7th september 2015- college Activity

1. ThoracicOutlet Syndrome
consequence of the compression of
upper limbs vascular and nervous
elements
: Brachial plexus (C5-T1)
Subclavian vein
Subclavian artery

2. Thoracic Outlet Syndrome

4. ANATOMY
outlet is composed of 5 successive spaces the
vascular and nervous elements go through :
• The intercosto scalenic defile
• Theprescalenic defile
• Thecostoclavicular space
• The sub-pectoral tunnel
• The humeralspace

6. Theintercosto-scalenicdefile
Prescalenicdefile

7. Costo-clavicular space
• Ant : clavicle, subclavius
muscle
• Post medial: 1st rib
• Post lateral: superior border
of scapula

8. Interscalenetriangle

9. contents
viscera
• thymus
• trachea
• oesophagus
• lung apices
vessels, nervesand lymphatics
• common carotid arteries
• confluences of internal jugular
and subclavian veins
• phrenic nerves
• vagus nerves
• recurrent laryngeal nerves
• thoracic duct
prevertebral fascia
muscles
• sternocleidomastoid muscle
• anterior and middle scalene
muscles
• sternohyoid muscle
• sternothyroid muscle

11. 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

13. Anatomicalabnormalities
1- Ossseous congenital abnormalities
Subnumerous cervical ribs
2- C7 apophysis hypertrophy
3- rib agenesy
4- Clavicle congenital abnormalities

14. Bones limiting thethoracicoutlet

15. cervical ribs

16. 5- Osseous post traumatic
abnormalities
• Clavicle
• First rib
6- Muscular and/or
ligamentary abnormalities
7- Difficult to reveal
preoperatively

17. RiskFactors
• occupations that involve heavy usage of the
upper extremities against resistance, including
jack-hammer operators and dental hygienists,
• weight lifting,
• pregnancy, and obesity.
• Any condition that causes encroachment of the
space for the brachial plexus at the thoracic
outlet can lead to thoracic outlet

18. 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

19. 2-Arterial compression :
• Easily Fatigue
• Weakness
• Coldness
• Upper limb claudication
• Thrombosis
• Paraesthesia
• Gangrene
• Raynaud's phenomenon due to
thrombosis with distal
embolisation
• Ischemic signs, distal gangrene due
to repeated embolization, or to
subclavian artery thrombosis

21. 3-Venous compression
• edema
• Collateral formation
• Superficial vein distension
• Cyanosis
• 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

22. Diagnosis
I. 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
I. Physical Exam:
• 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

23. ClinicalEXAMINATION
diagnostictests
are used to reproduce the compression and T.O.S. familiar
symptoms
1- ‘‘Hands up’’ test ( Roos test)
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.

24. Position of thearms fortheRoos
test

25. 2- ADSON or scalene maneuver
patient rotates his head
towards the tested arm
while the examiner
extends the arm

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

27. 4.Exaggerated military position
• shrugs shoulders with
deep inhalation while
drawing the shoulders
backward in an
exaggerated military
position – radial pulse
diminishes.
5.Tinel sign – in supra and infraclavicular region
6.Phalens sign – in carpel tunnel syndrome

28. Hyperabduction syndrome7.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

29. Investigations
Imaging
1. Standard X-Ray neck and thoracic examination
looking for osseous abnormalities
2. MRI, cervical myelography
r/o narrowing of intrevertebral foramen, disc
compression
3.Dynamic angiogram: may show
the compression
4. explores arterial complications
(stenosis, aneurysms…)

30. 5. CT – MRA 3D technique
6. Dynamic phlebography

31. Electrophysiology Testing
EMG & NCV
• Electromyography& Nerve
conduction study:
may help to assess nervous
‘‘motor affection
• somatosensory evoked
responses

32. Arterial cervical outlet syndrome:
compression of
both subclavian
and both vertebral
arteries by
scalenus anterior
muscle
magnetic
resonance
angiography

33. Computer reconstructed image of CT
angiography
1- The right vertebral artery
2- The left hypoplastic
vertebral artery
3- Site of compression of the
left vertebral artery
4- Site of compression of the
left subclavian artery
5- Site of compression of the
right vertebral artery
6- Site of compression of the
right subclavian artery

34. Differentialdiagnoses

35. DD neurological sypmtoms
• Carpel tunnel syndrome
• Spinal canal tumors
• Cervical spine strain sprain
• Cervical disck disease
• Cervical arthritis
• Shoulder myositis
• Angina pectoris
• Raynaud's disease
• Ulnar nerve compression –
epicondylitis
• Fibromyositis
DD vascular symptoms
• Other sources of emboli:
Cardiac and aortic arch causes,
coagulopathies
• Vasculitis
• Radiation-induced arteritis
• Connective tissue disorders
• Arterial dissection
• Atherosclerotic disease
• Traumatic

36. TREATMENT
I. MEDICALTREATMENT
• Analgesic treatment
• Anti-inflammatory non steroid drugs
• Muscle relaxing drugs
• Weight reduction
2-PHYSICALTHERAPY
Is the key of T.O.S. treatment
Its purpose :
1- open the costo-clavicular space
2- fight against physiological shoulders falling attitude
3- Has to be progressive, painless, bilateral
4- Average duration : 3 to 6 months
5- If properly executed : 70 to 90% of good results

37. • Muscular relaxation
• Neck stretches
• Correct posture
• Reinforce muscles that
‘‘open’’ the costo-
clavicular space
• Respiratory reduction
• Avoid neck traction,
weights, resistance
exercises, strengthening
exercises

39. ForNeurological symptoms
• no improvement after
several months
• Live with symptoms
• Surgical decompression
ForVascular symptoms
• Catheter-directed
thrombolysis
• Anticoagulation
• Surgical decompression with
intraoperative venography
and subclavian vein PTA

40. 3-Surgerical decompression
indicated:
1- When failure of physiotherapy
2- Neurologic compressions :
sus-clavicular approach
axillary approach
3- When osseous or musculo-ligamentar abnormalities:
sub-clavicular approach
4-Non complicated arterial compressions:
axillary approach
5- Complicated arterial compression (thrombosis, aneurysms…):
sub-clavicular approach ± sub-clavicular approach
6- Complicated veinous compressions:
difficult to choose

41. Complications
Injury to
• Subclavian artery/vein
• Brachial plexus
• Phrenic nerve
• Long thoracic nerve
• Thoracic duct
• Sympathetic chain
• Intercostal brachial cutaneous nerve (axillary)
Pneumothorax
Lymphleakage

42. Cervical rib resection & safe dividing

43. Adjuvantprocedures
• Scalenectomy
• Pectoralisminor tenotomy.
• Sympathectomy

46. Recurrence

47. Tank Yu;)

48. ResearchTeam
Datacollection & formating by:
Yomna Ahmed Emad 561
Yasmin Magdy Metwally 559
Powerpoint by :
Jasmin Magdy Mohammed 560
Presented by:
Yasmin Essam Khalil 558
Group leader Dr Doaa Rifaat
Supervised by Dr Fady
Head department Dr Tarek Ezzat
General Surgery Department, ZagazigUniversity
Date :7 september ,2015