an update of my original presentation

1. THORACIC OUTLET SYNDROME

2. 
Thoracic outlet syndrome (TOS)- a collection
of symptoms brought about by abnormal
compression of the neurovascular bundle by
bony, ligamentous or muscular obstacles in the
narrow space between clavicle and 1 st rib.

3. ANATOMY

Interscalene triangle

Costoclavicular space
−
Med : 1st rib
−
Med : 1st rib
−
Ant : clavicle,
scaleneus anterior
−
Ant : clavicle
−
Post : scaleneus
anterior
−
Lat : costoclavicular
ligament, subclavius
muscle
−

Post : scaleneus
medius
Subcoracoid tunnel
compressed by pectoralis minor tendon, head of
humerus or coracoid process.

6. Subcoracoid tunnel

7. contents

Brachial plexus

Subclavian artery

Subclavian vein

8. Causes

Cervical rib

Long C7 transverse process

Anomalous insertion of scalene muscles

Scalene muscle hypertrophy

Scaleneus minimus

Abnormal bands, ligaments

Fracture clavicle/ 1st rib

Exostosis

Tumours

Brachial plexus trauma / diseases

9. Cervical rib




A cervical rib is a supernumerary (or extra) rib
which arises from the seventh cervical vertebra.
Sometimes known as "neck ribs"
Congenital abnormality located above the
normal first rib.
A cervical rib is present in only about (0.2%) of
people.

Half unilateral, common in right side.

Usually asymptomatic

10. Types :
1) Completely bony
2) Completely
fibrous
3) Combined
4) Bony swelling

11. 

Type 3 is most common.
Type 3 – a band stretching from C7 vertebra to
Scalene tubercle on 1st rib. It elevates the
neurovascular bundle compressing it in the
interscalene triangle.

13. Cervical rib

14. Cervical rib

15. Clinical features

Most commonly seen in middle aged women

Usually due to neural compromise.
Interscalene
triangle
Artery , Nerves
Scaleneus anticus
syndrome
Costoclavicular
space
Vein
Edens syndrome
Subcoracoid area
Artery, Vein ,
Nerves
Hyperabduction
syndrome

16. Interscalene triangle

17. Costoclavicular space

18. Hyperabduction syndrome

19. Arterial compromise

Fatigue

Weakness

Coldness

Upper limb claudication

Thrombosis

Paraesthesia

Gangrene

Raynaud's phenomenon due to thrombosis with
distal embolisation

21. Venous compromise

Edema

Venous distension

Collateral formation

Cyanosis

Paget-Schroetter syndrome – effort thrombosis
−
"Effort" axillary-subclavian vein thrombosis (PagetSchroetter syndrome) is an uncommon deep
venous thrombosis due to repetitive activity of the
upper limbs.

22. Neural compromise

Paraesthesia

Pain in shoulder, arm, forearm and fingers


Occipital headache – referred from tight
scalene muscles
Weakness of forearm, hand.

23. Clinical tests

24. Roos Test


Hold both arms in surrendering position
(90°overhead with shoulders in external
rotation) – reproduction of symptoms within 1
minute . Arm collapses if continued.
modified Roos test / Elevated Arm Stress
Test(EAST)– same as above. Symptoms
precipitated by opening and closing fists
continuously.

25. Elevated arms stress test

26. Adson's (Scalene) Test


Radial pulse diminishes and disappears on
turning chin to same side.
Decreases space between scaleneus anterior
and medius .

27. Adsons test

28. Halsted's costoclavicular
compression test

45° abduction and extension of arm with
downward pressure on shoulders –neck turned
to opposite side- reproduce symptoms

29. Exaggerated military position

Patient shrugs shoulders with deep inhalation
while drawing the shoulders backward in an
exaggerated military position – radial pulse
diminishes.

30. Military position

31. Wright's hyperabduction test


Arm hyperabducted
to 180°-diminishing
radial pulse.
Neurovascular
structures
compressed in
subcoracoid region by
pectoralis minor
tendon, head of
humerus or coracoid
process.

32. Wright's hyperabdution test

33. 

Tinel sign – in supra and infraclavicular region
Phalens sign – in carpel tunnel syndrome
(CTS)

34. Differential diagnoses

Carpel tunnel syndrome

Spinal canal tumors

Shoulder myositis

Angina pectoris

Raynaud's disease

Ulnar nerve compression - epicondylitis

35. Investigations

Chest x ray, cervical spine x ray

MRI, cervical myelography
−

Doppler , vascular
imaging(angiogram/venogram)
−

r/o narrowing of intrevertebral foramen, disc
compression.
r/o aneurism, thrombosis
Nerve conduction study, electromyography
−
confirm neurogenic TOS, localise the area of
compression- r/o CTS

36. 
Double crush syndrome – TOS with other
peripheral sites of nerve compression(CTS)

37. Treatment

38. Non operative treatment

Posture improving exercises.

Breathing exercises.

Avoid aggravating activities.

Avoid repetitive upper extremity mechanical
work and muscular trauma.

Analgesics,muscle relaxants, antidepressants.

Physiotherapy .

39. Surgical treatment
Indications:

Symptoms persists with non operative
treatment.

Associated vascular compression.

Progression of neurological symptoms.

Nerve conduction velocity < 60m/s

40. 

Trans cervical or trans axillary(Roos) resection
of 1st rib often with release of scalene muscles.
Extraperiosteal excision of Cervical rib(to
prevent its regeneration) .Often a cervical
sympathectomy is also needed.

41. Roos approach

42. Thank you....