thoracic outlet syndrome

THORACIC OUTLET
SYNDROME
BY
DR. HANI AL-DAKAR
SPECIALIST OF ORTHOPEDIC SURGERY
AL MAHMOUDIA HOSPITAL
3/18/2018
Physio-Ortho meeting

HISTORICAL REVIEW
•Galen –was the first who described the
presence of Cervical rib in medical
literature 150 years AD
•Vesalius – 1543 – A Belgian anatomist
described Cervical ribs
3/18/2018Physio-Ortho meeting

SIR ASTLEY COOPER (1768- 1841)
• “Prince of surgery”
• Guy’s hospital in London
• Many contribution in vascular surgery
• President of the royal collage of
surgeons
• In 1821 he described a case of a
woman with pulseless, cold arm and
gangrenous changes to the fingers due
to compression and thrombosis of the

•Gruber – 1842 – 4 types of cervical
ribs
•Coote - 1861 – first cervical rib
resection
•Paget – 1875 – subclavian vein
thrombosis

WILLIAM HALSTED
In 1916 - described how
cervical ribs cause subclavian
artery post-stenotic dilatation

• Law – 1920 – described congenital bands and
ligaments that compressed the lower brachial
plexus
• Adson and coffey – 1927 – division of anterior
scalene muscle without cervical rib resection
• Ochsner, gage, debakey – 1935 – scalene anticus
syndrome (naffziger’s syndrome) – scalenotomy
in the absence of cervical rib

•PEET – 1956 – Introduced the term
“Thoracic outlet syndrome”
•Clagett – 1962 – posterior approach to first
rib resection
•Roos – 1966 – trans-axillary first rib
resection
•Gol – 1968 – infraclavicular approach3/18/2018Physio-Ortho meeting

DEFINITION
Thoracic outlet syndrome (TOS)- is 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 1st rib.3/18/2018Physio-Ortho meeting

EPIDEMIOLO
GY
20-50yo
<5% teenagers
10% over 50
Rarely >65
70% female
70% cervical ribs
occur in females
3/18/2018 Physio-Ortho meeting

ANATOMY
BOUNDARIES OF T.O.
• Posteriorly: T1
vertebral body
• Laterally: first rib
and costal cartilage
• Anteriorly:
manubrium sterni

Thoracic outlet is
subdivided to three
spaces where the
obstruction always
occur
1. Inter-Scalene
triangle
2. Costoclavicular
space
3. Pectoralis minor

1- Inter-scalene Triangle
•Med : 1st rib
•- Ant : clavicle &
Scaleneus anterior
•- Post : scaleneus
Medius

2- Costoclavicular Space
• Med : 1st rib
• - Ant : clavicle
• - Post : scaleneus
Anterior
• - Lat : costoclavicular
Ligament, subclavius
Muscle

3- Pectoralis Minor Space (Subcoracoid
Space)
Compressed by
•pectoralis minor
tendon,
•head of humerus,
•or coracoid process. 3/18/2018Physio-Ortho meeting

CONTENTS
Brachial Plexus
Subclavian Artery
Subclavian Vein

PRINCIPA
L CAUSES
OF TOS
Skeletal and bone
abnormalities
•Cervical rib 0.74%,
•Anomalous 1st rib 0.76%
•Elongated C 7 transverse
process
•Exostosis or tumor of the
first rib or clavicle

Soft tissue abnormalities
• Fibous band
• Congenital variations
• Insertion variation
• Supernumery muscle
• Hypertrophied muscle
• Acquierd soft tissue abnormalities
• Post traumatic fibrous scarring
• Postoperative scarring
PRINCIPAL
CAUSES
OF TOS

•Poor Posture And Weak Muscular Support In Thin
Women
Posture and predisposing morphotype
PRINCIPA
L CAUSES
OF TOS

CERVICAL RIB
• It is a superneumary
rib that arises from
seventh cervical
vertebra or rarely
from sixth or fifth
cervical vertebrae.
• Incidence 0.5-0.6%
• Bilateral in 60-80 %
• Symptomatic in 10 -

TYPES OF CERVICAL RIB

TYPES
OF TOS
Neurogenic TOS – 95%
•Most difficult to diagnose and
treat
Venous TOS – 2-3%
Arterial TOS - <1%

NEUROGENIC
TOS.

NEUROGENIC TOS
Etiology
• Hyperextension neck
injury (whiplash)
• Repetitive stress injuries
(typing, assembly lines)
• Falls on slippery floors/ice

Pathophysiology
•Neck trauma stretches and tears scalene
muscle fibers
•Swelling of muscle belly
Pain, parathesia, numbness, weakness
•Scarring/fibrosis of muscle belly
• Occipital headaches.

Predisposing factors
• Scalene muscle anomalies
• Narrow scalene triangles
• Congenital ligaments/bands
• High plexus roots
• Cervical ribs

Symptoms
• Pain, paresthesia, numbness, weakness
• Throughout affected hand/arm
• Not necessarily localized to peripheral nerve
distribution
• Extension to shoulder, neck, upper back not
infrequently
• “Upper plexus” disorders
• radial and musculocutaneous nerve distributions
• “Lower plexus” disorders
3/18/2018

Symptoms
•Occipital headaches
• Perceived muscle weakness
•Actual weakness and atrophy are rare
•Vasomotor symptoms
•Vasospasm, edema, hypersensitivity

Pectoralis minor syndrome
• Compression of
neurovascular bundle
under the pec minor
• Pain over anterior chest
and axilla
• Fewer head/neck
symptoms
• Consider pec minor
tenotomy with thoracic
outlet decompression

VENOUS TOS

VENOUS TOS
Etiology
• Developmental anomalies of costoclavicular
space
• Repetitive arm activities
• Throwing
• Swimming
• Overhead Activities

Predisposing factors
• Relationship of vein to subclavius tendon and
costoclavicular ligament
• Dimensions of costoclavicular space
• Repetitive trauma to vein causing fibrosis,
stenosis, thrombosis

Acute occlusion
• Pain
• Tightness
• Discomfort during exercise
• Edema
• Cyanosis
• Increased venous pattern
• Tenderness over the
axillary vein
• Gangrene rarely
3/18/2018

PHYSICAL ACTIVITIES
• Lifting or heavy objects, basketball,
baseball, painting, tennis, racquet ball,
football, golf, Up to 40% had residual
symptoms after treatment

PAGET-SCHROETTER SYNDROME
“EFFORT THROMBOSIS”
"Effort" Axillary-subclavian Vein Thrombosis
(Paget-schroetter Syndrome) Is An
Uncommon Deep Venous Thrombosis Due To
Repetitive Activity Of The Upper Limbs.

ARTERIAL TOS

ARTERIAL TOS
•Etiology
• Cervical or anomalous first rib
• Anomalous anterior scalene insertion

•Pathophysiology
•Arterial compression resulting in post-
stenotic dilatation or aneurysm
•Distal embolization by a thrombus

•Symptoms
•Digital or hand
ischemia
•Cutaneous ulcerations
•Forearm pain with use
•Pulsatile
supraclavicular 3/18/2018Physio-Ortho meeting

Diagnosis

•“The most accurate diagnosis of
TOS…must rely on A careful history
and thorough, appropriate physical
examination”
David B roos, MD
•No single diagnostic test has sufficient
specificity to prove or exclude the
diagnosis 3/18/2018Physio-Ortho meeting

HISTORY
Neck trauma preceding onset of
symptoms
Repetitive stress injury
Occipital headaches
Pain over trapezius, neck, shoulder,
chest
Specific disabilities regarding work
and daily activities
Exertional arm pain
Other special tests/procedures
performed

PHYSICAL EXAMINATION
Pulse Exam
Listen For Bruits
Edema/Cyanosis/Collateral Veins
Tenderness Over Scalene Muscles (Trigger Points) Or Pectoralis Minor
Reduced Sensation To Very Light Touch In Fingers

PROVOCATIVE MANEUVERS
(SPECIAL TESTS)

ADSON'S TEST
• The examiner palpates the radial
pulse on the side to be tested. The
examiner extends, abducts and
externally rotate the patient’s arm.
The patient is asked to take a deep
breath and hold it.
• Positive if the examiner detects a
significant decrease in strength, or
complete disappearance of the radial
pulse.
• Up to 50% of healthy volunteers have
3/18/2018

ROOS TEST (EAST)
• Elevated arm stress
test
• Most accurate clinical
test (roos)
• Hold “surrender”
position for 3 minutes
while opening/closing
hands

ROOS TEST (EAST)
•nTOS
• Heaviness, progressive weakness, numbness
• Tingling in fingers, progressing up arm
•vTOS
• Cyanotic arm with distended forearm veins
•aTOS
• Ischemic, cramping pain 3/18/2018Physio-Ortho meeting

HALSTED'S COSTOCLAVICULAR
COMPRESSION TEST
• 45° abduction and
extension of arm with
downward pressure on
shoulders
• Neck turned to opposite
side will reproduce
symptoms

EXAGGERATED MILITARY POSITION
• Patient shrugs
shoulders with deep
inhalation While drawing
the shoulders backward
in an Exaggerated
military position – radial
pulse Diminishes. 3/18/2018Physio-Ortho meeting

WRIGHT'S HYPERABDUCTION TEST
•Arm hyper-abducted to
180- diminishing radial
pulse.
• Neurovascular structures
compressed in
subcoracoid region by
pectoralis minor tendon,
head of humerus or

IMAGING
• X-rays
• Cervical rib
• Elongated C7 transverse process
• Hypoplastic 1st rib
• Callous formation from clavicle or 1st rib fracture
• Pseudoarthrosis of 1st rib
• Unable to image soft tissue anomalies and
fibromuscular bands – seen only at time of surgery

IMAGING
•CT/MRI
usually negative but can rule out other
pathologies
•MR neuro-graphy
newer technology to detect localized
nerve function abnormality

IMAGING
• aTOS
• Segmental arterial pressures
• Angiography
• vTOS
• Duplex U/S
• Venography
• Use positional maneuvers during the studies
• Consider bilateral studies

EMG/NCS
• Reduction in NCV to <85m/s
• Positive results
• Aid in evaluation of other conditions
• Poor prognostic factor if truly nTOS – indicate
advanced neural damage
• Negative results
• Exclude other conditions
• May still be nTOS

Electrophysiology Testing
•Medial antebrachial cutaneous nerve (MAC)
• Lowest branch of inferior trunk of brachial
plexus
• More sensitive to compression than other
branches
•Higher sensitivity and specificity than
EMG/NCS

Scalene muscle block
•Most useful when diagnosis is
unclear
•Correlation between relief of
symptoms after block and successful
outcome after surgical
decompression

DEFERENTI
AL
DIAGNOSIS
Carpal tunnel syndrome
Ulnar nerve compression
Rotator cuff tendinitis
Cervical spine strain/sprain
Fibromyositis
Cervical disk disease
Cervical arthritis
Brachial plexus injury

TREATMEN
T

NON
OPERATI
VE
TREATME
NT
Physical therapy
Physical therapy
Physical therapy
•Therapist must have experience in
evaluation and treatment of nTOS
•20-30% of patients respond & do
not require surgical treatment

PHYSICA
L
THEREBY
postural changes
and correct faulty
postures.
• Step 2 manipulate
and mobilize and
relax 1st rib and
clavicular,
scapular, pectoral
muscles.
• Step 3 strengthen
the shoulder
girdle muscles
and stretch
Aims to
increase the
space in the
thoracic
outlet area
and to
relieve
compression
on the
neurovascul
ar
structures.

PAIN
CONTRO
L
NSAIDs
Muscle relaxants
Trans-cutaneous electric nerve stimulation.
(Tens)
Local anesthetic injections “anterior scalene
block”

EDEMA
CONTRO
L
Edema gloves
Compressive garments
Elevation of limb
Active range of motion exercises
Retrograde massages
Phonophoresis controls pain and
edema

ERGONOMIC
S
Work posture related changes
Relative adjustment of chair height
so that forearm rests comfortably
and without shoulders being
elevated or depressed.Avoid carrying heavy weights on
effected side
Avoid hyperextension of neck and
hyper-abducting postures

EXERCIS
ES
Involves relaxing shoulder
girdle and stretching the
scalene and pectoral
muscles.
•neck side bending exercises
•Neck rotation exercises
•Neck flexion exercises
Neck :
•Shrugging of shoulders
•Pendulum exercises
Shoulder :

SURGICA
L
TREATME
NT
•Symptoms persists beyond
2 months of conservative
management.
•Associated vascular
compression with
poststenotic dialatation.
•Complete occlusion of a
large vessel.
•Progression of neurological
symptoms.
Indications

PROCEDURES
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.

SCALENECTO
MY
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

1ST RIB
RESECTIO
N
1. Trans-axillary approach
2. Supraclavicular approach
3. Infraclavicular approach
4. Posterior approach.

TRANSAXILL
ARY
APPROACH
• Limited field of operative dissection
• Cosmetically placed incision
• Sufficient exposure (for 1 person)
• Achieve 1st rib resection and anterior
scalenectomy
• Removal of anomalous ligaments and
fibrous bands
Advantages
• Incomplete exposure of entire scalene
triangle
• Difficulty achieving brachial plexus
neurolysis
• Limited if vascular reconstruction is
needed
Disadvantages

• Advantages
• Wide exposure of all anatomic
structures
• Permits complete resection of
anterior and middle scalene as
well as brachial plexus
neurolysis
• Allows resection of cervical ribs
and anomalous 1st ribs
• Vascular reconstruction is
possible
SUPRACLAVICUL
AR APPROACH

ADJUNCTIV
E
PROCEDUR
ES
Pectoralis minor tenotomy
Cervical sympathectomy

Treatment vTOS
• Anticoagulation therapy with
heparin and oral anticoagulants.
• Fibrinolytics
• Catheter-directed thrombolysis.
• Thrombosis is < 3days old :
thrombectomy
• Chronic thrombosis : venous
bypass
• Surgical decompression with

COMPLICATION
S
Nerve injury
• brachial plexus injury
• Long thoracic nerve
• Phrenic nerve
• Intercosto-brachial nerve.
• Vagus and Reccurent laryngeal nerve
Vascular injury
• Subclavian vein and artery

COMPLICATIO
NS
Thoracic duct injury
• Lymphatic fistula
• Lymphocele
• Chylothorax
Pleural complication
• pleural damage
• Pneumotharax
• Pleural effusion

RECURRE
NT N.TOS
Postoperative scarring is
the most common cause.
Recurrence usually is
seen within 3months.
To minimize scar
tissue formation
•patient is instructed to
perform active range of
motion
•exercises beginning the day
after surgery.
•Performed every 3-4 hrs for
at least 6 months

Conclusio
ns
nTOS most common
nTOS most difficult to diagnose
Treatment
•Physical therapy
•Anterior scalene block
•Informed consent prior to surgery

Conclusions
• “A surgeon recognizing nTOS should not be
dissuaded by the impression that these
problems are frequently associated with
psychiatric overtones, dependency on pain
medications, and ongoing litigation”
RUTHERFORD’S VASCULAR SURGERY 7TH EDITION 3/18/2018Physio-Ortho meeting

3/18/2018
Physio-Ortho meeting

thoracic outlet syndrome

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