalene muscles – sternohyoid muscle – sternothyroid muscle
  6. 6. Interscalene triangle
  7. 7. Costoclavicular space
  8. 8. Subcoracoid area
  9. 9. • Race No racial predilection exists. • Sex Thoracic outlet syndrome is traditionally more common in women than in men, with a female-to- male ratio as high as 3:1. • Age Thoracic outlet syndrome is most common in people aged 10-50 years
  10. 10. Causes of TOS • Anatomical defects- • Bony abnormalities- Cervical rib Long C7 transverse process Abnormal bands, ligaments Fracture clavicle/ 1st rib Exostosis
  11. 11. • Muscle anomalies • Anomalous insertion of scalene muscles • Scalene muscle hypertrophy • Scaleneus minimus • Passage of the brachial plexus through the substance of the anterior scalene muscle, • A broad, excessively anterior middle scalene muscle insertion on the first rib
  12. 12. • Tumours • Trauma Brachial plexus trauma/Whiplash injury • Poor posture. Drooping the shoulders or holding the head in a forward position.
  13. 13. • Repetitive activity. Typing on a computer, Athletes and swimmers Baseball pitcher • Obesity • Pregnancy.
  14. 14. Cervical rib • It is a superneumary rib that arises from seventh cervical rib or rarely from sixth or fifth cervical vertebrae. • Sometimes known as "neck ribs“ • Congenital abnormality located above the normal first rib. • incidence 0.5-0.6% • Bilateral in 60-80 % • Symptomatic in 10 -15%
  15. 15. Cervical rib
  16. 16. TYPES • Type1 small projection from costal faset. Less than 2.5cm • Type 2 projection beyond transverse process. > 2.5cm • Type 3 nearly complete rib which is partly fibrous • Type 4 complete rib with costal cartilage attached to 1st rib or sternum.
  17. 17. Classification
  18. 18. Neurologic type • 95% of cases • This type is secondary to compression of the brachial plexus caused by various soft tissue and bony abnormalities at the point where the nerves pass between the anterior and middle scalene muscles.
  19. 19. Venous type • 3-4% of cases. • Venous thrombosis may be categorized into primary and secondary thrombosis based on the etiology. • Primary venous thoracic outlet syndrome, or primary venous thrombosis, is also called Paget- Schrötter syndrome named after the 2 individuals who first described this entity: Paget, who described it in 1875, and von Schrötter, in 1884.
  20. 20. Arterial type • 1-2% of cases. • This type is associated with the most serious complications, including limb ischemia (which may result in the loss of the affected upper extremity).
  21. 21. Neurogenic TOS • Etiology – Hyperextension neck injury (whiplash) – Repetitive stress injuries
  22. 22. Neurogenic TOS • Predisposing Factors – Scalene muscle anomalies – Narrow scalene triangles – Congenital ligaments/bands – Cervical ribs
  23. 23. Neurogenic TOS • Pathophysiology – Neck trauma stretches and tears scalene muscle fibers – Swelling of muscle belly pain, parathesias, numbness, weakness – Scarring/fibrosis of muscle belly occipital headaches.
  24. 24. Neurogenic TOS • Symptoms – Pain, parathesias of the neck, shoulder region, arm or hand, depending on the root involved , numbness, weakness throughout affected hand/arm. • Often bilateral • Difficulty with fine motor tasks of the hand Examination reveals : • sensitive disorders • muscle weakness • muscle atrophy (long fingers flexors) • Palpation of subclavicular area may cause pain Not necessarily localized to peripheral nerve distribution – Extension to shoulder, neck, upper back – “Upper plexus” disorders – “Lower plexus” disorders
  25. 25. Neurogenic TOS • Symptoms – Occipital headaches – Perceived muscle weakness – Vasomotor symptoms • Vasospasm, edema, hypersensitivity • Pectoralis minor syndrome – Compression of neurovascular bundle under the pec minor muscle – Pain over anterior chest and axilla – Fewer head/neck symptoms
  26. 26. Venous TOS • Etiology – Developmental anomalies of costoclavicular space – Repetitive arm activities – throwing, swimming, overhead activities.
  27. 27. Venous TOS • Predisposing Factors – Relationship of vein to subclavius tendon and costoclavicular ligament – Decrease in dimensions of costoclavicular space • Repetitive trauma to vein causing stenosis, thrombosis
  28. 28. Venous TOS • Acute occlusion • Pain of upper limb • Tightness • Discomfort during exercise • Edema • Cyanosis • Swelling • Feeling of heaviness • Easily fatigued arm and hand • Superficial vein distension • Thrombophlebitis of the upper limb • Tenderness over the axillary vein • Gangrene rarely
  29. 29. Arterial TOS • Etiology – Cervical or anomalous first rib – Anomalous anterior scalene insertion • Pathophysiology – Arterial compression resulting in post-stenotic dilatation or aneurysm – Distal embolization of thrombus
  30. 30. Arterial TOS • Pathophysiology • – Arterial compression • resulting in post-stenotic • dilatation or aneurysm • – Distal embolization of • thrombus
  31. 31. Arterial TOS • Symptoms –Digital or hand ischemia –Cutaneous ulcerations –Forearm pain with use –Pulsatile supraclavicular mass/bruit --Easily fatigued arms and hands --Rest pain of hand and fingers --Paleness – coldness of the hand --Raynaud’s phenomenon --distal gangrene due to repeated embolization, or subclavian artery thrombosis
  32. 32. DIAGNOSIS • Clinical maneuvers • Radiography • Ultrasonography • Magnetic resonance (MR) angiography • Computed tomographic (CT) angiography • Angiography and venography
  33. 33. Adson maneuver Patient is instructed to take and hold a deep breath and extend his neck fully and then asked to turn his head towards the side being examined. Obliteration or diminuation in the radial pulse suggest compression.
  34. 34. The Roos test The patient repeatedly clenches and unclenches the fists while keeping the arms abducted and externally rotated (palms forward and upward). The elbows are braced slightly behind the frontal plane for 3mins. The test is positive when symptoms are reproduced with this maneuver. A positive test is very suggestive of the thoracic outlet syndrome.
  35. 35. Hyperabduction maneuver • Evaluates compression of the neurovascular bundle between the coracoid process and the pectoralis minor muscle. • The patient externally rotates the shoulders and extends the arms out from the chest and then above the head.
  36. 36. Wright's hyperabdution test
  37. 37. Halsted's Costoclavicular maneuver • Evaluates compression of the neurovascular bundle between the clavicle and the first rib. • The patient assumes an exaggerated military position with shoulders pushed backward and pressed downward.
  38. 38. ALLEN maneuver • Patient elbow flexes to 90 degrees, while the shoulder is extended horizontally and rotated laterally. • The patient is asked to turn the head away from the tested arm. If radial pulse appears, then the test is considered positive
  39. 39. CERVICAL ROTATION LATERAL FLEXION TEST • Patient seated, Examiner passively rotates the head away from the affected side and gently flexes the neck forward to end range moving the ear toward the ventral chest. • Positive test: forward flexion part of the movement is notably decreased with a hard end feel.
  40. 40. ADDITIONNAL TESTS • Angiography and venography --may show the compression --explores arterial complications (stenosis, aneurysms…)
  41. 41. Imaging • X-rays – Cervical rib – Elongated C7 transverse process – Hypoplastic 1st rib – Callous formation from clavicle or 1st rib fracture – Pseudoarthrosis of 1st rib
  42. 42. • CT/MRI can rule out other pathologies • Magnetic resonance (MR) angiography and computed tomographic (CT) angiography of the thoracic inlet, especially with recently devised techniques and protocols, are noninvasive modalities that provide image quality comparable to that of angiography and venography. • MR neurography – newer technology to detect localized nerve function abnormality
  43. 43. EMG/NCV • Reduction in NCV and low amplitude motor responses • Positive results – Confirms the clinical diagnosis – Poor prognosis if true neural damage is present • Negative results – Does not exclude TOS • Both EMG/NCV have low sensitivity for TOS
  44. 44. Scalene muscle block • Most useful when diagnosis is unclear • Patient in supine position with neck hyperextended and turned to opposite side. Lateral border of sternocledomastoid is palpated andabout 1.5 inches above the clavicle anterior scalene muscle is palpated. • 5- 7ml of plane bupivacaine and 1ml of • betamethasone is injected. • Relief of symptoms ranging from few days to weeks. • Good relief of symptoms confirms the diagnosis. • 2-3 injections can be given.
  45. 45. TREATMENT • MEDICAL TREATMENT -- Analgesic treatment -- Anti-inflammatory non steroid drugs -- Muscle relaxing drugs -- Transcutaneous electric nerve stimulation.(TENS) -- Local anesthetic injections.
  46. 46. • Conservative management aims to increase the space in the thoracic outlet area and to relieve compression on the neurovascular structures. (1) proper postural changes and correct faulty postures. (2) manipulate and mobilize and relax 1st rib and clavicular, scapular, pectoral muscles. (3) strengthen the shoulder girdle muscles and stretch scalene muscles
  47. 47. • PHYSICAL THERAPY -- Is the key of T.O.S. treatment -- Its purpose : • open the costo-clavicular space • fight against physiological shoulders falling attitude • Has to be progressive, painless, bilateral • Average duration : 3 to 6 months • If properly executed : 70 to 90% of good • results
  48. 48. Edema control • Edema gloves • Compressive garments • Elevation of limb • Active range of motion exercises • Retrograde massages • Phonophoresis controls pain and edema
  49. 49. Exercises • Involves relaxing shoulder girdle and stretching the scalene and pectoral muscles. • Neck : neck side bending exercises neck rotation neck flexion exercises • Shoulder : shrugging of shoulders pendulum exercises
  50. 50. SURGICAL TREATMENT OF T.O.S. • Surgical treatment is indicated: • In case of symptomatic cervical rib Symptoms persists beyond 2 months of conservative management • after failure of physiotherapy • in T.O.S. with venous or arterial complications (thrombosis, aneurysms…) • Complete occlusion of a large vessel. • Progression of neurological symptoms. • Nerve conduction velocity < 60m/s
  51. 51. • 1st rib resection and scalenectomy are standard procedures for TOS • 1st rib resection is recommended for lower type TOS • Scalenectomy is recommended for upper type TOS • Best results and less chance of recurrence with combined 1st rib resection and scalenectomy.
  52. 52. Scalenectomy • Incision :8cms incision, 1.5cm above middle third of clavicle. • 80-90% of scalenus anterior muscle and • 40-50% of scalenus medius muscle removed. • Protect long thoracic nerve and phrenic nerve. • Complications : neck hematoma, chylus drainge, dyspnea due to phrenic nerve irritation.
  53. 53. 1st rib resection • 1. Transaxillary approach • 2. Supraclavicular approach • 3. Infraclavicular approach • 4. Posterior approach. • 5. Thoracoscopic First Rib Resesction Adjunctive procedures – Pectoralis minor tenotomy. – Sympathectomy :
  54. 54. Treatment vTOS • Anticoagulation therapy with heparin and oral anticoagulants. • Fibrinolytics • Catheter-directed thrombolysis. • Thrombosis is < 3days old : Thrombectomy • Chronic thrombosis : Venous Bypass
  55. 55. Complications • Nerve injury bracial plexus injury Long thoracic nerve of bell Phrenic nerve Intercostobrachial nerve. Vagus and Reccurent laryngeal nerve • Vascular injury Subclavian vein and artery
  56. 56. • Thoracic duct injury Lymphatic fistula Lymphocele Chylothorax • Pleural complication pleural damage Pneumotharax Pleural effusion
  57. 57. CONCLUSIONS • T.O.S management requires : • a good knowledge of the anatomy of the area • a good patient questionning and examination • the key of the treatment is physiotherapy :when properly conducted it improves symptomatology in more than 70% cases • surgical treatment is decided only after failure of physiotherapy
  58. 58. 2/3/2023 61 Parul Institute of Medical Sciences and Research Thank You!