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THORACIC OUTLET
SYNDROME
DISCUSSED BY – DR KUNWAR SIDHARTH SAURABH
CREDITS –
DR NAVNITA KISKU
DR SUBRATA
DEFINITION
• Refers to compression of subclavian vessels and
the brachial plexus at the superior aperture of
the chest.
• Most compressive factors operate against the
first rib.
Surgical
Anatomy
• The subclavian vessels and the brachial
plexus traverse the cervicoaxillary canal
to reach upper extremity.
• The first rib divides the canal into two
parts –
• Proximal – Scalene triangle and
costoclavicular space (more critical
for neurovascular compression)
• Distal – Axilla
• The scalaneus anterior muscle divides
costoclavicular space into two parts –
• Anteromedial
• Posterolateral – known as Scalene
triangle
Surgical Anatomy
Surgical Anatomy
Surgical Anatomy
Thoracic outlet syndrome
Causes of Neurovascular Compression
Anatomic –
Potential site of neurovascular compression –
• Interscalene triangle
• Costoclavicular space
• Subcoracoid area
Traumatic –
SUDDEN UNACCUSTOMED MUSCULAR EFFORTS
INVOLVING SHOULDER GIRDLE MUSCLES.
Fracture of clavicle
Dislocation of head of humerus
Crushing injury of upper thorax
Cervical SPONDYLOSIS and injury to Cervical
spine
Causes of Neurovascular Compression
• CONGENITAL –
• CERVICAL RIB
• RUDIMENTARY FIRST THORACIC RIB
• SCALENE MUSCLES ANOMALY
• FIBROUS BANDS
• BIFID FIRST RIB
• EXOSTOSIS OF FIRST RIB
• ENLARGED PROCESS OF C7
• FLAT CLAVICLE
• ABNORMAL INSERTION OF SOTOCLAVICULAR LIGAMENT
SIGNS AND
SYMPTOMS
Neurogenic
manifestations more
common.
•Pain
•Paraesthesia
•Motor weakness
•Atrophy of hypothenar
and interosseous muscles
Symptoms occurs
most commonly in
area supplied by
ulnar nerve.
Upper type involves
C5-C6 – pain usually
in deltoid area and
lateral aspect of the
arm – Must exclude
herniated cervical
disc.
C7-C8 entrapment
produces symptoms
in distribution of
median nerve.
SIGNS AND SYMPTOMS
• PSEUDOANGINA –
• Atypical pain, in the area of anterior chest wall or parascapular area.
• Symptoms of arterial compression –
• Coldness, weakness, easy fatiguability of arm and hand
• Diffuse pain – Raynauds phenomenon in 8% patients.
• May be precursor of arterial thrombosis.
• Palpation in parascapular area may reveal prominent pulsation indicating
post-stenotic dilatation of subclavian artery.
• Less commonly symptoms are due to venous compression – known
as effort thrombosis or PAGET – SCHROETTER SYNDROME
SIGNS AND SYMPTOMS
CLINICAL TESTS
CLINICAL TESTS
CLINICAL TESTS
DIAGNOSIS
HISTORY, PHYSICAL EXAMINATION
CXR, CERVICAL SPINE X RAY
PERIPHERAL ANGIOGRAPHY – Indicated in –
• Paraclavicular pulsating mass
• Absence of radial pulse
• Presence of supra or infra clavicular Bruits
• Phlebography – Paget –Schroetter syndrome
ULNAR NERVE CONDUCTION VELOCITY
• 66-69m/sec – slight
• 60-65 m/sec – mild
• 55-59 m/sec – moderate
• <54 m /sec – severe
NEW MODALITY – MRI WITH POSTURAL MANOUVERES
CXR
DIFFERENTIAL
DIAGNOSIS
Ruptured intervertebral disc
Osteoarthritis
Spinal cord tumors
Brachial plexus tumors
POSTURAL PALSY
Entrapment neuropathy
Embolism , Thromboangitis obliterans
Vasculitis, collagen disease etc
Angina pectoris, esophageal spasm
TREATMENT
PHYSIOTHERAPY
IMPROVING POSTURE
PATIENTS HAVING “UNCV >60” IMPROVE
WITH CONSERVATIVE MANAGEMENT.
UNCV < 60 –> REQUIRES SURGICAL
INTERVENTION
INDICATIONS
FOR SURGERY
AREA OF COMPRESSION SYMPTOMS INDICATING NEED FOR
SURGERY
NERVE SENSORY :- PERSISTENT SYMPTOMS
INSPITE OF PHYSICAL THERAPY
MOTOR : WEAKNESS OR ATROPHY
ARTERY ANEURYSM OR SYMPTOMATIC
INSUFFICIENCY
VEIN OCCLUSION (PAGET – SCHROETTER)
MULTIPLE THEAPEUTIC TRAIL
APPROACHES
TYPE OF PROBLEM SURGICAL APPROACH
NERVE COMPRESSION TRANSAXILLARY
VENOUS COMPRESSION TRANSAXILLARY
ARTERIAL COMPRESSION SUPRA & INFRACLAVICULAR
RECURRENT TOS POSTERIOR HIGH THORACOPLASTY
TRANSAXILLARY
APPROACH (ROOS
et al)
• Return the arm to the
neutral position every 20
minutes during the course
of the operation to further
minimize positioning-
related brachial plexopathy
• The incision is located just
above the lower border of
the axillary hair line and
extends from the border of
the latissimus to the border
of the pectoralis.
• Preserve the thoracodorsal
and long thoracic nerves
Operative
exposure by this
approach.
• Blunt dissection cephalad exposes
first rib and permit palpation of
subclavian artery.
• Wylie vein retractor permits
focused deep retraction
• Subclavian pulse is used to guide
the retractor placement to avoid
compressing brachial plexus
Division of
anterior scalene
muscle
• The phrenic nerve courses laterally to
medially across the anterior surface of
the muscle at the cephalad extent of the
field of exposure.
• In general, the phrenic nerve courses
posterior to the subclavian vein, but in
rare cases it will pass anterior to the vein.
• Divide the muscle carefully as cephalad as
it may be adequately visualized,
permitting an effective resection or
scalenectomy at the time of first rib
removal, rather than a simple division or
scalenotomy.
• This additional effort is of importance in
averting the portion of persistent or
recurrent TOS that is attributed to
inadequate resection of this muscle
Division of
middle scalene
• A periosteal elevator or the Metzenbaum
scissors may then be used to separate the
middle scalene from its insertion on the
first rib, a technique that preserves the
long thoracic nerve that courses rather
variably through the belly of this muscle,
thus avoiding denervation of the serratus
anterior muscle and the attendant
complication of “winged scapula”
• If a scalenus minimus is present between
the subclavian artery and the brachial
plexus, it should be resected at this stage,
as should any other ligamentous bands
encountered constraining the plexus.
• These may insert on the first rib or even
extend to insert into Sibson’s fascia over
the pleural cupola
Dissection of
inferior border of
first rib
• Dissect the inferior border of
the first rib free from the
intercostal musculature,
exposing the underlying
parietal pleura.
• The parietal pleura should be
gently bluntly dissected free of
the posterior surface of the rib,
with care taken to avoid
entering the pleural space.
• The rib should be dissected
free from the level of the
costochondral junction
medially to the lateral-most
extent of the middle scalene
posteriorly
Resection of first
rib using Roos
first rib shear
• Roos bone shear is inserted
carefully, with the surgeon’s
finger placed between the
shear and the brachial
plexus.
• The rib should be divided
just beyond the divided
insertion of the middle
scalene muscle.
• Anteriorly,the Roos bone
shear should be used to
resect the first rib segment
as close as possible to the
costochondral junction
Complete medial
rib removal by
Kerrison rongeur
• Kerrison rongeur is
used to smooth the
rib end posteriorly
and extend the
resection to the level
of the costochondral
junction anteriorly to
permit full
decompression
Complete lateral
rib removal by
Kerrison rongeur.
• complete resection of the
costoclavicular ligament
and the subclavius tendon
and muscle to permit full
venolysis and
decompression of the
vein at this key point of
entrapment.
• Air leak should be
checked, wound should
then be closed over a
chest drain.
Thoracic outlet syndrome
SUPRACLAVICULAR
APPROACH
• A sandbag is placed
between the scapulae
and the neck extended
to the nonoperative
side.
• Long-acting paralytic
agents are avoided.
• An incision is made in
the supraclavicular
fossa, in a neck crease
parallel to and 2 cm
above the clavicle
Identification of
supraclavicular
nerves
• identified just
beneath the platysma
and mobilized to
allow vessel loop
retraction.
Division of
omohyoid
• The omohyoid is divided
• the supraclavicular fat pad is
elevated, after which the scalene
muscles and the brachial plexus
are palpated.
• The lateral portion of the clavicular
head of the. sternocleidomastoid
is divided and at the end of the
procedure is repaired.
• The phrenic nerve is seen on the
anterior surface of the anterior
scalene muscle; the brachial
plexus is noted at the interscalene
position, and the long thoracic
nerve is noted on the posterior
aspect of the middle scalene
muscle.
Anterior
scalene division
• The anterior scalene muscle
is divided from the first rib,
and the subclavian artery is
noted immediately behind
this.
• An umbilical tape is placed
around the subclavian
artery. The phrenic nerve is
not mobilized, but rather is
protected by direct
visualization, while the
anterior scalene muscle is
divided
Middle scalene
division
• The upper, middle, and lower
trunks of the brachial plexus
are visualized and gently
mobilized.
• The middle scalene muscle is
now divided from the first rib.
• It has a broad attachment to
the first rib, and care must be
taken to avoid injury to the
long thoracic nerve, which in
this position may have multiple
branches and may pass
through or posterior to the
middle scalene muscle
Division of
congenital bands
• With division of the
middle scalene muscle,
the brachial plexus is
visualized and mobilized,
and the lower trunk is
identified with the C8 and
T1 nerve roots resting
above and below the first
rib, respectively.
• Congenital bands and
thickening in Sibson’s
fascia are divided.
Exposure &
division of first
rib
• The first rib is then
encircled and divided
where it is easily visible
with bone-cutting
instruments.
• Note the relationship of
the C8 and T1 nerve roots
with the head of the first
rib.
• These roots are reflected
and protected to allow
maximum exposure of the
first rib.
Division of
posterior part of
1st rib
• The posterior segment of the
divided first rib is removed back to
its spinal attachments by rongeur
technique.
• The posterior edge of the first rib
is grasped firmly with a rongeur,
and a rocking and twisting motion
is used to remove the entire
aspect of the rib.
• This technique facilitates removal
of the entire posterior portion of
the rib to ensure residual bone
does not remain, thereby
preventing new bone formation
and the potential for production of
recurrent compression.
Division of
anterior part of
first rib
• The anterior portion of
the first rib is removed
in a similar fashion to
decompress the
neurovascular
elements.
• Cervical ribs or long
transverse processes
are removed by the
same technique.
Completed
dissection
• The brachial plexus, subclavian
artery, phrenic nerve, and long
thoracic nerve are protected.
• Open the pleura, facilitating
drainage of any postoperative
blood collection into the chest
cavity rather than allowing the
blood to collect in the operative
site around the brachial plexus.
• When opening the pleura, care is
taken to protect the intercostal
brachial nerve, which is noted on
the dome of the pleura.
• The sternocleidomastoid muscle is
repaired
Thoracic outlet syndrome
RECURRENT THORACIC OUTLET SYNDROME
• Recurrent symptoms, primarily neurogenic, should be documented by
objective NCVs.
• When NCVs are depressed in a patient whose symptoms are unrelieved by
prolonged conservative therapy, a posterior procedure should be
considered.
• Removal of any rib remnants or regenerated fibrocartilage and neurolysis
of C7, C8, and T1 nerve roots and the brachial plexus are performed .
• Dorsal sympathectomy is added to minimize the contribution of causalgia
to symptoms.
• Methylprednisolone acetate and hyaluronic acid are employed to minimize
recurrent scarring
Thoracic outlet syndrome
THANKS

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Thoracic outlet syndrome

  • 1. THORACIC OUTLET SYNDROME DISCUSSED BY – DR KUNWAR SIDHARTH SAURABH CREDITS – DR NAVNITA KISKU DR SUBRATA
  • 2. DEFINITION • Refers to compression of subclavian vessels and the brachial plexus at the superior aperture of the chest. • Most compressive factors operate against the first rib.
  • 3. Surgical Anatomy • The subclavian vessels and the brachial plexus traverse the cervicoaxillary canal to reach upper extremity. • The first rib divides the canal into two parts – • Proximal – Scalene triangle and costoclavicular space (more critical for neurovascular compression) • Distal – Axilla • The scalaneus anterior muscle divides costoclavicular space into two parts – • Anteromedial • Posterolateral – known as Scalene triangle
  • 8. Causes of Neurovascular Compression Anatomic – Potential site of neurovascular compression – • Interscalene triangle • Costoclavicular space • Subcoracoid area Traumatic – SUDDEN UNACCUSTOMED MUSCULAR EFFORTS INVOLVING SHOULDER GIRDLE MUSCLES. Fracture of clavicle Dislocation of head of humerus Crushing injury of upper thorax Cervical SPONDYLOSIS and injury to Cervical spine
  • 9. Causes of Neurovascular Compression • CONGENITAL – • CERVICAL RIB • RUDIMENTARY FIRST THORACIC RIB • SCALENE MUSCLES ANOMALY • FIBROUS BANDS • BIFID FIRST RIB • EXOSTOSIS OF FIRST RIB • ENLARGED PROCESS OF C7 • FLAT CLAVICLE • ABNORMAL INSERTION OF SOTOCLAVICULAR LIGAMENT
  • 10. SIGNS AND SYMPTOMS Neurogenic manifestations more common. •Pain •Paraesthesia •Motor weakness •Atrophy of hypothenar and interosseous muscles Symptoms occurs most commonly in area supplied by ulnar nerve. Upper type involves C5-C6 – pain usually in deltoid area and lateral aspect of the arm – Must exclude herniated cervical disc. C7-C8 entrapment produces symptoms in distribution of median nerve.
  • 11. SIGNS AND SYMPTOMS • PSEUDOANGINA – • Atypical pain, in the area of anterior chest wall or parascapular area. • Symptoms of arterial compression – • Coldness, weakness, easy fatiguability of arm and hand • Diffuse pain – Raynauds phenomenon in 8% patients. • May be precursor of arterial thrombosis. • Palpation in parascapular area may reveal prominent pulsation indicating post-stenotic dilatation of subclavian artery. • Less commonly symptoms are due to venous compression – known as effort thrombosis or PAGET – SCHROETTER SYNDROME
  • 16. DIAGNOSIS HISTORY, PHYSICAL EXAMINATION CXR, CERVICAL SPINE X RAY PERIPHERAL ANGIOGRAPHY – Indicated in – • Paraclavicular pulsating mass • Absence of radial pulse • Presence of supra or infra clavicular Bruits • Phlebography – Paget –Schroetter syndrome ULNAR NERVE CONDUCTION VELOCITY • 66-69m/sec – slight • 60-65 m/sec – mild • 55-59 m/sec – moderate • <54 m /sec – severe NEW MODALITY – MRI WITH POSTURAL MANOUVERES
  • 17. CXR
  • 18. DIFFERENTIAL DIAGNOSIS Ruptured intervertebral disc Osteoarthritis Spinal cord tumors Brachial plexus tumors POSTURAL PALSY Entrapment neuropathy Embolism , Thromboangitis obliterans Vasculitis, collagen disease etc Angina pectoris, esophageal spasm
  • 19. TREATMENT PHYSIOTHERAPY IMPROVING POSTURE PATIENTS HAVING “UNCV >60” IMPROVE WITH CONSERVATIVE MANAGEMENT. UNCV < 60 –> REQUIRES SURGICAL INTERVENTION
  • 20. INDICATIONS FOR SURGERY AREA OF COMPRESSION SYMPTOMS INDICATING NEED FOR SURGERY NERVE SENSORY :- PERSISTENT SYMPTOMS INSPITE OF PHYSICAL THERAPY MOTOR : WEAKNESS OR ATROPHY ARTERY ANEURYSM OR SYMPTOMATIC INSUFFICIENCY VEIN OCCLUSION (PAGET – SCHROETTER) MULTIPLE THEAPEUTIC TRAIL
  • 21. APPROACHES TYPE OF PROBLEM SURGICAL APPROACH NERVE COMPRESSION TRANSAXILLARY VENOUS COMPRESSION TRANSAXILLARY ARTERIAL COMPRESSION SUPRA & INFRACLAVICULAR RECURRENT TOS POSTERIOR HIGH THORACOPLASTY
  • 22. TRANSAXILLARY APPROACH (ROOS et al) • Return the arm to the neutral position every 20 minutes during the course of the operation to further minimize positioning- related brachial plexopathy • The incision is located just above the lower border of the axillary hair line and extends from the border of the latissimus to the border of the pectoralis. • Preserve the thoracodorsal and long thoracic nerves
  • 23. Operative exposure by this approach. • Blunt dissection cephalad exposes first rib and permit palpation of subclavian artery. • Wylie vein retractor permits focused deep retraction • Subclavian pulse is used to guide the retractor placement to avoid compressing brachial plexus
  • 24. Division of anterior scalene muscle • The phrenic nerve courses laterally to medially across the anterior surface of the muscle at the cephalad extent of the field of exposure. • In general, the phrenic nerve courses posterior to the subclavian vein, but in rare cases it will pass anterior to the vein. • Divide the muscle carefully as cephalad as it may be adequately visualized, permitting an effective resection or scalenectomy at the time of first rib removal, rather than a simple division or scalenotomy. • This additional effort is of importance in averting the portion of persistent or recurrent TOS that is attributed to inadequate resection of this muscle
  • 25. Division of middle scalene • A periosteal elevator or the Metzenbaum scissors may then be used to separate the middle scalene from its insertion on the first rib, a technique that preserves the long thoracic nerve that courses rather variably through the belly of this muscle, thus avoiding denervation of the serratus anterior muscle and the attendant complication of “winged scapula” • If a scalenus minimus is present between the subclavian artery and the brachial plexus, it should be resected at this stage, as should any other ligamentous bands encountered constraining the plexus. • These may insert on the first rib or even extend to insert into Sibson’s fascia over the pleural cupola
  • 26. Dissection of inferior border of first rib • Dissect the inferior border of the first rib free from the intercostal musculature, exposing the underlying parietal pleura. • The parietal pleura should be gently bluntly dissected free of the posterior surface of the rib, with care taken to avoid entering the pleural space. • The rib should be dissected free from the level of the costochondral junction medially to the lateral-most extent of the middle scalene posteriorly
  • 27. Resection of first rib using Roos first rib shear • Roos bone shear is inserted carefully, with the surgeon’s finger placed between the shear and the brachial plexus. • The rib should be divided just beyond the divided insertion of the middle scalene muscle. • Anteriorly,the Roos bone shear should be used to resect the first rib segment as close as possible to the costochondral junction
  • 28. Complete medial rib removal by Kerrison rongeur • Kerrison rongeur is used to smooth the rib end posteriorly and extend the resection to the level of the costochondral junction anteriorly to permit full decompression
  • 29. Complete lateral rib removal by Kerrison rongeur. • complete resection of the costoclavicular ligament and the subclavius tendon and muscle to permit full venolysis and decompression of the vein at this key point of entrapment. • Air leak should be checked, wound should then be closed over a chest drain.
  • 31. SUPRACLAVICULAR APPROACH • A sandbag is placed between the scapulae and the neck extended to the nonoperative side. • Long-acting paralytic agents are avoided. • An incision is made in the supraclavicular fossa, in a neck crease parallel to and 2 cm above the clavicle
  • 32. Identification of supraclavicular nerves • identified just beneath the platysma and mobilized to allow vessel loop retraction.
  • 33. Division of omohyoid • The omohyoid is divided • the supraclavicular fat pad is elevated, after which the scalene muscles and the brachial plexus are palpated. • The lateral portion of the clavicular head of the. sternocleidomastoid is divided and at the end of the procedure is repaired. • The phrenic nerve is seen on the anterior surface of the anterior scalene muscle; the brachial plexus is noted at the interscalene position, and the long thoracic nerve is noted on the posterior aspect of the middle scalene muscle.
  • 34. Anterior scalene division • The anterior scalene muscle is divided from the first rib, and the subclavian artery is noted immediately behind this. • An umbilical tape is placed around the subclavian artery. The phrenic nerve is not mobilized, but rather is protected by direct visualization, while the anterior scalene muscle is divided
  • 35. Middle scalene division • The upper, middle, and lower trunks of the brachial plexus are visualized and gently mobilized. • The middle scalene muscle is now divided from the first rib. • It has a broad attachment to the first rib, and care must be taken to avoid injury to the long thoracic nerve, which in this position may have multiple branches and may pass through or posterior to the middle scalene muscle
  • 36. Division of congenital bands • With division of the middle scalene muscle, the brachial plexus is visualized and mobilized, and the lower trunk is identified with the C8 and T1 nerve roots resting above and below the first rib, respectively. • Congenital bands and thickening in Sibson’s fascia are divided.
  • 37. Exposure & division of first rib • The first rib is then encircled and divided where it is easily visible with bone-cutting instruments. • Note the relationship of the C8 and T1 nerve roots with the head of the first rib. • These roots are reflected and protected to allow maximum exposure of the first rib.
  • 38. Division of posterior part of 1st rib • The posterior segment of the divided first rib is removed back to its spinal attachments by rongeur technique. • The posterior edge of the first rib is grasped firmly with a rongeur, and a rocking and twisting motion is used to remove the entire aspect of the rib. • This technique facilitates removal of the entire posterior portion of the rib to ensure residual bone does not remain, thereby preventing new bone formation and the potential for production of recurrent compression.
  • 39. Division of anterior part of first rib • The anterior portion of the first rib is removed in a similar fashion to decompress the neurovascular elements. • Cervical ribs or long transverse processes are removed by the same technique.
  • 40. Completed dissection • The brachial plexus, subclavian artery, phrenic nerve, and long thoracic nerve are protected. • Open the pleura, facilitating drainage of any postoperative blood collection into the chest cavity rather than allowing the blood to collect in the operative site around the brachial plexus. • When opening the pleura, care is taken to protect the intercostal brachial nerve, which is noted on the dome of the pleura. • The sternocleidomastoid muscle is repaired
  • 42. RECURRENT THORACIC OUTLET SYNDROME • Recurrent symptoms, primarily neurogenic, should be documented by objective NCVs. • When NCVs are depressed in a patient whose symptoms are unrelieved by prolonged conservative therapy, a posterior procedure should be considered. • Removal of any rib remnants or regenerated fibrocartilage and neurolysis of C7, C8, and T1 nerve roots and the brachial plexus are performed . • Dorsal sympathectomy is added to minimize the contribution of causalgia to symptoms. • Methylprednisolone acetate and hyaluronic acid are employed to minimize recurrent scarring