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THORACIC OUTLET SYNDROM (TOS)

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  • 1. THORACIC OUTLET SYNDROM (T.O.S.) Lucien MATYSIAK Vascular Surgery – L. Pasteur Hospital COLMAR - FRANCE
  • 2. DEFINITION
      • Thoracic outlet syndrom is the consequence of the compression of upper limbs vascular and nervous elements
  • 3. ANATOMY
      • The thoracic outlet is composed of five successive spaces the vascular and nervous elements go through :
        • The inter costo scalenic defile
        • The prescalenic defile
        • The costoclavicular space
        • The sub-pectoral tunnel
        • The humeral space
  • 4. 1) The intercosto-scalenic defile
  • 5. 2) Prescalenic defile
  • 6. 3) Costo-clavicular space
  • 7. 4) Pectoralis minor muscle and coracoid process
  • 8. Anatomical abnormalities (1)
    • Present in less than 10% of T.O.S.
      • Osseous congenital abnormalities
        • Subnumerous cervical ribs uni- or bilateral
  • 9. Anatomical abnormalities (2)
      • C7 apophysis hypertrophy
      • First rib agenesy
      • Clavicle congenital abnormalities
  • 10. Anatomical abnormalities (3)
      • Osseous post traumatic abnormalities
        • Clavicle
        • First rib
      • Muscular and/or ligamentary abnormalities
        • Difficult to reveal preoperatively
  • 11. Signs and symptoms of T.O.S. (1)
      • Neurologic compression
        • Pain and/or parasthesia of the neck, shoulder region, arm or hand, depending on the root involved
        • 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
  • 12. Signs and symptoms of T.O.S. (2)
      • Arterial compression :
        • Easily fatigued arms and hands
        • Rest pain of hand and fingers
        • Paleness – coldness of the hand
        • Raynaud’s phenomenon
        • Ischemic signs, distal gangrene due to repeated embolization, or to subclavian artery thrombosis
  • 13. Signs and symptoms of T.O.S. (3)
      • Venous compression
        • Pain of the upper limbs
        • Swelling
        • Feeling of heaviness
        • Easily fatigued arm and hand
        • Superficial vein distension
        • Thrombophlebitis of the upper limb
  • 14. PATIENT EXAMINATION (1)
    • Certain diagnostic tests are used to reproduce the compression and T.O.S. familiar symptoms
      • ‘‘ Hands up’’ test
    • In this position, the patient opens and closes his hands repeatedly : a positive test reproduces pain, heaviness or arm weakness within the first minute after beginning.
  • 15. PATIENT EXAMINATION (2)
      • ADSON or scalene maneuver
    • The patient rotates his head towards the tested arm while the examiner extends the arm
  • 16. PATIENT EXAMINATION (3)
      • 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 disappears, then the test is considered positive
  • 17. ADDITIONNAL TESTS (1)
      • Electromyography :
          • may help to assess nervous ‘‘motor affection’’
        • Standard X-Ray neck and thoracic examination looking for osseous abnormalities
        • Dynamic angiogram
          • may show the compression
          • explores arterial complications (stenosis, aneurysms…)
  • 18. ADDITIONNAL TESTS (2)
      • Computed Tomography – MR angiographic 3D technique
      • Dynamic phlebography
    May show venous compression after arm abduction May show aneurysms related to compression with T.O.S.
  • 19. TREATMENT OF THORACIC OUTLET SYNDROM
      • MEDICAL TREATMENT
        • Analgesic treatment
        • Anti-inflammatory non steroid drugs
        • Muscle relaxing drugs
  • 20. TREATMENT OF T.O.S.
      • PHYSICAL THERAPY (1)
        • 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
  • 21. TREATMENT OF T.O.S.
      • PHYSICAL THERAPY (2)
        • Muscular relaxation
  • 22. TREATMENT OF T.O.S.
      • PHYSICAL THERAPY (3)
        • Correct shoulder falling attitude
  • 23. TREATMENT OF T.O.S.
      • PHYSICAL THERAPY (4)
        • Reinforce muscles that ‘‘open’’ the costo-clavicular space
  • 24. TREATMENT OF T.O.S.
      • PHYSICAL THERAPY (5)
        • Respiratory reeducation
  • 25. SURGICAL TREATMENT OF T.O.S.
    • Surgical treatment is indicated:
      • after failure of physiotherapy
      • in T.O.S. with venous or arterial complications (thrombosis, aneurysms…)
      • in case of nervous compression
      • in case of symptomatic cervical rib
  • 26. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Possible approaches
  • 27. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Instruments
  • 28. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Instruments
  • 29. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Instruments
  • 30. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Instruments
  • 31. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Instruments
  • 32. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION : Transaxillary approach (ROOS technique)
        • Patient installation
  • 33. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • Arm position
    The secret of 1 st rib resection in this technique is discontinued traction 5 minutes !
  • 34. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • First rib liberation
  • 35. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION
        • First rib section
  • 36. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION : Other approaches
        • Sus-clavicular approach
  • 37. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION : Other approaches
        • Sub-clavicular approach
  • 38. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION : Other approaches
        • Posterior extrapleural approach
  • 39. SURGICAL TREATMENT OF T.O.S.
      • FRIST RIB RESECTION : Other approaches
        • Antero-lateral transpleural approach
  • 40. SURGICAL TREATMENT OF T.O.S.
      • POSSIBLE ADDITIONNAL TECHNIQUES
        • Thoracic sympathectomy
        • Cervical rib resection
        • Vascular repair
  • 41. INDICATIONS OF SURGICAL TREATMENT OF T.O.S.
      • When failure of physiotherapy
      • Neurologic compressions :
        • sus-clavicular approach
        • axillary approach
      • When osseous or musculo-ligamentar abnormalities:
        • sus-clavicular approach
      • Non complicated arterial compressions:
        • axillary approach
      • Complicated arterial compression (thrombosis, aneurysms…):
        • sus-clavicular approach ± sub-clavicular approach
      • Complicated veinous compressions:
        • difficult to choose…
  • 42. SURGICAL TREATMENT OF T.O.S.
      • COMPLICATIONS OF SURGICAL TREATMENT OF T.O.S.
        • Minor
          • transcient dysesthaesia
          • pleural entering
          • hemo- or chylo-thorax
        • Major :
          • veinous or arterial injuries
          • brachial plexus injuries
  • 43. 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