thoracic outlet syndrome

1. THORACIC OUTLET
SYNDROME
Alfredo Dente

2. Classification
• Arterial
• Venous
• True Neurogenic
• Non-specific Neurogenic (disputed)
Vascular type accounts for 10% of all TOS cases
True Neurogenic type accounts for 5%
Non-Specific type accounts for 85%

3. Causes of TOS
Ault et al (1998)
Osseous
Trauma
• Fractured first rib
• Fractured clavicle
Congenital
• Abnormal or anomalous
first rib
• Cervical rib
• Elongated transverse
process C7
Soft Tissues
Trauma
• Scalene (anterior and
medius) muscle injury
Congenital/ Acquired
• Cervical ligaments &
bands
• Anomalous Scalene
muscles insertions
• Scalenus minimus muscle
• Pectoralis Minor tightness

4. Brachial Plexus

5. Sites of compression

6. Sits of compression cont.

7. Non-specific Neurogenic TOS
Symptomatology
• Pain (dull, aching feeling)
• Paresthesia (C8-T1deep arm pain,chest )
• Weakness (hand, muscle atrophy)
• Dysfunction (movement, postural)
NO OBJECTIVE FINDINGS
• NORMAL X-RAY
• NORMAL NCV TEST

8. Differential Diagnosis
• RA
• Angina
• Pancoast Tumor
• Hypothyroidism
• Spinal Cord lesion
• GH jt. Instability or Impingement
• Cx Deg. Disease
• Cx Radiculopathy
• Myofascial System referred pain
• Peripheral Nerve entrapment (CTS)

9. Diagnostic Methods
Provocation and diagnostic tests
Provocation tests
• Wright (costoclavicular space
compression), 92% false
positives (Oates et al 96)
• Roos or EAST (vascular
insufficiency), 74% false
positive 92% on CTS patients
(Oates et al 96)
• Adson (Scalene ant.entrapment)
most effective when used with
Ross test
(Gillard et al 01)
Diagnostic tests
• Plain X-Ray
• NCV (validity disputed)
(Ault et al 98,Gillard et al 01,
Roos 99)
• Doppler US
• Helical 3D CT
NON OF THE ABOVE TESTS
CAN BE USEFUL TO
DIAGNOSE NON-SPECIFIC
or DISPUTED TOS

10. Non-Specific N. TOS
Clinical Presentation
Progressing, light, occasional, nocturnal or
positional paresthesia in the arm and hand, to
incapacitating pain with disuse and weakness with
possible atrophy in the intrinsic muscles of the
hand with decrease sensation in the ulnar n.
distribution.
Roos (1999)
Not known mechanisms and manifestation behind
the progression
Wilbourn (1999)

11. Physical Examination
• Main goal to rule out mimicking pathologies
especially malignancy and facilitate differential
diagnosis if possible
All findings have to correlate, including available
objective investigations in order to implement a
plan of intervention if it is indicated, to restore
homeostasis.
Elvey, O’Sullivan (2002)

12. SURGICAL MANAGEMENT
• Cervical rib resection
• Scalenotmy
• Scalenectomy
• First rib resection
• Excision of anomalous fibrous band
• Claviculectomy
• Combinations of the above
Transaxillary first rib resection and cervical
scalenectomy are considered the most popular and
standard procedures.

14. Surgical Management
• Franklin et al (2000) study> surgical group had 50% higher medical
costs and 3>4 times likely to be work disabled
• Axelrod et al (2001) f/u 47 months (average) 65% reported improved
symptoms, 35% remained on medication and 18% were disabled
Socioeconomics status was found to be related to outcomes
• Landry et al (2001) f/u 4.2 years fifteen pt.s first rib res. 64 pt.s had
conservative Rx> no significant difference with most patients returned
to work and improved symptoms at long-term f-u. The patients who
had surgery did not improve functional outcome.
• Lindgren (1997) examined conservative Rx (home ex.s) in 119
patients f/u 24.6 months > 88% satisfied with outcome, 73% returned
to work although often successfully if sedentary rather then heavy.

15. Conclusions
• Unclear whether or not we can use non-specific
neurogenic TOS as a diagnosis
• Unclear what are the pathological mechanisms
causing this “pain syndrome”
• Validity of surgical and conservative treatment to
be reevaluated through more studies
• Thorough and comprehensive P/E to facilitate
differential diagnosis at early stages is
recommended.