Thoracic outlet syndrome

1. Thoracic Outlet Syndrome

3. ANATOMY OF TOS
• Boundaries
• Anteriorly-Manubrium sterni
• Posteriorly-T1 vertebrae
• Laterally-1st rib

4. • Contents
• 1) Subclavian artery
• 2)Subclavian vein
• 3)Brachial plexus

6. • 3 potential spaces for compression of neurovascular structures
• 1)Interscalene space-Anteriorly by scalaneus anterior,Posteriorly by
scalaneus medius and inferiorly 1st rib.
• 2)Costoclavicular space-Anteriorly by clavice and posteriorly by 1st rib
• 3)Subpectoralis minor space-Pectoralis minor and costocoracoid
membrane.

9. Thoracic Outlet Syndrome
• Definition:A collection of symptoms that occur due to compression of
neurovascular structures between clavice and 1st rib.(Thoracic outlet
• Peet introduced this term in 1956.
• It is usually common in the female sex between 10-50 years of age.

11. Causes
• 1)Cervical rib
• 2)Elongated C7 transverse process
• 3) Exostosis of 1st rib
• 4)Fibrous band
• 5)Post traumatic-Clavicle fracture ,brachial plexus injury
• 6)Poor posture-Holding head in forward position
• 7)Muscle abnormalities-Scalaneus muscle hypertrophy, scalaneus
minimus

12. Clinical features
• 1)Neurological
• 2)Venous
• 3)Arterial

13. • Neurological
• Neck pain/shoulder pain
•
• Tingling, numbness
• Muscle atrophy

14. Arterial
• Coldness
• Cyanosis
• Ulcers
• Gangrene

15. • Venous
•
• Edema
• Venous distension
• Paget Schroetter syndrome-Effort thrombosis of axillary subclavian
vein.

16. Clinical tests to diagnose TOS
• 1)ROOS/EAST test
• 2)Adsons test
• 3)Wright’s hyperabduction test
• 4) Costoclavicular manaeuver
• 5)Allens test

17. • Roos test/East test
• 90 degree abduction and external rotation of arm.
• Hold elevation for 3mins and open and close fists.
• Test is positive if there is pain,parasthesia
•

18. • Adsons test
• Sitting/Standing position
• Take deep breath and turn head to affected side
•
Check radial pulse and see for obliteration of radial pulse or presence
of bruit infraclavicular.

19. • Wright’s hyperabduction test
• First abduct till 90 and then hyperabduction till 180 degree
•
• Diminished radial pulse due to Costoclavicular space compression.

20. • Allen’s test
•
• Occlude radial artery
• Clench fist
• Unclench and continue compression of radial artery
•
• If ulnar artery patent, colour returns to normal ,if occlusion pallor present

21. • Costoclavicular manaeuver
• Sitting position
• Titanic position
• Shoulders shrugged downwards and backwards and elbow extended
palpate radial pulse.If pulse reduces test is positive.

22. Investigations
• 1)Routine x-rays-Xrays of cervical spine to see for cervical rib, Exostosis, calcifications
•
• 2)Chest x-ray
• 3)Arteriography-Post stenotic dilation
• 4) Venography-Venous obstruction
• 5)Nerve conduction studies-To rule out CTS
•
• 6)MRI-To see for SOL,disc compression

23. Treatment
• Non operative
• 1) Physiotherapy-Breathing and posture strength excercises
• 2)Pain-Analgesics and muscle relaxants
• 3)BOTOX A
-Binds presynaptically to sites causing neuromuscular Blockade due to
decreased release of acetylcholine
4)Avoid repetitive upper extremity work

24. Operative
• Indications
•
• Persistent symptoms
• progressive neurodeficit
• Vascular compromise

25. • First rib resection and anterior scalenectomy using
• -Transaxillary approach
• -Anterior approach
• -Posterior approach

26. Complications
• 1)Post stenotic dilatation
• 2) Reccurent ulcers
•
• 3)Gangrene
• 4) Venous thrombosis