Thoracic Outlet Syndrome: Anatomy, Symptoms, Diagnostic Evaluation and Surgical Treatment
THORACIC OUTLET SYNDROME : ANATOMY, SYMPTOMS, DIAGNOSTIC
EVALUATION AND SURGICAL TREATMENT
Prof., Dr. Scs. Povilas Pauliukas
The thoracic outlet is called the space through which the neurovascular bundle: subclavian vein, subclavian artery
and brachial plexus (nerves) are passing from the neck to the armpit. This space must be sufficiently broad to allow
freely pass all the brachial plexus nerves, subclavian artery and subclavian vein through it. If the thoracic outlet is
too narrow, the nerves, artery and vein are compressed in it and corresponding problems and symptoms develop. A
complex of emerging problems and symptoms in such case is called the thoracic outlet syndrome (TOS).
The main anatomic structures limiting the thoracic outlet space are: the clavicle, the first rib (space between
these two bony structures is called in latin the costoclavicular space), the subclavius muscle, situated in the
costoclavicular space, the anterior and posterior scalene muscles. Very seldom a neurovascular bundle can be
compressed in the armpit in the athletes due to the hypertrophied abnormal pectoralis minor muscle.
Figure 1 illustrates the anatomic structures, limiting the thoracic outlet. The subclavius muscle is not shown in
this picture to allow better visualization of the neurovascular bundle, passing the thoracic outlet (subclavius muscle
will be shown in the following pictures).
Figure 2 illustrates the thoracic outlet anatomical structures in detail.
Figure 1: Anatomy of the thoracic outlet
This picture is only a schematic drawing of the thoracic outlet
anatomy. The subclavius muscle and vertebral artery are not
shown in this picture. These anatomical structures will be
shown in the following pictures. The brachial plexus nerve
roots and the subclavian artery are passing through the gap
between the anterior and medius scalene muscles (cervical
outlet). The subclavian vein passes in front of the scalene
muscles and they can not compress it. All three neurovascular
structures: subclavian vein, subclavian artery and brachial
nerve plexus can be compressed between the clavicle and the
first rib. The subclavius muscle and the lower part of anterior
scalenus muscle (inserting to the first rib) are situated in the
costoclavicular space and they additionally reduce this space.
Some authors attribute to the thoracic outlet syndrome
compression of the neurovascular bundle between the
pectoralis minor muscle and chest wall. This situation in
clinical practice is encountered rarely.
Figure 2: Anatomy of the thoracic outlet
The subclavius muscle is shown in this picture. It
originates from the first rib in the medial corner
of the costoclavicular space and inserts to the
lateral (shoulder) part of the clavicle. It reduces
the space between the clavicle and the first rib.
The subclavian vein is situated in the medial,
most narrow corner of the costoclavicular space
and it is compressed against the first rib by the
subclavius muscle and the clavicle. The anterior
scalenus muscle can not compress the
subclavian vein, because the vein passes in front
of it. The anterior scalenus muscle can compress
the subclavian artery, the vertebral artery and
the brachial nerve plexus roots.
All three scalene muscles are depicted in figure 3.
When the gap between the anterior and medius scalene muscles (spatium interscalenum) is too narrow or absent for
passing of the subclavian artery and brachial plexus, they are compressed by these two muscles, especially when the
muscles contract and squeeze the nerves and arteries. The vertebral artery does not pass the gap between the scalene
muscles (spatium interscalenum), but it is situated very close to the anterior scalenus muscle and in cases of brachial
nerve plexus compression with the abnormal scalene muscle, abnormally inserting to the vertebral column or to the
first rib, it is compressed by this muscle together with the brachial plexus. That’s, why many patients with symptoms
of brachial nerve plexus roots compression (neurogenic thoracic outlet syndrome) have symptoms of vertebrobasilar
insufficiency (insufficiency of blood flow in vertebrobasilar region of the brain, supplied with the blood by vertebral
arteries). When the vertebral artery is compressed by the scalenus anterior muscle against the vertebral column, it is
compressed at the entrance into the cervical outlet (spatium interscalenum) and it is wise to attribute such
compression of vertebral arteries to the cervical outlet syndrome, especially due to the fact, that scalenectomy cures
both problems at once: the neurogenic symptoms and symptoms of vertebrobasilar insufficiency.
Normally, the vertebral artery enters its bony vertebral canal (canalis transversarius) at the sixth cervical
vertebra. The anterior scalenus and longus colli muscles attach to the transverse process of the sixth cervical vertebra
just above the vertebral artery entrance into the bony canal, leaving the free triangle space in the neck for the
vertebral artery to pass from its origin on the subclavian artery to the entrance of the vertebral bony canal at the
transverse process of the 6-th cervical vertebra (Figure 4). Normally, the vertebral artery is not compressed against
the vertebrae by the scalenus anterior muscle, the longus colli muscle and between them. However, when the anterior
scalenus muscle abnormally attaches to the transverse process of the 7-th cervical vertebra, the vertebral artery is
entrapped between this muscle and the transverse process of the 7-th cervical vertebra. The same situation arises
when the vertebral artery enters bony vertebral canal abnormally at higher level: at the transverse process of the 5-th,
4-th, or even 3-rd cervical vertebrae. In these cases, the vertebral artery is compressed against the transverse
processes of the 6-th cervical vertebra and above situated vertebrae until the vertebral artery enters the bony canal.
Therefore, the deviation of the vertebral artery from its normal course in the neck, or deviation of the scalene muscles
anatomy from normal, creates the conflict between the anterior scalene muscle and the vertebral artery, causing
compression of vertebral artery and symptoms of vertebrobasilar insufficiency. Due to the fact, that scalene muscles
anomalies typically are bilateral, symmetrical, as a rule, both vertebral arteries are compressed by the anterior scalene
muscle in cases of cervical outlet syndrome, which is also typically bilateral, on both sides. Another very important
pathogenetic mechanism of impaired blood flow through the vertebral arteries and of vertebrobasilar insufficiency is
the spasm of vertebral arteries. Vertebral arteries are arteries of muscle type, not elastic: they have smooth muscles in
their walls and can contract. They react to compression by contraction of their walls and reduce their lumen
sometimes twice or even more times. Duplex scanning of vertebral arteries in such cases reveals narrow, spastic, with
diminished blood flow, vertebral arteries. A spasm of vertebral arteries causes the paroxysm of vertebrobasilar
insufficiency, sometimes even a vertebrobasilar stroke. Clinical manifestations of such spastic paroxysm of vertebral
Figure 3: Cervical outlet (spatium interscalenum)
All three scalene muscles, the brachial nerve plexus, the
subclavian artery, the vertebral artery and the subclavian vein
are depicted in this picture. The anterior and medius scalene
muscles originate from the first rib. The posterior scalenus muscle
originates from the second rib. The anterior scalenus muscle
inserts to the transverse processes of the third-sixth cervical
vertebrae. The scalenus medius muscle inserts to the transverse
processes of all cervical vertebrae. The posterior scalenus muscle
inserts to the transverse processes of the three lowest cervical
vertebrae. Due to the fact, that anterior and medius scalene
muscles both originate from the first rib and insert to the
transverse processes of the same cervical vertebrae, they are very
prone to the developmental anomalies: they can be as a one solid
muscle mass not divided into the separate muscles (brachial
plexus and subclavian artery penetrate through the muscle in such
cases), an additional scalenus minimus muscle can develop, they
can attach to the first rib with the common tendon etc.
arteries are headaches, dizziness, nausea, sometimes even vertigo episodes, visual and hearing disturbances (tinnitus,
noise in the ears, visual blurring, scotomas, visual field defects etc.)
Figure 4 illustrates the anatomy of a normal vertebral artery triangle left by the longus colli and scalenus
anterior muscles for the free passage of the vertebral artery from its origin on the subclavian artery to the bony canal
at the transverse process of the 6-th cervical vertebra.
On the left side, the anterior scalenus muscle is removed to show the place of its insertion onto the first rib (the
tubercle of scalenus anterior muscle).
The overwhelming majority of patients with cervical outlet syndrome have combined symptoms of vertebrobasilar
insufficiency and of compression and irritation of brachial plexus nerve roots. In some patients, dominate
vertebrobasilar symptoms, in other – symptoms of compression and irritation of nerve roots. Therefore, some of these
patients seek doctor’s advice and help for vertebrobasilar insufficiency, some – for irritation of brachial plexus nerve
roots. Doctors should know that symptoms of vertebrobasilar insufficiency are very common in patients with cervical
outlet syndrome and that scalenectomy cures these symptoms ceasing the compression and irritation of vertebral
artery by anterior scalenus muscle. The problem is that most doctors are unfamiliar with the thoracic outlet
syndrome and particularly - with the cervical outlet syndrome. Consequently, many patients, suffering from the
thoracic outlet and cervical outlet syndromes, despairingly are trying to find their diagnosis visiting and consulting
many doctors of various specialities, performing countless sophisticated examinations like magnetic resonance
imaging, CT scans etc. The correct diagnosis usually is established only when the patient finds the doctor, who not
only knows the symptoms of the thoracic outlet and cervical outlet syndromes, but also is able to diagnose them and
to correct the problem. Generally, vascular surgeons operate patients with thoracic outlet and cervical outlet
syndromes and they are best familiar with symptoms, diagnostics and treatment of these patients. As an example,
how it is difficult to find the correct diagnosis and help from doctors, even in the USA, is an article on the internet,
written by the patient with the thoracic outlet syndrome from the New York City, who was seeking the diagnosis and
help from doctors. The patient was consulted by many doctors of various specialities, a lot of examinations, including
three magnetic resonance imaging were done for her and the diagnosis was established only when she has addressed
the vascular surgeon, familiar with the thoracic outlet syndrome and operating these patients. Indeed, the worst
situation is, when the patient cannot find the correct diagnosis. He cannot know what the cause of his symptoms is
and consequently, he cannot get the help. Following illustration is an article about the thoracic outlet syndrome,
written by Dr. Carlos Selmonosky, who is an expert in the thoracic outlet syndrome in the USA. He stressed in this
article, that “One of the most unfortunate complications is a misdiagnosis or no diagnosis because patients fail
to receive adequate therapy”.
Figure 4: Anatomy of the vertebral artery triangle
Normally, the longus colli and anterior scalenus muscles
conjugate and attach to the transverse process of the 6-th
cervical vertebra, creating the muscle roof for the vertebral
artery, entering the hole in the transverse process of the 6-th
cervical vertebra. These two muscles create the lateral
borders of vertebral artery triangle. At the top of this
triangle is the transverse process of the 6-th cervical
vertebra. The first rib forms the bottom of this triangle. This
triangle is free of muscles and left for the free vertebral
artery passage from its origin on the subclavian artery to its
entrance into the bony vertebral canal at the transverse
process of the 6-th cervical vertebra. Problems arise when
the course of vertebral artery in the neck is abnormal (high
entrance of vertebral artery into the bony vertebral canal at
the 5-th, 4-th, o even 3-rd cervical vertebrae, or abnormal
lateral branching of vertebral artery from the subclavian
artery under the scalenus anterior muscle), or abnormal
anatomy of the anterior scalenus muscle.
Dr. Carlos Selmonosky has his internet site for thoracic outlet syndrome: http://www.tos-syndrome.com/. American
Thoracic Outlet Syndrome Association also has its internet site at: www. atosa.org.
Due to the fact, that even in the USA many doctors are unfamiliar with symptoms and diagnostics of TOS, still
there is unknown what percent of population has the TOS. Opinions vary on this point, but most authors agree, that
the TOS is a frequent problem and it is encountered in as many as 1-8 % of population. Usually young, 20 - 40 years
old people have this problem and the neurogenic (due to compression and irritation of brachial nerve plexus) variant
of TOS is encountered in women 4 times more frequently than in men. Venous variant of TOS (subclavian vein
thrombosis due to its compression) is more common in males than in females. Arterial TOS (subclavian artery
thrombosis or aneurysm formation due to its compression) has no gender predilection. Hence, the thoracic outlet
syndrome can be: 1) neurogenic; 2) venous and 3) arterial. Neurogenic TOS is the most common variant of TOS and
is encountered in 95 % of all clinical TOS cases. Venous variant of TOS is encountered in 4 % of clinical cases and
arterial TOS variant is infrequent and is encountered only in 1 % of clinical TOS cases. Such big difference in the
frequency of clinical manifestations of neurogenic and vascular (venous and arterial) TOS is due to the high
sensitivity of nerves for compression and irritation. Compression of nerves causes numbness, tingling and even
unbearable pain and consequently, patients seek doctor’s help. The subclavian vessels: artery and vein are
compressed almost as often as nerves, but the patient doesn’t feel the compression of vein or artery until it
thromboses. When the subclavian artery or vein thromboses, a vascular complication of TOS manifest and it is a
vascular emergency: the patient needs an urgent treatment. In cases of cervical outlet syndrome (when brachial
plexus nerve roots are compressed in the scalene triangle (gap between the anterior and medius scalene muscles), the
upper nerve roots (fifth to seventh) are most forcefully compressed. When the compression of brachial plexus is
between the clavicle and the first rib in the costoclavicular space (in the true thoracic outlet), usually most forceful
compression experience the lower roots (8-th cervical and first thoracic roots) of the brachial nerve plexus. This
feature determines the differences in pain, tingling, numbness distribution areas in the arm as well as muscle motor
weakness distribution differences in cervical and thoracic outlet syndromes. Thereby, according to the symptoms
distribution, diagnosis of cervical and thoracic outlet syndromes can be distinguished and established. Most authors
define two kinds or levels of thoracic outlet syndrome: the upper (corresponding to the gap between the anterior and
medius scalene muscles in the neck) and the lower thoracic outlet syndrome (actual thoracic outlet syndrome in the
costoclavicular space). D. Ranney1
suggested to denominate the upper thoracic outlet as a cervical outlet, because
actually it is in the neck and brachial plexus nerve roots and subclavian artery pass the gap between the scalene
muscles (spatium interscalenum) in the neck, not in the actual thoracic outlet.
Subclavian vein can be compressed between the clavicle and the first rib (in the thoracic outlet), not in the cervical
outlet. All three elements of neurovascular bundle (vein, artery and neural plexus) can be compressed in the thoracic
outlet. Only the subclavian artery and nerve roots of the brachial plexus can be compressed in the cervical outlet. The
vertebral artery can be compressed by the scalenus anterior muscle against the cervical vertebrae or their transverse
processes as well. This particular situation arises when the scalenus anterior muscle is abnormal, or the course of
vertebral artery in the neck is abnormal (it enters the bony vertebral canal higher than normally: at the 5-th, 4-th or
even 3-rd cervical vertebrae or it originates from the subclavian artery more lateral than normally. I shall write
separately about the vertebral artery compression with the scalenus anterior muscle later, because this situation and
this pathology is very important: it is encountered in patients relatively frequently and it considerably diminishes
blood flow in the vertebrobasilar region of the brain and causes symptoms of vertebrobasilar insufficiency from mild
up to the vertebrobasilar stroke.
Compression of the upper (5-7-th cervical nerve) roots between the anterior and medius scalene muscles (in the
spatium interscalenum) most of the authors, writing on this topic, denominate as an upper thoracic outlet syndrome
and the true thoracic outlet between the clavicle and the first rib they denominate as a lower thoracic outlet and
symptoms arising from compression of the neurovascular bundle in it they denominate as a lower thoracic outlet
I support D. Ranney’s1
proposal to distinguish these two totally different anatomical regions (levels) into two
separate definitions: cervical outlet and thoracic outlet and to denominate symptoms arising from the compression
of neurovascular bundle in these two regions as a cervical outlet syndrome and thoracic outlet syndrome, because
the cervical outlet is in the neck: it is the gap between the anterior and medius scalene muscles and the brachial nerve
plexus together with subclavian artery is compressed in the neck, not in the true thoracic outlet. The true thoracic
outlet is between the clavicle and the first rib and all three structures of the neurovascular bundle (subclavian vein,
subclavian artery and brachial nerve plexus) can be compressed here.
Symptomatology, diagnostics and especially the surgical treatment greatly differ between these two separate
entities and therefore it is wiser not to relate and to confuse them together and to denominate them by different
names: cervical outlet syndrome and thoracic outlet syndrome. That’s, why I adhere to such denomination of these
two separate pathological entities earlier, and later in this article I shall refer to them as a cervical outlet syndrome
and thoracic outlet syndrome.
Figure 6 illustrates the anatomy of the cervical outlet.
Figure 5: Anatomy of the thoracic outlet
(View from the armpit)
The thoracic outlet and all three elements of the neurovascular
bundle: subclavian vein, subclavian artery and brachial nerve
plexus are seen from the armpit. The subclavius muscle,
situated between the clavicle and the first rib is clearly seen. It
occupies the most narrow medial corner of the costoclavicular
space, where the subclavian vein passes it.
The subclavian vein passes in front of the anterior scalenus
muscle (through the spatium antescalenum) and can not be
compressed by this muscle in the cervical outlet (spatium
The pectoralis minor muscle can compress the neurovascular
bundle in the armpit in case of its hypertrophy as this problem
is encoutered in some athletes. Such situation is relatively rare.
Figure 7 shows the anatomy of the cervical and thoracic outlets in detail.
Different congenital developmental anomalies: anomalous clavicle, anomalous first rib, cervical ribs, elongated
anomalous transverse process of the seventh cervical vertebra, anomalous fibrous and cartilaginous bands etc.
account for the thoracic outlet syndrome. In some clinical cases no congenital anomalies exist in the thoracic outlet,
except the congenital narrow space between the clavicle and the first rib. It is important to stress, that cartilaginous
cervical ribs and fibrous bands are invisible on the plain roentgenograms and that only bony structures are visible on
them. That’s, why normal plain roentgenograms do not rule out the existence of all congenital anomalies in the
thoracic outlet, especially cartilaginous cervical ribs and fibrous bands. These latter structures are well visualized
with magnetic resonance imaging. If the cervical rib exists, it originates from the seventh cervical vertebra and
conjugates with the first rib usually by the joint. Such a rib greatly diminishes the space between the clavicle and the
first rib (thoracic outlet) and creates a predisposition for the development of the thoracic outlet syndrome. In these
cases the subclavian artery and the brachial plexus are compressed by the clavicle against the cervical rib because the
neurovascular bundle must sling over the cervical rib in order to reach the armpit.
Figure 6: Anatomy of the cervical outlet
(View from the side)
The arm, shoulder joint, scapula and the clavicle together
with the muscles are removed in this picture. Only the
chest and the neck with the deep muscles are left.
It is clearly seen, that the gap between the anterior and
medius scalene muscles is in the neck and that the
compression of the brachial nerve plexus and subclavian
artery in this gap is in the neck and that this gap should be
called the cervical outlet.
The nerves and artery in this vertical gap are compressed
between the two scalene muscles in the sagital direction,
meanwhile in the thoracic outlet all three structures of the
neurovascular bundle are compressed in the horizontal
gap between the clavicle and the first rib in the vertical
Figure 7: Anatomy of the cervical and thoracic
All anatomical structures of the cervical and thoracic
outlets are depicted in detail in this picture.
Superficial muscles are removed from the front of the
neck and chest for better visualization of the cervical
and thoracic outlets. Part of the clavicle is also
removed for better visualization of the thoracic outlet
and its content: subclavian vein, subclavian artery
and brachial nerve plexus, passing through it. The
subclavius muscle is left intact. It occupies part of the
costoclavicular space. The subclavius muscle narrows
the most tight medial corner of the costoclavicular
space, where the subclavian vein passes from the neck
to the armpit.
V, VI, VII, VIII – the 5, 6, 7, 8-th brachial plexus
cervical nerve roots.
I - the first thoracic nerve root.
Figure 8 illustrates the normal anatomy of the bones, limiting the thoracic outlet.
Ribs and their equivalents are colored in red. Fishes have ribs in the neck. In mammals, including the man, ribs in the
neck region withered away due to the fact, that they are living on the land and need to rotate and flex the neck. Only
remnants (rudiments) of the ribs: the anterior parts (processus costarius) of the transverse processes and their anterior
tubercles remained in the neck region. They are colored in red in this picture, the same color as the ribs. Derangement
of fetal embryogenesis causes development of cervical ribs, mostly from the processus costarius of the seventh
cervical vertebra transverse process.
Figure 9 illustrates the lateral view of the bones, limiting the thoracic outlet.
Figure 8: Bones limiting the thoracic outlet
Bones of the shoulder girdle are shown in green color. Scapula,
the shoulder girdle with the arm are fixed to the skeleton only by
the medial end of the clavicle to the sternum.
The position of the scapula, clavicle and the shoulder girdle
depends on the tone and strength of the shoulder girdle muscles
and on the posture. Limp posture with depressed, rounded
shoulders reduce the space between the clavicle and the first rib
and can produce the symptoms of thoracic outlet syndrome due to
compression of brachial plexus. Correction of the posture and
physical therapy can be helpful in such cases.
However, the physical therapy and correction of posture can be
helpful only in the thoracic outlet syndrome, but not in the
cervical outlet syndrome, because they correct only the space
between the clavicle and the first rib, not between the scalene
muscles. In case of cervical outlet syndrome neither the physical
therapy, nor the posture correction or massage of the muscles can
help. Conversely, they can worsen the symptoms of cervical outlet
syndrome due to strengthening of the muscles, because the nerve
roots, subclavian artery and the vertebral artery are compressed
in this case by the muscles against the vertebral bodies or between
Figure 9: Lateral view of the bones, limiting the thoracic outlet
Bones of the shoulder girdle are shown in green color. Scapula,
shoulder joint, all the shoulder girdle and arm are fixed to the skeleton
(to the sternum) only by the medial end of the clavicle. Therefore, the
position of the scapula, clavicle and all the shoulder girdle depends on
the tone and strength of the shoulder girdle muscles and on the posture.
Limp posture with depressed, rounded shoulders reduce the space
between the clavicle and the first rib and can produce the symptoms of
thoracic outlet syndrome due to compression of the brachial plexus.
Correction of the posture and physical therapy can be helpful in such
However, the physical therapy and correction of the posture can be
helpful only in thoracic outlet syndrome, but not in cervical outlet
syndrome, because they correct only the space between the clavicle and
the first rib, not between the scalene muscles. In case of cervical outlet
syndrome neither the physical therapy, nor the posture correction or
massage of the muscles can help. Conversely, they can worsen the
symptoms of cervical outlet syndrome due to strengthening of the
muscles, because the nerve roots, subclavian artery and the vertebral
artery are compressed in this case by the muscles against the vertebral
bodies or between the muscles.
The roentgenogram of 22 year old girl with fully developed unilateral left cervical rib is shown in the figure 10.
The girl has had pain and numbness of the left arm and hand from the adolescence. The left hand became weak,
clumsy. She could not pick small things with the left hand. The body of the girl became “S” shaped due to the
deviation and distortion of the spinal column. The pain of the left arm became unbearable. She addressed me because
of the left arm pain. Inspection of the girl revealed the cervical rib on the left side of the neck. Roentgenogram
confirmed the fully developed cervical rib on the left side and rudimentary undeveloped cervical rib on the right side.
The Wright’s and Roos tests were strongly positive on the left side. The left arm and hand became weak and painful
just shortly after starting Roos test. She was unable to perform Roos test with the left hand even for one minute,
meanwhile she had not experienced any uncomfortable feelings in the right arm and hand during the Roos test. The
pulse disappeared in the left arm in the Roos test position (the subclavian artery was totally compressed and occluded
in the costoclavicular space on the left side) and the pulse was present and normal in the right arm in all positions
including Roos abduction-external rotation position of the arm.
The Roos test is performed with the arms in abduction-external rotation position as it is shown in figure 11. The
patient is asked to close and open the hands for 3 minutes in this position of the arms and to describe all sensations,
The girl was operated. The left first rib together with the cervical rib were removed, using the Roos technique,
through the axillary approach. (Removal of the cervical accessory rib alone, without the first rib, through the
supraclavicular anterior approach is unsatisfactory and usually is not adequate for decompression of the thoracic
Figure 11: Position of the arms for the Roos test
The arms are flexed in the elbow joints by 90 degree and abducted to the
frontal plane of the body. Both hands are closed and opened steadily for
3 minutes and patient is asked to describe all sensations that develop.
Normally, in the absence of thoracic outlet syndrome, patient does not
experience any discomfortable sensations during 3 minute such test. In
case of thoracic outlet or cervical outlet syndrome, patient usually is
unable to complete the 3 minute such test due to development of
weakness and numbness of arms, pain in the arms and neck. This test
provokes and reproduces the usual symptoms, which are torturing the
Figure 10: Roentgenogram of the cervical ribs
The roentgenogram shows fully developed left cervical rib, which
originates from the seventh cervical vertebra and has a joint at the
place where it attaches to the first rib.
The rudimentary short cervical rib, attached by the joint to the first
rib, is seen on the right side as well. The first ribs have a joint
processes at the places of insertion of the cervical ribs.
The right cervical rib was asymptomatic: no brachial plexus
compression symptoms were on the right side. Meanwhile, there
were dramatically expressed symptoms of the compression of
brachial plexus on the left side due to the narrowing of the thoracic
outlet by the fully developed cervical rib. The left cervical rib has
been pushing the cervical part of the spinal column to the right,
because there was no counteraction by the short undeveloped right
cervical rib. Therefore, the spinal column acquired a “S” shaped
distortion: the thoracic part of it deviated to the left, as a
compensation to the deviation of the cervical part of the spinal
column to the right. Therefore, the posture and the shape of the girl
were awfully distorted. This distortion is clearly seen on the
outlet. The removal of both: first and cervical ribs decompress thoracic outlet adequately and creates enough space
for passing of neurovascular bundle through it).
Operation and postoperative period were uneventful. The pleura was not entered and opened during the
operation. The girl was discharged from the hospital on the third postoperative day.
All symptoms, which were torturing the girl, disappeared after the operation. The pain and numbness in the left
arm and hand disappeared. The pulse in the left arm was present in all arm positions, including abduction and
elevation (Wright’s and Adson’s positions). The posture of the girl improved after the operation. She was able to
stretch her body and spinal column into the straight position, what was impossible before the removal of the
accessory cervical rib. I advised her to exercise the spinal column and the body together with the physiotherapy
specialist to get her spinal column straight and erect.
After the one year follow up she was absolutely healthy with normal posture, straight spinal column, free of
thoracic outlet symptoms.
In case of equal bilateral accessory cervical ribs no deviation of spinal column develop, just restriction of neck
movements exists. In case of unilateral cervical rib or when they are bilateral, but not equal in length, the deviation
and distortion of spinal column and body posture develop. That’s, why it is wise to remove them as early as they are
diagnosed and when the symptoms of thoracic outlet syndrome manifest. It is desirable to remove them in the
childhood or in the adolescence.
Figure 12 illustrates unequal in length bilateral accessory cervical ribs: the left - fully developed cervical rib
with the joint at the insertion onto the first rib and the right - undeveloped cervical rib, directly fused to the first rib.
This patient after the operations is free of symptoms. The pain, numbness and paresthesias of the arms and hands
disappeared. The erectness of spinal column and the body shape of the woman after one year follow up period
improved considerably, however the patient failed to straighten her body completely. Therefore, the conclusion is,
that patients with unilateral and unequal in length cervical accessory ribs should be operated as early, as possible,
before the deviation and distortion of the spinal column and the body develops.
Figure 13 illustrates the roentgenograms of patient with bilateral symmetrical accessory cervical ribs before and
after the removal of first and cervical ribs on both sides by the two-staged operation.
(Before operations) Figure 13 (After the operations)
Figure 12: Fully developed left cervical rib with the joint between it
and the first rib and undeveloped right cervical rib fused with the
right first rib without the joint
Due to the asymmetrical development of both cervical ribs, the spinal
column deviated to the right in the neck region and to the left – in the
chest region (it is clearly seen on this roentgenogram). The posture
and the shape of the woman were awfully distorted.
Thoracic outlet syndrome (brachial plexus nerve compression)
symptoms were more expressed on the left side, though they were
present and on the right side. Therefore, two- staged operation was
performed for this patient: the left first and cervical ribs were
removed first, and at the second operation the right first rib together
with the cervical rib were removed.
Figure 13: The roentgenograms of the patient with equal bilateral cervical ribs before and after the two-staged
removal of both cervical and first ribs. The white arrows on the right point to the stumps of the removed cervical ribs
and the blue arrows point to the stumps of the removed first ribs. The spinal column of the patient was almost straight
due to the equal length of the symmetrical accessory cervical ribs. The reason for seeking the doctor’s help was the
pain and numbness in both arms and hands, sensitivity of the hands to the cold exposure. Two-staged operation was
performed: at first, the right first and cervical ribs were removed and one month later, the left first and cervical ribs
were removed. All thoracic outlet syndrome (brachial nerve plexus compression) symptoms cleared on both sides.
Thoracic outlet syndrome symptoms can arise and manifest not only due to the accessory cervical ribs, but they
can be present even in the absence of the cervical ribs: in cases of too narrow costoclavicular space, due to
hypertrophied first rib, or due to the callus of fractured clavicle as it was in operated by me and published in the
journal clinical case2
. The subclavian artery was compressed and crushed between the first rib and callus of
pseudoarthrosis of the fractured clavicle in that patient and subsequently thrombosis of the subclavian artery and
acute ischemia of the arm developed. Emergency operation was performed for that patient: first rib was removed on
the diseased side, the clavicle was reunited using the bone transplant and metallic plate, and autovenous bypass from
common carotid artery to the brachial artery was created. The arm and hand were saved. Anatomically too narrow
costoclavicular space without any other anatomical accessory abnormalities resulted in chronical mangling of the
subclavian artery between the clavicle and first rib in another operated by me patient3
. Chronical mangling and
crushing of the subclavian artery resulted in aneurysm formation and thrombus embolization from the aneurysm of
the subclavian artery to the distal arteries of the left arm and hand in that patient. Subsequently, the thrombosis of the
left subclavian artery aneurysm and distal arteries of the left arm developed and acute ischemia of the left arm and
hand occurred. Emergency operation was performed for that patient: the aneurysm of the left subclavian artery was
removed, thrombectomy of thrombosed arteries was performed and an extraanatomical bypass from the left common
carotid artery to the left axillary artery was created.
Embryological explanation for the development of thoracic and cervical outlet anomalies
Development of cervical ribs and malformation of first ribs are being linked to errors of bodily segmentation in early
embryological development. Cervical rib development is determined by the formation of the spinal nerve roots. The
regression of the C5 through the C7 ribs is occasioned by rapid development of the enlarging roots of the brachial
plexus in the region of the limb bud. In cases of a cervical C7 rib there is generally “prefixed” brachial plexus with
only a small neural contribution from the T1 nerve root to the brachial plexus. As a corollary, in the “postfixed”
brachial plexus in which there is a contribution of the T2 nerve root to the brachial plexus, the first thoracic rib is
often rudimentary, having been inhibited in its development by the unusual nerve growth. This embryologically
determined morphologic interdependence is evident with other structural relationships at the thoracic outlet.
Cervical ribs are inheritable by autosomal dominant way. Therefore, there is a considerable likelihood of
encountering the cervical ribs in children of patients having cervical ribs.
During development, the C7 rib forms, then regresses to the C7 transverse process. Various stages in this
evolution range from a complete C7 rib to rudimentary forms associated with a fibrocartilagineous band. The only
radiologic indication of this residual band may be an enlarged C7 transverse process.
emphasized the influence of neurovascular structure development on the ultimate configuration of the
scalene muscle mass. The scalenic muscle mass is only differentiated into specific scalene muscles by the traversing
of the neurovascular bundle. The persistence of certain muscle inclusions in the brachial plexus, as well as of muscle
groups that traverse various elements of brachial plexus, is related to the original mass of the scalene muscle being
variously fragmented by the passage of these developing structures as the limb bud develops. This separation of
muscle bundles interdigitating between the neurovascular structures accounts for the muscular bridges seen between
the anterior and middle scalene muscles that often penetrate the brachial plexus. Sanders and Roos5
their anatomical dissections that these abnormalities of scalene fragmentation are seen quite frequently in the adult.
The causes of thoracic outlet syndrome can be divided into: 1) anomalies of the first rib or cervical rib
(including the residual fibrous band from an incomplete cervical rib; 2) anomalies of scalene muscle development or
insertion; 3) subclavius muscle anomalies; 4) anomalies of the clavicle; 5) anatomical anomalies (e.g. narrow
costoclavicular space) not clearly identifiable as a developmental variation.
Makhoul and Machleder6
in 200 consecutive transaxillary procedures for thoracic outlet syndrome have found
the following anatomical anomalies: 8,5 % of operated patients have had a cervical rib; 10% of patients had
accessory scalenus minimus muscle; 19,5% of patients had anomalous subclavius muscle; 43% of patients (the
biggest group) had an anomaly of scalene muscle development or insertion; 19% of patients had no discernible
anomaly from the axillary surgical approach. Nevertheless, their symptoms cleared after the removal of the first rib.
These cases were treated as a narrow costoclavicular space without any discernible congenital anatomic anomaly.
Fully developed cervical ribs with joints at the insertion to the first rib has 0, 2 % of population. In a study of 40
000 consecutive chest x-rays in American army recruits, Etter7
encountered 68 (0,17%) complete articulated cervical
ribs and 98 anomalous first ribs (0,25 %). Adson8
reviewed his experience with cervical ribs by radiologic study at
Mayo clinic. He identified an incidence of 0,56% or 5,6 patients per thousand with cervical ribs. Of these 28% were
male and 72% were female. 47% of cervical ribs were bilateral. The right side was involved in 23% and the left side
in 30% of unilateral cervical rib cases. Forty five percent of cases in this Mayo clinic group was symptomatic.
in the Soviet Union reported fluorographic examination of 510 893 people and observed 1379 cervical ribs,
for an incidence of 0,27%. Women accounted for 76,8% and men for 23,2% of cervical rib cases; 33% of cervical
ribs were bilateral. Hence, the Firsov’s data are very similar to the Etter’s and Adson’s data. Therefore, 02%-025%
incidence of cervical ribs in population is accurate.
The fact, that incidence of cervical ribs in women is 3,3 time higher than in men, explains the fact, that neurogenic
variant of thoracic outlet syndrome in women is 4 times more common than in men and that the ratio of operations
for neurogenic thoracic outlet syndrome in women and men is 4:1.
The abdominal, thoracic and cervical musculature develops from the hypomeric portion of the paraxial and
epaxial mesoderm, with the scalene and prevertebral muscles in the neck corresponding to the intercostal and
ventrolateral abdominal muscles in the thorax and abdomen respectively10
. In the embryo, plates of axially running
muscle segments differentiate into the discrete muscle groups seen in adult.
The subclavian artery, which is the artery of the seventh cervical segment, and the spinal nerves from C5 to T1
pierce the muscle plates in the cervical segment much the same as the intercostal nerve and artery do in the thoracic
segments. The growth of the limb bud and development of pectoral girdle then lead to the particular structural
changes seen in this region.
Therefore, the anomalies of scalene muscles are very frequent and encountered in clinical practice very often.
The scalene muscle can be as a solid mass without any differentiation into anterior, middle and posterior scalene
muscles. In such cases subclavian artery and brachial plexus roots are piercing the scalene muscle mass and are
compressed by muscle fibers. The interscalene gap (spatium interscalenum) can be too narrow and tight or abnormal
with crossing insertions of scalenus anterior and middle muscles onto the first rib or with “V” shaped interscalene gap
due to common insertion with the common tendon onto the first rib. In such cases, brachial nerve plexus and
subclavian artery are compressed in the interscalene gap. Sanders and Roos5
, studying the anatomy of the interscalene
triangle, found interdigitating fibers between the scalene muscles through the brachial plexus in 75% of dissections in
patients with thoracic outlet syndrome and in 40% of consecutive cadaver dissections. Their data suggest that scalene
muscle anomalies are very common in human being and that they have very big clinical importance in thoracic outlet
As I mentioned earlier, the thoracic outlet and cervical outlet syndromes differ greatly by their clinical
symptoms, diagnostic evaluation disparities and particularly differ their surgical treatment. Therefore, I shall describe
them separately: at first the thoracic outlet syndrome and later – the cervical outlet syndrome.
There are three types of thoracic outlet syndrome: venous, arterial and neurogenic. The most common of them
is neurogenic TOS. It is encountered in 95% of all TOS cases. Venous TOS is encountered in 4% of cases and arterial
TOS is encountered in 1% of all TOS cases.
Venous thoracic outlet syndrome
Venous thoracic outlet syndrome is a complex of symptoms arising due to chronic compression of subclavian vein in
the costoclavicular space and subsequent its thrombosis. In 1875, James Paget11
described the symptoms resulting
from subclavian vein thrombosis. Nevertheless, he misunderstood the cause and ethiopatogenesis of the arm swelling
and thought that it is due to the vein imflammation and vasospasm. In 1884, L. Schroetter12
correctly identified that
thrombosis of subclavian and axillary vein causes the complex of symptoms described by Paget and attributed these
upper extremity venous symptoms to the compression or thrombosis of subclavian vein at the thoracic outlet. In 1949,
applied a term Paget-Schroetter’s syndrome to delineate the clinical picture of symptoms arising due to
subclavian vein thrombosis. From that time, the symptoms arising due to subclavian vein thrombosis and their
clinical manifestation are called Paget-Schroetter’s syndrome.
The frequency of spontaneous (primary) subclavian vein thrombosis due to thoracic outlet syndrome is 2 per
100 000 population per year14
Venous TOS results from repetitive subclavian vein compression in the costoclavicular space between the
subclavius muscle or costoclavicular ligament against the first rib and tends to occur in the more active dominant
extremity. Usually, subclavian vein thrombosis occurs after the intensive work or physical activity in young,
physically active adults aged 25-40 years. Repetitive compression of subclavian vein damages its internal layer
(intima) and thrombus formation on the damaged intima occurs15-25
. As a rule, these patients have neurogenic TOS as
well. Acute thrombosis of subclavian vein almost completely blocks the venous return from the arm and results in
swelling, bluish color and painfulness of the involved arm. Subsequent thrombosis of axillary, brachial veins and all
other veins in the involved arm results from the prominent venous outflow block and venostasis in the involved arm.
In extreme cases, venous gangrene (phlegmasia coerulea dolens) of the involved arm develops due to cessation of
blood circulation in the arm, because of blood venous return block.
Clinical diagnosis is easy and usually does not create any problems. The involved arm and hand is swollen,
bluish, firm. During the days, collateral veins on the involved arm and on the upper part of the involved side of the
chest appear. Duplex scanning of the veins in the involved extremity reveals thrombosed, with thrombus in the lumen
deep veins of the involved arm, absent blood flow in the thrombosed deep veins. The final diagnosis is established by
ascending venography of the involved arm, which reveals thrombosed deep veins of the extremity, delineates the
starting point and the extension of the thrombus in the deep veins of the axilla and the arm and demonstrates the
collateral veins returning the blood from the arm.
Most authors are prone to treat these patients by thrombolytic therapy or heparinization22-25
. Some of them
additionally employ the device for thrombus fragmentation ad thrombus elimination by suction with Angiojet device
(Possis Medical Inc, Minneapolis, Minnesota, USA) 26
Other authors, including me, are advocates of a single-stage radical surgical treatment. During the same
operation, the first rib is removed and thrombectomy from the deep veins of the arm is performed. Such operation
eliminates the cause of subclavian vein thrombosis and restores the lumen and passage of blood in the deep veins of
the arm at the same time27-29
. This type of treatment is better, because it resolves both problems at the same operation:
the tightness of thoracic outlet and thrombosis of subclavian vein, and its results (early and late) are better than results
of treatment with thrombolytic agents or heparinization alone, without the first rib removal. Two staged treatment
with thrombolysis in acute phase, and later removal of the first rib 30
, is inferior to the single-stage radical surgical
treatment as well.
Arterial thoracic outlet syndrome
Subclavian artery can be compressed in the cervical outlet (interscalene gap) or in the true thoracic outlet between
the clavicle and the first rib or cervical rib, if present. The compression of the subclavian artery in the cervical outlet,
as a rule, is asymptomatic, because its compression between the muscles in the interscalene gap has no sequelae.
Muscles are soft and compression of the subclavian artery between them is not felt by the patient. This compression
between the muscles does not result in the aneurysm formation or thrombosis of the subclavian artery. Meanwhile,
the repetitive compression and crushing of subclavian artery between the two bones: the clavicle and the first or
cervical rib causes its intimal (internal layer) and medial layer degeneration and aneurysm formation or acute its
thrombosis. This results in acute ischemia of the involved arm. I have never met in my clinical practice the cases of
arm ischemia due to the cervical outlet syndrome, but I have operated several patients with acute arm ischemia due
to the subclavian artery thrombosis as a result of true thoracic outlet syndrome 2, 3
. Compression and mangling of
the subclavian artery in the interscalene gap (cervical outlet) causes another problem: irritation of the sympathetic
nerves passing inside the arterial wall of the subclavian artery, which later supplies sympathetic innervation to the all
arterial tree of the arm and hand and this causes the spasm of small arteries in the hands and their fingers: Raynaud’s
syndrome develops. Patient fingers and hands are bluish in color and very sensitive to the cold. Exposure of the hands
to the cold causes vasoconstriction (spasm of the arteries) and hands become pale, cold and painful. Vasoconstriction
and Raynaud’s syndrome can be caused by compression and irritation of the brachial plexus inside the cervical outlet
as well, because fibers of sympathetic nerves passes through the cervical outlet inside the brachial plexus.
Compression and irritation of brachial plexus inside the cervical outlet (interscalene gap) irritates sympathetic fibers,
present in the brachial plexus, and later spreading to all the arterial tree of the arm and hand. Scalenectomy (removal
of anterior scalene muscle) ceases the compression and irritation of the brachial plexus and subclavian artery and of
all the sympathetic fibers, present in both these structures: Raynaud’s syndrome, as a rule, disappears. Therefore,
scalenectomy in cervical outlet arterial syndrome is justified only for the treatment of Raynaud’s syndrome, to stop
the irritation of sympathetic nerves, present in the brachial plexus and in the wall of the subclavian artery, not for the
compression of the subclavian artery itself. Typically, patients with irritation of sympathetic fibers and Raynaud’s
syndrome have neurogenic cervical outlet or thoracic outlet syndrome (symptoms of compression and irritation of
brachial plexus itself). Significant part of patients, having neurogenic cervical outlet syndrome, have compression of
vertebral arteries as well. Neurogenic cervical outlet syndrome typically is bilateral and compression of vertebral
arteries is bilateral as well. These patients have symptoms of vertebrobasilar insufficiency up to the vertebrobasilar
stroke (in cases of prolonged spasm of vertebral arteries). Vertebral arteries are not merely compressed, but they react
to the compression by spasm. This spasm of vertebral arteries causes not only pronounced symptoms of
vertebrobasilar insufficiency, but it can be even the cause of vertebrobasilar stroke. Typically, these patients seek
doctor’s help because of vertebrobasilar insufficiency symptoms, not for symptoms of brachial plexus compression,
though they have symptoms of brachial plexus compression as well. The problem is, that most physicians are
unfamiliar with thoracic and particularly with the cervical outlet syndromes, they do not know their symptoms and
treatment. That’s, why patients cannot obtain adequate diagnostic procedures and receive adequate treatment.
In cases of thoracic outlet syndrome, the subclavian artery is compressed and mangled between two bones: the
clavicle and the first rib. Therefore, the damage to the arterial wall is significant and aneurysm formation of
subclavian artery results in the age of 25-40 years, because the thorax completely develops and forms up to the 25
years and people in such age are most active physically. Therefore, mangling and traumatizing of their subclavian
arteries between these two bones is most intensive in that age.
Patient does not feel the process of compression and mangling of the subclavian artery until the development of
subclavian artery thrombosis (or its aneurysm thrombosis), or the thrombus embolisation from the aneurysm to the
distal arteries of the arm. Acute ischemia of the arm develops in such cases. Only then, patients addresses the hospital
or the physician. Physician’s obligation in this situation is to establish the correct diagnosis and to provide adequate
treatment for the patient. Emergency diagnostic evaluation and surgery is needed in such cases. Anterior-posterior
plain view roentgenogram of thorax and neck should be taken and emergency angiography of diseased subclavian
artery through the femoral route should be performed. Presence of subclavian artery aneurysm, or thrombosis of
subclavian artery, particularly with embolisation to the distal arteries of the arm, indicate the presence of mangling of
subclavian artery between the clavicle and first rib or cervical rib, if present, and existing arterial thoracic outlet
syndrome. Roentgenogram of the chest is helpful only if cervical rib or abnormal first rib or clavicle is seen on it. If
no deformities or bone anomalies are seen in the thoracic outlet, it does not preclude the existence of thoracic outlet
syndrome due to the too narrow costoclavicular space. Magnetic resonance tomography of the thoracic outlet is
helpful in such cases, if performed by adequate computer program and mode by qualified magnetic resonance
tomography staff. After the establishment of arterial thoracic outlet syndrome diagnosis and subclavian artery
thrombosis or embolisation from the subclavian artery to the distal arm arteries, the emergency operation should be
undertaken: typically, first rib resection through the axillary approach and revascularization procedure, depending on
the underlying cause of arm ischemia is performed at the same operation.
I have operated patient with such situation. The case report is published on the internet3
Best treatment results of these patients are obtained by vascular surgeons, because they are best familiar with
the revascularization procedures and their tactics.
Neurogenic thoracic outlet syndrome
Neurogenic thoracic outlet syndrome is a complex of symptoms arising due to compression of brachial plexus
between the clavicle and first or cervical rib, if present. Usually, the lower roots of brachial plexus (8-th cervical and
first thoracic) are most intensively compressed and suffer more prominently. Therefore, symptoms usually are most
expressed in the area of distribution of nerves, which are constituted by the fibers coming from C8-Th1 roots (medial
or ulnar side of the arm). Nevertheless, all brachial plexus roots are compressed in most cases: just the intensity of
compression can vary in lower and upper roots of brachial plexus. Only those nerves, which branch from the brachial
plexus higher than thoracic outlet and innervate neck, upper portion of the back, between the shoulder-blades
(scapulae) and upper portion of the chest anteriorly cannot be compressed in the true thoracic outlet. They can be
compressed only in the cervical outlet (interscalene gap). All other brachial plexus roots can be compressed in the
cervical outlet as well. Keeping in mind this peculiarity and obtaining the existing patient’s symptoms, one can
diagnose which of neurogenic outlet syndromes is present: thoracic or cervical.
Patients with neurogenic thoracic outlet syndrome experience tingling, numbness and pain in the arms. In more
advanced cases muscle atrophy and weakness develop in the area of distribution of affected nerves.
Electromyography is an unreliable test and should not be used for diagnosing thoracic or cervical outlet
syndromes. Electromyographic changes appear only in late stages of thoracic outlet syndrome and they always mean
pronounced pathologic changes in the nerves and muscles, which should be avoided. Patients should be operated in
earlier stages of the disease, before the development of nerve dystrophies and muscle atrophies.
Below there are four postulates, established in thoracic outlet syndrome and written by David Roos:
1. Patients, having thoracic outlet syndrome, have anatomical congenital anomalies, predisposing them to the
development of thoracic outlet syndrome. Trauma, physical stress, profession are provoking factors for the
thoracic outlet syndrome;
2. 95% of patients with tight thoracic outlet develop neurogenic thoracic outlet syndrome symptoms, 4% -
develop venous symptoms and only 1 % of patients develop arterial symptoms of thoracic outlet syndrome;
3. Therefore, all tests demonstrating compression of subclavian artery has only the significance in
demonstrating the compression of subclavian artery, not of brachial plexus. Patient does not feel the
compression of subclavian artery until it develops aneurysm or embolisation from the aneurysm into the
distal arteries of the arm, or aneurysm becomes acutely thrombosed. Consequently, compression of the
subclavian artery and pulse disappearance in the arm are not the diagnostic criteria for the neurogenic
thoracic outlet syndrome, because patient address the physician not because of subclavian artery
compression, but because of brachial plexus compression. Brachial plexus compression can exist in cases
with no compression of subclavian artery in the same patient;
4. Effective treatment of thoracic outlet syndrome is surgical: elimination of anatomical congenital anomalies,
causing compression and irritation of brachial plexus.
Anamnestic data, inspection of the patient and objective assessment of patient symptoms are very important in
establishing the diagnosis. Plain chest and neck roentgenograms visualize anatomic bone abnormalities: accessory
cervical ribs, abnormal first rib or abnormal clavicle. Absence of bone abnormalities on roentgenograms does not
exclude the presence of thoracic outlet syndrome. Cartilaginous or fibrous abnormal anatomic structures, which can
be the causes of thoracic outlet syndrome, are not visible on the plain roentgenograms. Laboratory analyses are not
diagnostic and are performed only as a preoperative assessment of patient status. Electromyographic tests are of
minimal value in establishing the diagnosis and in decision making as to operate the patient or not. All diseases,
which can mimic the compression of brachial plexus: cervical disk herniation, cervical spine spondylosis or
osteochondrosis, arthrosis of the shoulder joint etc should be ruled out. Neurologic examination of sensory and motor
disturbances as well as of muscle reflex changes are essential in establishing the diagnosis.
Most reliable test in establishing thoracic outlet syndrome diagnosis is an Elevated Arm Stress Test (EAST) as
depicted in figure 11. Patients with thoracic outlet syndrome in this position during the test develop progressive
distress and reproduction of their usual symptoms: fatigue, heaviness, paraesthesias and pain in the involved arm and
they finally drop the arm to the lap, unable to complete the three minute exercise in this arm position.
Surgical treatment of thoracic outlet syndrome remains the most definitive approach to permanent cure, but it should
be employed only when more conservative measures prove ineffective. Mild symptoms of TOS require no special
treatment, but the patient is advised to minimize activities or arm positions that precipitate the symptoms. Moderate
symptoms may also respond to avoidance of aggravating activities. Nevertheless, other measures may be required as
well, such as nonnarcotic medication for pain control, muscle relaxation and light physical therapy.
The decision of when to advise surgical treatment for TOS patients is simple: if the patient can control his
symptoms by non-surgical methods to the extent that he is normally active, able to work effectively, and sleep well,
surgery is not indicated. If these symptoms, however are severe enough to interfere with his general activities, job,
sleep, or simply make him feel miserable, and conservative measures have failed, surgery is indicated to restore his
limb and life back to normal.
The only type of surgical treatment that offers relief for patients with advanced TOS uncontrollable by
conservative measures is the elimination of mechanical irritation or compression of neurovascular structure,
responsible for the symptoms. Currently, the most effective means of accomplishing this is to resect the first thoracic
rib and all congenital anomalies in the thoracic outlet, such as cervical rib or fibromuscular bands, to remove the
triggering causes, responsible for the symptoms. Presently, the easiest, safest and most complete exposure to
accomplish this is by the use of transaxillary approach as proposed by David Roos.
Surgical treatment of TOS was begun in 1861, when H. Coote in London removed accessory cervical rib for the
patient, suffering arm pain. The second operation for TOS (removal of accessory cervical rib) was performed by
French surgeon J. Perier in 1890. F. Bramwell in 1903 was the first, who understood, that even in the absence of
accessory cervical rib, the costoclavicular space can be too narrow and can compress the brachial plexus.
Consequently, TOS can be present even in the absence of accessory cervical rib. Australian surgeon Thomas Murphy
in 1910 was the first, who removed the first thoracic rib for the thoracic outlet syndrome and cured patient from the
pain, caused by compression of brachial nerve plexus. Then, it was a long period of time when the surgical treatment
of TOS was neglected. Only in 1962 O. Clagett restored enthusiasm for surgical treatment of TOS, proposing the
posterior thoracotomy approach for the removal of the first thoracic rib. David Roos was the surgeon, who made a
revolution in the surgical treatment of TOS by developing and proposing the transaxillary approach for the removal
of the first thoracic rib as well as removal of accessory cervical rib and all other congenital abnormal anatomical
structures in the thoracic outlet in 1966. This approach is the most popular approach for removal of the first thoracic
and accessory cervical ribs in nowadays all around the world.
Personally, I use exclusively this D. Roos transaxillary approach for all true thoracic outlet syndrome cases: for
arterial 2, 65
, venous and neurogenic.
I shall describe in this article the most important aspects of this operation only in short, because most patients
want to know how the operation is performed, what are the risks and dangers of this operation.
Technique of the operation
Patient is intubated and placed in a straight lateral position with the symptomatic side uppermost, then tilted back
slightly towards the surgeon, who stands behind the patient (figure 14). The second assistant stands cephalad to the
surgeon to elevate and control the upper extremity for exposure at appropriate times. He abducts the brachium 900
from the thorax and holds the forearm in a double wrist-lock, which is the most comfortable and effective grip to
elevate the shoulder intermittently during the operation. The surgeon must instruct the assistant to elevate the arm and
shoulder slowly and gently, with a “light touch “to avoid sudden or prolonged stretching of the brachial plexus.
Figure 15 illustrates the schematic representation of the important anatomic structures in the thoracic outlet from the
right armpit view.
Figure 16 illustrates the schematic representation of the important anatomic structures in the thoracic outlet while
cutting the first rib with bone shears. It is important for surgeon to be very careful for preserving the brachial plexus,
particularly the first thoracic root from damaging, while exposing, denuding, cutting and removing the first rib. First
thoracic root is protected during the rib cutting with special spatula, as it is showed in figure 16.
After the first and cervical rib (if present) removal, the wound is closed. Drainage of pleural cavity may be
required if the pleura was inadvertently opened during the first rib stripping. In most instances, good lung inflation
and expansion is sufficient even in opened pleura cases and wound can be closed airtight, if the wound hemostasis is
Figure 15: Schematic representation of the
important anatomic structures in the
Skin incision is made over the third rib below
the hairline of the axilla between pectoralis
major and latissimus dorsi muscles.
Subclavian vein is depicted in blue,
subclavian artery - in red and brachial
plexus - in yellow colors. Scalene muscles
are depicted in brown color. Anterior
scalene muscle passes between the
subclavian artery and vein and inserts to the
Figure 14: Position of the patient on the operation table and
position of the second assistant and of his arms and hands in
elevation of patient’s arm
Picture clearly indicates the patient’s position on the table and the
second assistant’s position in regard to the patient. Symptomatic
arm is elevated by the assistant with a double wrist-lock grip, when
the operation proceeds to the thoracic outlet deep in the armpit.
Cervical outlet syndrome
Cervical outlet syndrome is by far more prevalent in comparison to the thoracic outlet syndrome and is encountered
in 5-10% of population. The problem is that most physicians are unfamiliar with the symptoms, diagnostics and
treatment of this widespread health trouble. Many patients with cervical outlet syndrome symptoms are
unsuccessfully seeking the true diagnosis and help. These patients have neurogenic symptoms due to the compression
of brachial plexus nerve roots in the interscalene gap, but most of them suffer by far more prominently because of
vertebrobasilar insufficiency (insufficiency of blood flow through the vertebral arteries to the brain stem and to the
occipital region of the brain hemispheres). The most common symptoms of vertebrobasilar insufficiency are:
dizziness, vertigo episodes, fatigue, visual disturbances (diplopia, blurring of the vision, skotomas, sometimes even
blindness), noise in the ears, deafness. Many patients have cardiac symptoms: paroxysmal tachycardias, arhytmias,
extrasystolias, heartaches. Almost all of them have symptoms resulting from insufficient brain blood flow:
nervousness, sleep disorders, mental retardation and exhaustion, memory deterioration. Some patients develop even
frank vertebrobasilar strokes with paralysis. The overwhelming majority of these patients can be cured and can be
healthy, if the correct diagnosis would be established and adequate surgical treatment would be provided to them by
qualified and experienced in this field surgeon. Compression of brachial plexus roots manifest as numbness, tingling,
pain in the arms, upper chest, face, neck, between the scapulae. However, most patients with cervical outlet syndrome
suffer by far more from vertebrobasilar insufficiency than from neurogenic symptoms and they are seeking doctor’s
help because of vertebrobasilar insufficiency symptoms. Some of these patients have Raynaud’s syndrome in the
upper extremities due to the compression and irritation of sympathetic fibers in the interscalene gap, passing in the
brachial plexus roots and in the wall of subclavian artery. Hands of these patients are cold, bluish, extremely sensitive
to the cold exposure and react to the cold by contraction of small arteries and arterioles. After exposure to the cold,
hands become pale, cold, and even painful. Scalenectomy (removal of scalenus anterior muscle) cures all the
symptoms: vertebrobasilar insufficiency, neurogenic symptoms and Raynaud’s syndrome. The most important
clinical expression of cervical outlet syndrome is vertebrobasilar insufficiency due to the compression (by
scalenus anterior muscle: inside the muscle or between the muscle and spinal column) and spasm of vertebral
arteries in the cervical outlet. The health problem typically is bilateral, symmetrical, because, as a rule, cervical
outlet syndrome is bilateral, symmetrical as well as compression of vertebral arteries with scalenus anterior muscle is
My intensive experience in diagnosing and operating cervical outlet syndrome in patients (over 1 000 operations)
enable me to state the following postulates:
Compression of vertebral arteries with scalenus anterior muscle is the most common sequela of cervical outlet
syndrome. Nerve roots of brachial plexus can be compressed, but can be not compressed in cervical outlet
syndrome. Therefore, most of patients with cervical outlet syndrome have symptoms of vertebrobasilar
insufficiency and complain of them.
Consequently, duplex scanning and color doppler studies of vertebral arteries and assessment of their flow are
mandatory in evaluation of these patients, especially if the patient is intended to be operated. During the
operation, vertebral artery must be exposed, explored totally from the origin on the subclavian artery up to its
Figure 16: Schematic illustration of safe dividing
of the posterior part of the first rib
Eighth cervical and first thoracic roots of brachial
plexus are protected with special spatula while
dividing the first rib.
These nerve roots should be clearly seen by the
surgeon, while stripping and cutting the first rib.
5,6,7,8 – cervical nerve roots
1 – first thoracic root.
entrance into the vertebral column not to leave uncorrected its problem while removing scalenus anterior
muscle, because left unrepaired vertebral artery problem results in remaining vertebrobasilar symptoms after
the operation. Repetitive second time operation for correction of vertebral artery pathology is by far more
complicated and dangerous than to repair its problem while removing scalenus anterior muscle.
Patients having symptoms of vertebrobasilar insufficiency and who for this reason have had angiographic
evaluation of vertebral arteries and their data have not suggested vertebral artery pathology, should be
evaluated by duplex and color doppler studies, because angiography can be misleading if performed in
standard fashion (vertebral arteries can appear normal in the anterior-posterior standard view on angiograms,
because they will be compressed minimally due to relaxation of deep neck muscles while patient lying on the
angiography table and because the main mechanism of vertebrobasilar insufficiency is the spasm of vertebral
arteries in response to their compression and irritation by scalenus muscle). Duplex scanning and color
doppler in experienced hands are very sensitive and accurate tools for diagnosing compression of vertebral
arteries by scalenus muscle. They permit to obtain the qualitative and quantitative analysis of blood flow
disturbances in vertebral arteries as well as alterations of vertebral artery lumen.
The main diagnostic tool for cervical outlet syndrome is duplex scanning and color doppler studies of
Isolated neurogenic cervical outlet syndrome symptoms without symptoms of vertebrobasilar insufficiency
usually manifest after the whiplash injury to the neck scalenus muscles during the car accident or similar
injury. Scalenectomy is curative in these patients.
Some patients with cervical outlet syndrome have Raynaud’s syndrome due to the compression and irritation
of sympathetic fibers in the brachial plexus and arterial wall of subclavian artery. Scalenectomy cures the
Raynaud’s syndrome in these patients.
Many of patients with cervical outlet syndrome suffer from intensive headaches and, as a rule, are treated as a
migrenous patients. Considerable part of these patients have symptoms of vertebrobasilar insufficiency as
well. Scalenectomy cures the headache and the symptoms of vertebrobasilar insufficiency in these patients.
Neurogenic cervical outlet syndrome is diagnosed in accordance with appropriate symptoms and their distribution:
pain, tingling and numbness in the neck, arms, upper chest, upper back, sometimes in the face and head region,
tightness and stiffness of the muscles in the neck, upper back, upper chest, arms. Diagnosis is confirmed by the
positive Roos test in elevated arms position as it is showed in figure 11. This test is a reliable diagnostic tool in
establishing the cervical and thoracic outlet syndromes. Typically, this test provokes and enhances the existing
neurogenic symptoms of cervical outlet syndrome. If this test is negative, strong suspicion for cervical outlet
diagnosis should emerge. Patients having cervical outlet syndrome typically have taut painful scalenus anterior
muscle: pressure by finger on it above the clavicle provokes the pain and the muscle is felt as a taut roll.
Typically, in case of cervical outlet syndrome, subclavian artery as well as roots of brachial plexus is
compressed between the scalenus muscles. Therefore, disappearance or diminution of pulse in the wrist during
Adson’s maneuver or Roos test strongly supports the cervical outlet syndrome diagnosis. Symptoms of
vertebrobasilar insufficiency are very characteristic for cervical outlet syndrome as well. Raynaud’s syndrome or
phenomenon are very common in these patients too. Wrist and palm arteries are very spasmatic in these patients and
this spasm can be demonstrated by sphygmomanometer or by continuos wave doppler apparatus.
Other instrumental investigations: electromyography, nerve conduction studies, assessment of evoked potentials
are of minimal value in establishing the cervical and thoracic outlet syndrome diagnoses, because they are positive
only in delayed cases when pronounced morphologic changes in nerves are present. Patients should be operated
earlier, before the appearance of such delayed pronounced and not reversible changes in nerves.
The main and crucial point in evaluation of the patient is to distinguish the cervical outlet syndrome from
thoracic outlet syndrome, because in the cervical outlet syndrome scalenectomy through the supraclavicular
approach is required and in the thoracic outlet syndrome – first rib resection through the transaxillary approach is
required. Consequently, different approaches and different surgical procedures are required in these both different
Patient should ask two questions for surgeon before deciding to have the operation: 1) how many such
operations the surgeon have performed and 2) what are the results and personal surgeon’s complications in these
operations. Only then, patient can decide to entrust or not his health or even the life to that surgeon.
Scalenectomy and first rib resection procedures are not risky and dangerous or otherwise difficult for the
experienced surgeon and their results are gratifying if the diagnosis was made correct and the procedure is performed
adequately and professionally.
Arterial cervical outlet syndrome (compression of vertebral artery with scalenus anterior muscle)
Anterior scalenus muscle is prone to the development anomalies. It can originate more medially than normal on the
first rib or insert lower than normally to the spine, to the transverse process of seventh vertebra or can be as a one
solid mass together with the medius scalenus muscle. These development anomalies create problems for brachial
plexus nerve roots, passing the interscalene gap, and can compress the vertebral artery against transverse processes of
cervical vertebrae. Normally, vertebral artery originates from subclavian artery just medial from the medial border of
the scalenus anterior muscle. In case, the vertebral artery originates more lateral than normally from subclavian artery
(so called lateral branching of vertebral artery), it falls into conflict with scalenus anterior muscle and is compressed
by it. The same problem arises when the scalenus anterior muscle originates more medial than normally on the first
rib and compresses the vertebral artery. Vertebral artery is compressed when it enters bony canal of cervical vertebrae
higher than normally. Normally vertebral artery enters bony canal at the sixth cervical vertebra (into transverse
process of the sixth cervical vertebra). Scalenus anterior muscle starts to attach to the sixth transverse process and
attaches to the fifth, fourth and the third cervical vertebrae. That’s, why vertebral artery passes the neck in the bony
canal (it is preserved by the bony canal from the compression and entrapment by muscle fibers and tendons). If the
vertebral artery enters bony canal higher than normally (into fifth, fourth, or even third cervical vertebrae), it
inevitably falls into conflict with the scalenus anterior muscle and is compressed by it against the cervical vertebrae.
Compression of vertebral artery narrows its lumen and diminishes blood flow through it. Another, even more
important factor of blood flow diminution through the vertebral arteries is their spasm. Compression of vertebral
artery by the muscle causes its spasm and it can be very severe, up to the almost total occlusion of vertebral artery.
This results in deep fall of blood flow through the vertebral arteries and consequently - brain perfusion and results in
development of obvious ischemic vertebrobasilar stroke symptoms including paralysis. Usually, symptoms of
vertebrobasilar insufficiency are not so dramatic and manifest as dizziness, sometimes vertigo episodes, nausea,
equilibrium and visual disturbances, tinnitus or noise in the ears, headache, poor memory, rapid mental tiredness,
vegetodystonic symptoms, cardiac rhythm disorders: extrasystolia, tachycardia, heartaches etc.
Figure 17 represents the compression of both subclavian and both vertebral arteries by scalenus anterior muscle
as seen on the MRA (magnetic resonance angiography).
Both vertebral arteries and both subclavian arteries are compressed and narrowed by scalenus anterior muscle. Both
vertebral arteries originate from subclavian arteries more laterally than normally, together with the thyreocervical
trunk under the scalenus anterior muscle and are compressed by them (so called lateral branching of vertebral
arteries). Both subclavian arteries are compressed and narrowed by scalenus anterior muscle. It means that the gap
between the scalene muscles (spatium interscalenum) is too narrow.
Figure 18 represents the same patient and the same arteries as in figure 17 but the image is obtained by
computer reconstruction of CT angiography.
Figure 17: Arterial cervical outlet sindrome: compression
of both subclavian and both vertebral arteries by scalenus
anterior muscle (magnetic resonance angiography)
1- The right vertebral artery
2- The left hypoplastic vertebral artery
3- Sites of compression of the left subclavian and left
4- Sites of compression of the right subclavian and
The left vertebral artery from the embryological period is
compressed by scalenus anterior muscle. Therefore, she has
low blood flow from that period and due to this reason it
did not develop to the normal lumen and stayed narrow,
The diagnostic evaluation of arterial cervical outlet syndrome is based on the duplex scanning and color doppler
studies. The surgeon, operating this pathology, can diagnose compression and various other anomalies of vertebral
arteries best. The establishment of correct diagnosis is very important, because without correct diagnosis is
impossible the adequate treatment. The surgery for cervical outlet syndrome is very effective and, as a rule, patients
after the operation are completely healthy. Scalenectomy clears symptoms of vertebrobasilar insufficiency and
neurogenic symptoms due to the compression of brachial plexus roots as well.
Physician must know that compression of vertebral artery and of brachial plexus in cervical outlet syndrome are
usually combined and symptoms in patients exist from both these problems. The task for the physician is to sort and
to understand these symptoms arising from these two closely related problems: vertebral artery and brachial plexus
Below, I shall illustrate the capabilities of duplex scanning and color doppler studies in diagnostic evaluation of
cervical outlet syndrome (compression of vertebral arteries with scalenus anterior muscle).
Figure 19 illustrates uncolored duplex scan image and spectral blood flow analysis of the vertebral artery,
compressed with the scalenus anterior muscle due to its abnormal attaching to the seventh cervical vertebra. Figure
18 is the image of the same artery at the same site, just with switched on the color doppler. The vertebral artery is
compressed against the transverse process of the seventh cervical vertebra by abnormal pedicle of the scalenus
anterior muscle attaching to this transverse process. The vertebral artery is tightly narrowed at this site and this is
seen on the blood flow curve (high systolic and diastolic blood flow velocity values, abnormal curve with high level
of turbulence in the blood flow). The same features are seen and in the image with switched on color doppler (figure
20). Only the proximal part of vertebral artery is seen on the image, because higher it hides under the muscle. Very
intensive turbulence in vertebral artery (yellow and blue color) is seen on color doppler image. Blue color means that
even reversed blood flow in the whirls inside the vertebral artery is present. Upstream, in the bony canal, blood flow
in the same vertebral artery is slow (figure 21), but it is still with pronounced turbulence (flow curve descends below
the zero line during all the cardiac cycle).
Figure 18: Computer reconstructed image of CT
angiography (the same patient and the same arteries as in
the figure 17)
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
Both vertebral arteries originate from subclavian arteries
more laterally than normally, together with the
thyreocervical trunk under the scalenus anterior muscle and
are compressed by them (so called lateral branching of
vertebral arteries). The orifices of both vertebral arteries are
on the posterior aspect of the subclavian arteries and during
the compression are partially closed. Both subclavian
arteries are compressed and narrowed by scalenus anterior
muscle as well. It means that the gap between the scalene
muscles (spatium interscalenum) is too narrow.
In cases of high vertebral artery entrance into the bony canal (when it enters the bony canal higher than at the 6-th
cervical vertebra) always there is a conflict between the vertebral artery and muscles: scalenus anterior, longus colli
and longus capitis muscles. The vertebral artery is compressed by these muscles against the cervical vertebrae.
Consequently, high entrance of vertebral artery into the bony vertebral canal always is a pathology and always
interferes with blood flow in the vertebral artery.
Duplex scanning clearly defines not only the neck anatomy: muscles, vertebrae, blood vessels etc, but visualizes
the vertebral artery and its lumen as well.
Figure 19: Compression of the vertebral artery
with the abnormal scalenus anterior muscle at
the transverse process of the 7-th cervical
vertebra (black-white B ultrasound mode with
doppler blood flow measurement and spectral
blood flow analysis).
Note the very impressive turbulence of the blood
flow seen on the curve in the figure 19. The
blood flow in the compressed narrowed part of
the vertebral artery is fast (over 120 cm/sec).
All these features mean hemodynamically
significant narrowing of vertebral artery at the
site of compression.
Figure 20: Compression of the vertebral
artery with the abnormal scalenus anterior
muscle at the transverse process of the 7-th
cervical vertebra (the same artery and the
same site as in figure 19, just the color doppler
is switched on).
Blood whirls in the vertebral artery are colored
in blue, what means that blood flow in the
whirls is in reversed direction (very high
Blood flow velocity and the blood flow spectral
analysis curve are the same as in the figure 19.
Figure 21: Blood flow in the same vertebral
artery as in the figures 19 and 20 at the upper
level (inside the bony canal in the spinal
Blood flow velocity in the vertebral artery
above the obstruction is low, its curve is
flattened, poststenotic. However, it is still
markedly turbulent (blood flow curve descends
below the zero line, what means reversed blood
flow in the whirls).
Next five pictures illustrate the vertebral artery, compressed with the abnormal pedicle of scalenus anterior
muscle, attaching to the seventh transverse process of cervical vertebra. The compression of vertebral artery is mainly
with tendinous border of that abnormal pedicle, clearly seen on echo images. Figure 22 is the image, obtained with
color doppler. Compression of the vertebral artery close to its orifice is clearly seen as narrowing of its lumen at the
place of compression. During the cardiac contraction (systole) blood spurt is injected through the narrowed,
compressed part of vertebral artery, seen as yellow spurt on that picture. Yellow whirls of turbulent blood (yellow
rings) are flowing upstream. Before the obstacle, the whirls during cardiac systole are colored even in blue color,
because blood flow in these whirls assume reversed direction. Doppler probe is placed exactly on the narrowed
vertebral artery place and therefore linear blood flow in that place is accelerated (131 cm/sec in the systole).
Figure 23: The same vertebral artery at the same site
as in the figure 22, just with the color doppler
switched off (a probe moved about 2-3 mm cephalad
after the compression)
You can see the tendinous white border of the
additional abnormal pedicle of scalenus anterior
muscle, attaching to the transverse process of the
seventh cervical vertebra (on the image with color
doppler, fig.22, this site corresponds to the significant
narrowing of the vertebral artery).
Blood flow curve is very similar to the curve recorded
in fig. 22, just the turbulence is more pronounced.
Figure 24: Blood flow features 1 cm after (cephalad)
to the compression of vertebral artery. The same
vertebral artery as in figures 22, 23
Blood flow in the vertebral artery distal to the site of
compression is abnormal, very turbulent. Blood flow
curve is abnormal too. Dense turbulence is seen on the
Figure 22: Left vertebral artery is compressed by
abnormal additional pedicle of scalenus anterior
muscle, attaching to the transverse process of the 7-th
cervical vertebra (color doppler image)
There is a high turbulence at the site of compression.
Turbulent whirls of blood flow are seen as yellow and
blue spots and rings in the artery. The blue color
means that blood flow in the whirls in that place is in
reversed direction. The spurt of blood flow (yellow
color) is injected during the cardiac contraction
(systole) into the vertebral artery through the
compressed, narrowed its part.
Blood flow curve indicates high linear blood flow in
the systole and intensive turbulence during all the
These two cases of compressed vertebral artery by scalenus anterior muscle illustrate the effectiveness and
informativeness of duplex scanning and color doppler in evaluation of external (extravasal) compressions of vertebral
arteries. These ultrasound studies are superior to the angiographic studies, because they provide not only the anatomic
and morphologic data, but hemodynamic data as well. They enable the examiner not only to diagnose the pathology
of vertebral artery, but also to determine its hemodynamic significance. Of course, the examiner must be well trained
and experienced in this field. Otherwise, misdiagnosis or diagnostic failures will be inevitable.
In conclusion, the clinical diagnosis is established relying on anamnestic data, clinical inspection and evaluation of
patient, ultrasound studies. Angiographic evaluation is excessive and less informative than ultrasound studies of
Intensiveness of vertebrobasilar symptoms is the main factor in making decision as to operate or not the patient with
the cervical arterial outlet syndrome (compression of vertebral arteries). Light and mild symptoms can be managed
medically without an operation. Severe symptoms are the indication for surgical treatment – removal of scalenus
anterior muscle. The operation is simple and easy for patient and surgeon, provided the surgeon has enough
experience in these operations. In my practice, the patient makes the decision to have the operation or not. The duty
of surgeon is to provide all the information for the patient about his illness and the ways his problem can be managed.
As my extensive experience in this field of surgery indicates, most patients select the surgical treatment, because they
want to be completely healthy and surgery makes it real.
Supraclavicular approach is used for this operation. This approach enables to remove completely the anterior
scalenus muscle and to free from compression and inspect visually the roots of brachial plexus and vertebral artery.
Vertebral artery is accessible from its origin up to its entrance into the bony canal in the spine independently from the
height of its entrance.
The main and most important guarantee of successful treatment of these patients, including surgical treatment,
is correct diagnosis, because without the correct diagnosis there is no correct and successful treatment.
1. Ranney D. Thoracic outlet: an anatomical redefinition that makes clinical sense. Clin Anat 1996;
2. Pauliukas P. Poraktinių arterijų sužalojimai lūžus raktikauliui. (Subclavian artery lesions due to
clavicular fracture). Lietuvos Chirurgija 2005; 3 (1): 27-30. Internet address:
4. Milliez PY. Contribution a l’etude de l’ontogese des muscles scalenes (reconstruction d’un embryon
de 2,5 cm). June 28, 1991, University of Paris, Pantheon-Sorbone, Museum of Man, Museum of
5. Sanders RJ, Roos DB. The surgical anatomy of the scalene triangle. Contemporary Surgery 1989;
Figure 25: The same vertebral artery as in figures 22,
23, 24. Blood flow in the spine between transverse
High turbulence is still present in the vertebral artery.
Blood flow is slow (because here vertebral artery lumen
is normal, not compromised by compression with
scalenus anterior muscle). Its curve is abnormal,
flattened, poststenotic, with features of high turbulence.
6. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: An analysis of 200
consecutive cases. J Vasc Surg 1992; 16 (4): 534-545.
7. Etter LE. Osseous abnormalities of the thoracic cage seen in fourty thousand consecutive chest
photoroentgenograms. Am J Roentgenology 1944; 51: 359-363.
8. Adson WA. Surgical treatment for symptoms produced by cervical ribs and the scalenus anticus
muscle. Surg Gynecol Obstet 1947; 85: 687-700.
9. Firsov GI. Cervical ribs and their distinction from underdeveloped first ribs. Arch Anat Histol
Embriol 1974; 67: 101-103.
10. Hamilton WJ, Boyd JD, Mossman WJ. Human Embryology. 3-rd edition. Cambridge: W Heffer
and Sons Ltd, 1952: 548-559.
11. Paget J. Clinical Lectures and Essays. London, UK: Longmans Green and Co; 1875.
12. Von Schroetter L. Nothragel Handbuch der pathologie and therapie. Vienna, Austria: Holder; 1884.
13. Hughes ESR. Venous obstruction in the upper extremity (Paget-Schroetter Syndrome). Collective
Reviews. 1949; 88: 89-127.
14. Lindbald B, Tengborn L, Bergqvist D. Deep vein thrombosis of the axillary-subclavian veins:
epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg 1988; 2:
15. Zell L, Kindermann W, Marschall F, et al. Paget-Schroetter Syndrome in sports activities—case study
and literature review. Angiology 2001; 52: 337-342.
16. Vijaysadan V, Zimmerman AM, Pajaro RE. Paget-Schroetter sindrome in the young and active. J Am
Board Fam Med 2005; 18 (4): 314-319.
17. Matas R. Primary thrombosis of the axillary vein caused by strain. Am J Surg 1934; 24: 642-656.
18. Prandoni P, Polistena P, Bernardi E, et al. Upper Extremity deep vein thrombosis. Risk factors,
diagnosis, and complications. Arch Intern Med 1997; 157: 57-62.
19. Haire WD, Lynch TG, Lund GB, Lieberman RP, Edney JA. Limitations of magnetic resonance
imaging and ultrasound-directed (duplex) scanning in the diagnosis of subclavian vein thrombosis. J
Vasc Surg 1991; 13: 391-397.
20. Hartnell GG, Hughes LA, Finn JP, Longmaid HE 3rd. Magnetic resonance angiography of the central
chest veins. A new gold standard? Chest 1995; 107: 1053-1057.
21. Chang R, Horne MK 3rd, Mayo DJ, Doppman JL. Pulse-spray treatment of subclavian and jugular
venous thrombi with recombinant tissue plasminogen activator. J Vasc Interv Radiol 1996; 7: 845-851.
22. Aburahma AF, Sadler D, Stuart P. Role of thrombolytic therapy in axillary-subclavian vein
thrombosis. W V Med J 1990; 86 (4): 144-149.
23. Aburahma AF, Sadler DL, Robinson PA. Axillary subclavian vein thrombosis. Changing patterns of
etiology, diagnostic, and therapeutic modalities. Am Surg 1991; 57 (2): 101-107.
24. Becker DM, Philbrick JT, Walker FB. Axillary and subclavian venous thrombosis. Prognosis and
treatment. Arch Intern Med 1991; 151: 1934-1943.
25. Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation 2002; 106: 1874-1880.
26. Kasirajan K, Gray B, Ouriel K. Percutaneous AngioJet Thrombectomy in the management of extensive
deep venous thrombosis. J Vasc Interv Radiol 2001; 12: 179-185.
27. Drapanas T, Curran WL. Thrombectomy in the treatment of "effort" thrombosis of the axillary and
subclavian veins. J Trauma 1966; 6 (1): 107-119.
28. Roos D. Transaxillary first rib resection to relieve thoracic outlet syndrome. Ann Surg 1966; 163: 354–
29. Roos DB. Axillary-subclavian vein occlusion. In: Rutherford RB, ed. Vascular Surgery. Philadelphia,
Pa: WB Saunders; 1984: 1385-1393.
30. Lee MC, Grassi CJ, Belkin M, Mannick JA, Whittemore AD, Donaldson MC. Early operative
intervention after thrombolytic therapy for primary subclavian vein thrombosis: an effective treatment
approach. J Vasc Surg 1998; 27: 1101-1108.
31. Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Anatomy, symptoms,
diagnosis, and treatment. Am J Surg 1976; 132 (6): 771-778.
32. Roos DB. Essentials and safeguards of surgery for thoracic outlet syndrome. Angiology 1981; 32 (3):
33. Roos DB. Experience with first rib resection for thoracic outlet syndrome. Annals of Surgery 1971; 173
34. Roos DB. New concepts of thoracic outlet syndrome that explain etiology, symptoms, diagnosis and
treatment. Vascular Surgery 1979; 13(5): 313-321.
35. Roos DB. The place for scalenectomy and first rib resection in thoracic outlet syndrome. Surgery 1982;
92 (6): 1077-1085.
36. Coote H. Exostosis of the left transverse process of the seventh cervical vertebra, surrounded by blood
vessels and nerves: successful removal. Lancet 1861; 1: 360-361.
37. Bramwell F. Lesion of the first dorsal nerve root. Rev Neurol and Psychiat 1903; 1: 236-238.
38. Murphy T. Brachial neuritis caused by pressure of first rib. Aust Med J 1910; 15: 582-586.
39. Clagett OT. Presidential Address: Research and Prosearch. J Thorac Cardiovasc Surg 1962; 44: 153-
40. Martinez B. Thoracic outlet syndrome, endoscopic transaxillary first rib resection and thoracodorsal
sympathectomy for causalgia. In: White R, Fogarty T, editors. Peripheral endovascular interventions.
New York: Springer-Verlag, 1999, p. 531-538.
41. Martinez BD, Wiegand CS, Evans P, Gerhardinger A, Mendez J. Computer-assisted instrumentation
during endoscopic transaxillary first rib resection for thoracic outlet sindrome: a safe alternate
approach. Vascular 2005; 13 (6): 327-335.
42. Ruotolo C. Arteriographie positionnelle de l ' insuffisance vertebro-basilaire hemodynamique. In
Kieffer E, Rancurel G, Koskas F (editors) Chirurgie de l ' Artere Vertebrale, Paris, Editions AERCV,
2001: pp 145-152.
43. Aziz S, Strachley CJ, Whealan TJ. Effort-related axillosubclavian vein thrombosis: a new theory of
pathogenesis and a plea for direct surgical intervention. AM J Surg 1986; 152: 57-61.
44. Filis KA, Nguyen TQ, Olcott C 4th. Subclavian vein thrombosis caused by an unusual congenital
clavicular anomaly in an atypical anatomic position. J Vasc Surg 2002; 36: 629-631.
45. Sanders RJ, Monsour JW, Gerber WF, Adams WR. Scalenectomy versus first rib resection for
treatment of the thoracic outlet syndrome. Surgery 1979; 85 (1): 109-121.
46. Naffziger HC, Grant WT. Neuritis of the brachial plexus mechanical in origin: the scalenus
syndrome. Surg Gynecol Obstet 1938; 67: 722-730.
47. Machleder HI. Role du muscle scalene anterieur dans les syndromes de la traversee thoraco-
brachiale. Paris, Editions AERCV, 1989: 69-79.
48. Parziale JR, Akelman E, Weiss AP, Green A. Thoracic outlet syndrome. Am J Orthop 2002; 29: 353-
49. Hicken GJ, Ameli FM. Management of subclavian- axillary vein thrombosis: a review. Can J Surg
1998; 41: 13-25.
50. Adelman MA, Stone DH, Riles TS, Lamparello PJ, Giangola G, Rosen RJ. A multidisciplinary
approach to the treatment of Paget-Schroetter syndrome. Ann Vasc Surg 1997; 11: 149-154.
51. Urchel HC, Razzuk MA. Paget-Schroetter syndrome: what is the best management? Ann Thorac Surg
2000; 69: 1663-1669.
52. Khan SN, Stansby G. Current management of Paget-Schroetter syndrome in the UK. Ann R Coll Surg
Engl 2004; 86: 29-34.
53. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous
thrombosis of the axillary-subclavian vein. J Vasc Surg 1993; 17: 305-315.
54. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg 2007; 46 (3):
55. Fugate MW, Rotellini-Colvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr
Treat Options Cardiovasc Med 2009; 11 (2): 176-183.
56. Desai Y, Robbs JV. Arterial complications of the thoracic outlet syndrome. Eur J Vasc Endovasc Surg
57. Bacquey F, Haman M, Coskun O. Rotational vertebrobasilar insufficiency secondary to a fibrous band
of the longus colli muscle: Value of CT spiral angiography diagnosis. J Radiol 2002; 83: 979-982.
58. Hardin CA, Poser CM. Rotational obstruction of the vertebral artery due to redundancy and
extraluminal cervical fascial bands. Ann Surg 1963; 158: 133-137.
59. Dadsetan MR, Skerhut HE. Rotational vertebrobasilar insufficiency secondary to vertebral artery
occlusion from fibrous band of the longus colli muscle. Neuroradiology 1990; 32: 514-515.
60. Sell JJ, Rael JR, Orrison WW. Rotational vertebrobasilar insufficiency as a component of thoracic
outlet syndrome resulting in transient blindness. Case report. J Neurosurg 1994; 81:617-619.
61. Kuether TA, Nesbit GM, Clark WM, Bamwell SC. Rotational vertebral artery occlusion. A mechanism
of vertebrobasilar insufficiency. Neurosurgery 1997; 41 (2): 429-433.
62. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc
Surg. Sep 2007;46(3):601-604.
63. Sanders RJ, Hammond SC, Rao NS. Thoracic outlet syndrome. A review. The Neurologist 2008; 14:
64. Axelrod DA, Proctor MC, Geiser ME, Roth RS,Greenfield LJ. Outcomes after surgery for thoracic
outlet syndrome. J Vasc Surg 2001; 33: 1220-1225.
65. De Georges R, Reynaud C, Becqnemier JD. Thoracic outlet syndrome surgery: long term functional
results. Ann Vasc Surg 2004; 18 (5): 558-565.
For consultation and investigation call: +370 698 88112
For surgery call the same phone number: +370 698 88112
Skype name: povilas.pauliukas
Inquiries by E-mail: firstname.lastname@example.org
More information on the internet at address: vascularsurgery.eu