The document discusses Thoracic Outlet Syndrome (TOS), which causes upper extremity symptoms from compression of the neurovascular bundle in the neck. There are three main types - neurogenic (NTOS), arterial (ATOS), and venous (VTOS). NTOS causes pain, numbness, and weakness in the arm from brachial plexus nerve compression. ATOS involves subclavian artery compression leading to hand changes and loss of pulses. VTOS is caused by subclavian vein compression which can cause arm swelling and discoloration. Conservative management includes posture correction, exercises, and weight loss. Surgery to resect the first rib is indicated for failed conservative care or arterial/venous TOS.

1. Thoracic Outlet Syndrome
Dr. K Khaing Saw Lwin
MBBS,MRCSEd,MMedSc(Thoracic Surgery)

2. • presence of upper extremity symptoms
caused by compression of the neurovascular
bundle in the posterior triangle of the neck at
the level of the 1st rib.
• It has previously been described as scalenus
anticus syndrome, costoclavicular syndrome,
hyperabduction, cervical rib or 1st rib
syndrome.

5. • neurogenic (NTOS) - which is caused by
compression of the brachial plexus nerves;
• arterial (ATOS) - which is caused by
compression of the subclavian artery;
• venous (VTOS) - which is caused by
compression of the subclavian vein. It may
result in thrombosis of the subclavian vein
(Paget-Schroetter syndrome).

6. Neurogenic TOS
• Symptoms include pain, paraesthesia and
weakness in the arm and hand.
• Paraesthesia most often involves all five
fingers especially ulnar aspects.
• In addition, NTOS usually cause pain in the
neck, over the trapezius and anterior chest
wall, and occipital headaches.

7. Venous TOS
• swelling of the arm, forearm and hand
• discoloration, cyanosis,
• visible subcutaneous veins over the involved
shoulder and chest wall

8. Arterial TOS
• changes in the hands and fingers, including
pain, paraesthesia and cold fingers.
• loss of pulses with the arm by the side and
pulled downward or by elevating the arm
above the head (Typical feature)
• a tender lump, bony prominence or pulsation
of the subclavian artery in supraclavicular
fossa
• Gangrene of fingers (rare)

10. MANAGEMENT

11. • Conservative - all patients with NTOS should
initially receive at least a few months of
conservative therapy
-education regarding behaviour modification and
ergonomic correction;
-posture correction, with wrist splints, elbow pads
and lumbar support;
-weight loss (in obesity);

12. • -physiotherapy:
• i) relaxation exercises (such as abdominal
breathing);
• ii) stretching exercises of the neck and
shoulders;
• iii) nerve gliding exercises;
• iv) strengthening exercises.

13. Indications for surgery
• Failure of appropriate conservative therapy
together with significantly reduced NCVs
below 60 m/s (normal 85 m/s)
• Venous TOS
• Arterial TOS

14. • Resection of first rib
- Transaxillary approach
- Supraclavicular approach
- Posterior approach
Dorsal sympathectomy

15. Thank you