Thoracic outlet syndrome occurs when the blood vessels or nerves in the thoracic outlet - the space between the neck and upper chest - become compressed. There are three potential spaces where compression can occur as these structures travel from the neck to the arm. Symptoms depend on whether the artery, vein, or nerves are compressed, and may include pain, numbness, coldness, or weakness in the arm. Physical exams like the Roos test, Adson's test, and costoclavicular test aim to reproduce the patient's symptoms and help diagnose thoracic outlet syndrome.
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Thoracic outlet syndrome
Neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area
The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein
Anatomy
Thoracic outlet
Entrance/ Exit region of the upper limb
The thoracic outlet is defined as the interval from the supraclavicular fossa to the axilla that passes between the clavicle and the first rib
Anatomy - Scalane triangle
Anatomy of the costoclavicular space
Pectoralis minor space
Located inferior to the coracoid process
anterior to the second through fourth ribs
posterior to the pectoralis minor muscle
The cords of the brachial plexus
Axillary artery
Axillary vein.
Soft-tissue Causes (70%)
Scalene muscle
Variations in insertion
Hypertrophy
Accessory scalenus minimus muscle
Anomalous ligaments or bands
Soft-tissue tumors
Osseous Causes
Cervical rib
Prominent C7 transverse process
Displacement or callus from first rib fracture
Malunited clavicle or first rib fracture
AC or SC joint injury or dislocation
Osseous tumor
Poor posture
Drooping the shoulders
Holding the head in a forward position
Repetitive activity
Athletes and swimmers
Neurogenic TOS
Compression – scalene triangle and costoclavicular space
May be associated with normal anatomy
Traction of the lowest trunk of the brachial plexus
Often in association with arterial TOS
Features of Lower brachial plexus compression - Common
Female predominance
Appearance of Amedio Modigliani painting
Complains of pain and paresthesia extending from the shoulder /down the ulnar aspect of the arm into the medial two fingers
Neurogenic TOS
Upper brachial plexus compression C5,C6 and C7
Less common
Compression mainly occurs in scalene triangle
Symptoms
Unilateral occipito-frontal headache
Facial or jaw pain
The Gilliatt-Sumner hand
A characteristic finding of neurogenic TOS, is described as atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei.
Venous TOS
Causes
Hypertrophy of the subclavius muscle,
Chondroma formation
Clinical presentation
Most patients are sportsmen, musicians or manual workers undertaking repetitive arm movements.
The condition occurs more commonly in the dominant limb
Male predominance
Clinical presentation
Acute presentation -
Swollen and tensed upper limb
Upper limb aching pain
blueish- purple arm due to venous engorgement
Collateral veins may be visible
Feeling of heaviness that is worse after activity
Symptoms are precipitated by working with the arms elevated and are relieved by dependency, a pathognomonic feature of vTOS.
Arterial TOS
Rare but has more devastating consequences
Caused by
Intermittent subclavian arterial compression - Costoclavicular compression with normal anatomy.
Management of peripheral vascular disease by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management of peripheral vascular disease . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Can read freely here
https://sethiortho.blogspot.com/
Thoracic outlet syndrome
Neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area
The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein
Anatomy
Thoracic outlet
Entrance/ Exit region of the upper limb
The thoracic outlet is defined as the interval from the supraclavicular fossa to the axilla that passes between the clavicle and the first rib
Anatomy - Scalane triangle
Anatomy of the costoclavicular space
Pectoralis minor space
Located inferior to the coracoid process
anterior to the second through fourth ribs
posterior to the pectoralis minor muscle
The cords of the brachial plexus
Axillary artery
Axillary vein.
Soft-tissue Causes (70%)
Scalene muscle
Variations in insertion
Hypertrophy
Accessory scalenus minimus muscle
Anomalous ligaments or bands
Soft-tissue tumors
Osseous Causes
Cervical rib
Prominent C7 transverse process
Displacement or callus from first rib fracture
Malunited clavicle or first rib fracture
AC or SC joint injury or dislocation
Osseous tumor
Poor posture
Drooping the shoulders
Holding the head in a forward position
Repetitive activity
Athletes and swimmers
Neurogenic TOS
Compression – scalene triangle and costoclavicular space
May be associated with normal anatomy
Traction of the lowest trunk of the brachial plexus
Often in association with arterial TOS
Features of Lower brachial plexus compression - Common
Female predominance
Appearance of Amedio Modigliani painting
Complains of pain and paresthesia extending from the shoulder /down the ulnar aspect of the arm into the medial two fingers
Neurogenic TOS
Upper brachial plexus compression C5,C6 and C7
Less common
Compression mainly occurs in scalene triangle
Symptoms
Unilateral occipito-frontal headache
Facial or jaw pain
The Gilliatt-Sumner hand
A characteristic finding of neurogenic TOS, is described as atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei.
Venous TOS
Causes
Hypertrophy of the subclavius muscle,
Chondroma formation
Clinical presentation
Most patients are sportsmen, musicians or manual workers undertaking repetitive arm movements.
The condition occurs more commonly in the dominant limb
Male predominance
Clinical presentation
Acute presentation -
Swollen and tensed upper limb
Upper limb aching pain
blueish- purple arm due to venous engorgement
Collateral veins may be visible
Feeling of heaviness that is worse after activity
Symptoms are precipitated by working with the arms elevated and are relieved by dependency, a pathognomonic feature of vTOS.
Arterial TOS
Rare but has more devastating consequences
Caused by
Intermittent subclavian arterial compression - Costoclavicular compression with normal anatomy.
what is TOS? What are classification of thoracic outlet syndrome? What are impingement sites? How to diagnose TOS? What is physical therapy management of TOS? How to make Differential diagnosis? What are DD's of TOS?
Thoracic outlet syndrome is a condition that involves compression of the nerves or blood vessels that pass through the base of the neck. This can lead to disabling pain in the neck and shoulder, as well as pain, numbness, tingling and weakness in the hands and fingers.Thoracic outlet syndrome (TOS) is a term used to describe a group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels (arteries and veins) in the lower neck and upper chest area. Thoracic outlet syndrome is named for the space (the thoracic outlet) between your lower neck and upper chest where this grouping of nerves and blood vessels is found.
Who is affected by thoracic outlet syndrome?
Thoracic outlet syndrome affects people of all ages and gender. The condition is common among athletes who participate in sports that require repetitive motions of the arm and shoulder, such as baseball, swimming, volleyball, and other sports.
Neurogenic TOS is the most common form of the disorder (95 percent of people with TOS have this form of the disorder) and generally affects middle-aged women.
Recent studies have shown that, in general, TOS is more common in women than men, particularly among those with poor muscular development, poor posture or both.
What are the symptoms?
Download a Free Guide on Thoracic Outlet Syndrome
The signs and symptoms of TOS include neck, shoulder, and arm pain, numbness or impaired circulation to the affected areas.
The pain of TOS is sometimes confused with the pain of angina (chest pain due to an inadequate supply of oxygen to the heart muscle), but the two conditions can be distinguished because the pain of thoracic outlet syndrome does not occur or increase when walking, while the pain of angina usually does. Additionally, the pain of TOS typically increases when raising the affected arm, which does not occur with angina.
Signs and symptoms of TOS help determine the type of disorder a patient has. Thoracic outlet syndrome disorders differ, depending on the part(s) of the body they affect. Thoracic outlet syndrome most commonly affects the nerves, but the condition can also affect the veins and arteries (least common type). In all types of TOS, the thoracic outlet space is narrowed, and there is scar formation around the structures.
Types of thoracic outlet syndrome disorders and related symptoms
Neurogenic thoracic outlet syndrome: This condition is related to abnormalities of bony and soft tissue in the lower neck region (which may include the cervical rib area) that compress and irritate the nerves of the brachial plexus, the complex of nerves that supply motor (movement) and sensory (feeling) function to the arm and hand. Symptoms include weakness or numbness of the hand; decreased size of hand muscles, which usually occurs on one side of the body; and/or pain, tingling, prickling, numbness and weakness of the neck, chest, and arms.
Venous thoracic outlet syndrome
thoracic outlet syndrome; one of the disorder affecting shoulder joint and neck movements due to limitation and pain. this slideshow describes about; the definition, types, causes and physiotherapy management for the same.
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MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
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Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
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Chemical basis and signal transduction mechanisms for each taste
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Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. Thoracic Outlet :
• 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.
5. • There are three potential spaces for compression of the neurovascular structures along their
course to the upper extremity.
• These spaces are as follows:
• (l) the interscalene space or triangle
• (2) the costoclavicular space
• (3) the subpectoralis minor space
6. Spaces :
• INTERSCALENE TRIANGLE ( most commonly involved)
Inferiorly : 1st rib
Ant : scaleneus anterior
Post : scaleneus medius.
• COSTOCLAVICULAR SPACE
Ant : clavicle, subclavius muscle
Post medial: 1st rib
Post lateral: superior border of scapula
• PECTORALIS MINOR SPACE
Anteriorly by Pectoralis minor and posteriorly by Chest wall
8. • The subclavian vein follows a similar course but does not pass through the
interscalene triangle.
• It courses just medial and anterior to the anterior scalene muscle and runs
inferior and lateral to the subclavius tendon and costocoracoid ligament
• The brachial plexus is located—superior , posterior, and lateral to the
subclavian artery.
• Artery, vein, and the brachial plexus follow a similar course after passing
under the clavicle and subclavius muscle.
9. CAUSES:
• Causes of thoracic outlet syndrome can be divided into BONY AND SOFT-
TISSUE FACTORS.
Bony factors are abnormalities such as:
• 1. Anomalous cervical ribs,
• 2. Hypoplastic first thoracic ribs,
• 3. Exostoses of the first rib or clavicle
• The incidence of anomalous cervical ribs is believed to be 0.17-0.74% in the
general population, and the incidence of rudimentary first ribs is 0.29-
0.76%
10. • SOFTTISSUE FACTORS :
• Congenital anomalies such as anomalous fibrous muscular bands near
the brachial plexus
2. Hypertrophic muscles in athletes and weight lifters.
3. Space-occupying lesions (e.g., tumors, cysts)
4. Inflammatory processes also occur in the soft tissues
5.Trauma or mechanical stress to the neck, shoulders, or upper extremities
can result in thoracic outlet syndrome.
• A combination of neck trauma and anatomic predisposition (i.e., cervical
rib) is believed to be the main cause of thoracic outlet syndrome.
11. Post-traumatic conditions such as:
1. Hematoma,
2. Myositis ossificans
3. Scar formation,
4. A droopy shoulder secondary to trapezius muscle weakness
5.Thoracic outlet syndrome can be due to malunion of a clavicle fracture
13. • Dynamic factors. When the arm is in full hyperabduction above the head, the
axillary artery is bent 180, thus pulling the vessel across the coracoid and
head of the humerus
• The clavicle rotates and narrows the retroclavicular space.
14. • Static factors.
• Vigorous occupations may result in increased muscular bulk, thereby
reducing the space through which artery, vein, and nerves must pass.
• Inactive middle-aged adults lack muscle mass and tone,
sagging shoulders,
angulate ,compress the neurovascular structures.
15. • Anatomic predispositions/congenital factors.
• secondary role in etiology.
• Congenital bands and ligaments are observed in a large majority of
patients with neurogenic thoracic outlet syndrome (nTOS),
• A cervical rib, will encroach on the interscalene interval and the
retroclavicular space.
16. • The first rib
bifid present a bony protuberance,
• the clavicle may present an anomaly such as reduction of its anterior
curvature
• All these may encroach on the space between the first rib and the clavicle
18. Venous compromise
• Edema
• Venous distension
• Collateral formation
• Cyanosis
Neural compromise
• Paraesthesia
• Pain in shoulder, arm, forearm and fingers
• Occipital headache – referred from tight
• Weakness of forearm, hand.
19. • The classic finding in a person with neurogenic thoracic outlet syndrome is the
Gilliatt-Sumner hand.
• This physical examination finding includes atrophy of the abductor pollicis brevis
with lesser involvement of the interossei and hypothenar muscles.
• Patients may also have decreased sensation that follows the ulnar nerve
distribution because the lower trunks of the brachial plexus are usually more
involved than the upper trunks
20.
21. • The maneuvers used to detect the arterial compressions involved inTOS are the
Hyperabduction maneuver, orWright's test, (subcoracoid tunnel or retropectoralis
space),
• The Adson test (interscalene triangle) and
• Costoclavicular interval maneuver (between the clavicle and the first rib);
• However, none of these tests have been accepted as the gold standard for
diagnosis and they offer 53% mean specificity and 72% mean sensitivity.
22. Clinical tests :
RoosTest :
RoosTest is a common test included in the examination of the shoulder, specifically for
the presence ofThoracic Outlet Syndrome (TOS).
• It is also knows as the EAST (Elevated Arm StressTest)Test or the Hands UpTest.
Involved Structures
subclavian artery
brachial plexus
Starting Position
• In this test, the patient raises their arms to 90 degrees of abduction in the frontal plane
of the body with the arms fully externally rotated and the elbows at 90 degrees of
flexion.
23. Test Movement
• The patient opens and closes their hands for up to 3 minutes.
PositiveTest
• The test is considered positive if the patient is unable to hold the arms up
for the 3 minutes, or if the patient experiences pain, heaviness or
parasthesia in the shoulder, arm or hands.
24. Results if normal:
Only forearm muscle fatigue and minimal distress
Possible symptoms ifTOS is present:
• gradual increase in pain at neck and shoulder, progressing down the arm
• Paraesthesia in forearm and fingers
25. In case of arterial compression: arm pallor with arm elevated,
reactive hyperemia when limb is lowered
In case of venous compression: Cyanosis and swelling
• Inability to complete test, and patient drops arms in lap in
marked distress, recognized as reproduction of usual symptoms
• Reproduction of the usual symptoms that involve the entire
extremity!
26. ADSONTEST :
• The examiner locates the radial pulse in the affected arm of the seated patient.
• The patient is asked to rotate the head toward the affected side and to extend the head and
neck back.
• The shoulder and upper extremity is externally rotated and extended.
• Other versions of the test allow the arm to rest on the patient’s thigh or have it elevated as if
swearing under oath.
• The patient is asked to take a deep breath and hold it while the examiner continues to
monitor the patient’s pulse.
27. • The suggested mechanism of Adson’s test is that it
increases the tension of the scalene muscles
potentially compressing the neurovascular
bundle in a soft tissue tunnel or over a cervical rib.
• Historically, it has been associated with subsets of thoracic outlet
syndrome, such as scalenus anticus/anterior syndrome or cervical rib
syndrome.
28. A positive test
possible compromise of the neurovascular bundle somewhere
along its course through the thoracic outlet.
• positive test also suggests that the scalene muscles should be assessed
for hypertonicity and trigger points.
• It would be reasonable to pay special attention to scalene muscle
assessment.
29. • Positive test results can be seen as being on a continuum:
loss of pulse is the least
specific finding (and the
most likely to be positive
even in asymptomatic
subjects),
production of
paresthesia,
the most specific finding
which is pain production
in the upper extremity.
Reproduction of the patient’s familiar symptoms may be considered even a stronger positive
30. AllensTest
• The arm is passively elevated and the patient rapidly clenches his/her fist several times (3-5 times).
• Another option, found in the original description of the test, is to continue pumping for a full
minute.
• With the patient’s fist still clenched, the examiner compresses both radial and ulnar arteries of the
wrist
• The arm is then brought into a dependent position, the fist is opened, and one artery or the other
is released.
31. • Interpretation
• < 5-second refill time is considered normal.
• 6- to 15-second refill time is considered equivocal.
• >15-second refill time is considered abnormal.
• Evans (2001) suggests that an incidental finding of paresthesia may suggest an underlying
distal nerve entrapment such as carpal tunnel syndrome.
32. Costoclavicular test :
• Procedure
• Patient is sitting in neutral posture.
• The examiner palpates radial pulses
• The examiner extends the patient’s arms, then instructs the patient to “adopt an exaggerated
military posture with shoulders back and down and chest out.”
33. • An optional step is to instruct the patient to stick his/her chin out and neck forward or,
alternatively, flex the neck down.
• The patient takes in a deep breath, holds it and bears down.
• The position is held anywhere from 30 seconds
• The test can also be performed bilaterally.
• At each step, the examiner evaluates for change in pulse amplitude and reproduction of
symptoms.
• A positive test would be symptoms of upper limb neurovascular compression, such as cessation
or dampening of radial pulse with reproduction of symptoms, ischemic color changes (e.g.,
pallor, blanching), paresthesia or extremity pain
34. Halstead Maneuver (Reverse Adson’s)
• With the patient seated, the examiner locates
the radial pulse of the affected arm and notes
the amplitude.
• Then the examiner applies downward traction
on the patient’s extremity.
• The examiner directs the patient’s head into
• hyperextension and rotation away from the side
being tested.
• The patient is asked to take a deep breath and
hold it
• while the examiner continues to monitor the
patient’s pulse.
35. • A positive test suggests possible compromise of the neurovascular bundle somewhere along
its course through the thoracic outlet.
37. • If the examiner does not use enough shoulder extension keeping the arms posterior to the
patient’s ears along with abduction, then false negative results may occur.
38. Investigations
• To exclude systemic disease and inflammation
• blood glucose level, complete blood cell (CBC) count, erythrocyte sedimentation
rate (ESR), basic metabolic panel, thyrotropin level, and rheumatologic workup,
if indicated
39. I:
• Cervical spine x-ray films for assessment of arthritic or degenerative changes and presence
of cervical ribs.
• Chest x-ray film to identify apical lung pathology and superior sulcus tumor.
• Nerve conduction studies and electromyography to delineate the possible significance of
neuroforaminal or cervical disc disease, as well as median nerve compression at carpaltunnel
or ulnar nerve compression at the cubital tunnel.
• .
40. • Duplex scanning of subclavian artery and vein may reveal an aneurysm
orVenous thrombosis and may provide some anatomic information
before angiography.
41. • Arteriography:- It is performed only when the patient is suspected of
having arterial complication of thoracic outlet syndrome such as
supraclavicular bruit, a pulsatile mass or vascular symptoms and signs of
upper limb thromboembolism.
• Venography:- It can diagnose subclavian vein thrombosis or stenosis at
the level of first rib and status of the collateral circulation.
42. • Arteriography may reveal an angulation or stenosis of the subclavian or
axillary artery, aneurysmal widening of the artery beyond the point of
narrowing, and points of embolic occlusion,
• When venous obstruction is suspected, venography is confirmatory.
.
43. • A subclavian arteriography often demonstrates constriction of the artery
between the clavicle and the first rib when the arm is hyperabductcd.
• This finding is common in many asymptomatic people and is significant
only when correlated with other findings.
44.
45. Nerve Conduction Studies :
• . The brachial plexus is stimulated at Erb's point in the supraclavicular
fossa.
• Erb's point is at the angle formed by the clavicle and the
posterolateral fibers of the sternocleidomastoid muscle.
• The pickup electrode is placed over the ulnar nerve or median nerve at
the elbow.
• The mean velocity Of the median nerve is 62.8 msec and that of the ulnar
nerve is 58.4 msec.
• Compression at the thoracic outlet will substantially reduce the motor
nerve conduction velocity within this nerve segment.
46. Treatment :
• In majority of pts conservative management will effect in improvement or
complete relief of symptoms
• Initial management consists of
• Weight reduction
• Exercise programme directed towards improving posture , strengthening
shoulder muscles and avoiding hyperabduction
47. Exercises :
• Stand facing a corner of the room with one hand on each wall, arms at the shoulder level, palms
forward,elbows bent, and abdominal muscles contracted.
• Slowly let the upper part of the trunk lean and press the chest into the corner.
• Inhale as the body leans forward.
• Return to the original position by pushing out both the hands.
• Exhale with this movement.
48. • Lie down on the back with the arms at the sides and a rolled towel or a small pillow under the
upper part of your back, between the shoulder blades.
• There should not be a pillow under your head.
• Inhale slowly and raise the arms upward and backward overhead.
• Exhale and lower the arms to the sides.
• Repeat 5-20 times
49. • Stand erect with the arms at the sides.
• Bend the neck to the left attempting to touch the left ear to the left shoulder without
shrugging the shoulder.
• Bend the neck to the right attempting to touch the right ear to the right shoulder without
shrugging the shoulder.
• Relax and repeat
50. Exercises :
Stand erect with the arms at the sides holding in each hand a 2-pound weight Shrug the
shoulders forward and upward.
• Relax.
• Shrug the shoulders backward and upward.
• Relax.
• Shrug the shoulders upward.
• Relax and repeat.
Stand erect with the arms out straight from the sides at the shoulder level; hold a 2-pound
weight in each hand (palms should be down).
• Raise the arms sideways and up until the backs of the hands meet above the head (keep elbows
straight).
• Relax and repeat.
51. Cervical Rib:
• The cervical rib is a supernumerary rib that arises usually from the seventh and rarely
from the sixth or fifth cervical vertebrae.
• It is frequently bilateral.
52. • PATHOLOGIC ANATOMY
• Whether the rib is full developed or represented by a fibrous band, the
brachial plexus and the subclavian artery must pass over a higher barrier
before passing downward to the arm . The neurovascular structures are
hung up.
• In addition, the cervical rib or band inserts anteriorly at or near the
scalene tubercle, thereby narrowing the interval through which nerves
and artery pass.
• At the point of insertion, the tubercle on the first thoracic rib may
become enlarged and add to the compression and friction.
53. • Plexus and artery are further embarrassed when they are pulled distally
by downward traction on the arm, such as when carrying a heavy weight.
• Normally, with advancing age, the shoulder girdle droops downward and
increases tension on the neurovascular structures.
54. • Pronounced drooping of the shoulder occurs in
women of middle age,
in the course of unusual lifting occupations,
and following an acute illness when muscle weakness develops.
• This explains the frequency of symptoms in these situations.
55. prolongation and
pointing of the
seventh cervical
transverse process
type 2, short
articulating rib
with fibrous
prolongation
type 3, jointed rib
long enough to carry
the eighth cervical
nerve
The classification proposed by Sargent
56. type 4, jointed rib fused
at its end withthe first
rib or articulating with
it
type 5, a complete seventh
cervical rib with
cartilaginous union to the
first costal cartilage or to the
manubrium
57. Symptoms :
• CLINICAL PICTURE
• Symptoms can occur at any age but are often initiated under conditions
effecting descent of the shoulder girdle.
• Symptoms and findings are characteristically ulnar in distribution, pointing
to the lower trunk of the plexus.
• Complaints referable to the median nerve distribution usually implicate a
ruptured cervical disc.
58. • Pain and paresthesias occur in the ulnar aspect of the hand and the little and
ring fingers.
• Less commonly, they may be felt in the whole hand.
• The pain may be dull and aching or sharp and lancinating.
• A sensation of tingling of the forearm and the hand, which the patient
describes as "falling asleep," is ascribed to circulatory deficiency and is
associated with diminution of the radial pulse.
59. • The patient complains of weakness of the hand, clumsiness in use of the
fingers, and dropping of objects.
• Symptoms are accentuated by downward displacement of the shoulder
girdle (e.g. when carrying a heavy object or following the fatigue brought
on by excessive activity).
• Adson's sign intensifies the symptoms by increasing tension on the
scalenus anterior and narrowing the rib-muscle interval.
60. SCALENUS ANTICUS SYNDROME
• Cervicobrachial compression can occur in the interval between the scalenus
anterior and the scalenus medius in the absence of a cervical rib
i. Wide Insertion
ii. Bony Prominence on insertion
iii. Tendon edge extending either forward or backward
61. • Similar to cervical rib
• lowermost trunk of the plexus receives the greatest amount of
compression, the neurologic symptoms are referred to the C8 andTl nerve
root
• AdsonsTest
62. HYPERABDUCTION SYNDROME
• The main vessels and the brachial plexus are subject to stretching and
compression at 2 points
where they pass beneath the coracoid process posterior to the
pectoralis minor.
The Second point of
pressure is between
Clavicle and First
rib(CostoClavicular
Syndrome)
63. • These structures are relaxed in adduction but are stretched about the
coracoid in hyperabduction
• Strong contraction of the pectoralis minor will pull the coracoid
downward and similarly stretch the vessels and the nerves
64. Symptoms :
• Numbness and paresthesias are noticed first in the fingers and progress
centripetally to involve the hands and the arms.
• Pain is not a prominent feature.The pulse is obliterated in the
hyperabducted position.
• Occasionally, gangrene of the tips of the fingers may develop.
• AllensTest
• Wright Hyperabduction test
• Costpclavicular compressionTest
• 1st Thoracic rib excision and Pectoralis minor tenotomy
65. • Occlussion of mainartery with insufficient collateral circulation
Recurring ulcerations,Gangrene
67. Surgery :
• Indications:
• Symptoms persists with non operative treatment.
• Associated vascular compression.
• Progression of neurological symptoms.
• Nerve conduction velocity < 60m/s
• Absolute Indications:
• Expanding post-stenoticArterial Dilatation
• Embolic phenomenon in the distal extremities
• Complete Occlusion of large artery
• Specific Acquired compressive structure (malunion of clavicle )
68.
69. Supraclavicular approach Transaxillary approach Infraclavicular approach Posterior approach
best route to reach all
the structures
excellent cosmesis provides excellent access to
the costoclavicular space for
first rib resection
adopted when there is
history of
previous Operation by other
approach
direct visualization of the
anatomic
relationship between bony
and myofascial structures
readily palpable and easily
visible ligaments and bony
structures
Subclavian venous
thrombosis and
first rib excision.
brachial plexus through
scalene space in the thoracic
outlet
allows access for dorsal
sympathectomy
cosmetic results are less
favourable
congenital anomalies along
with access to the first rib
and
clavicle.
Sub optimal view of surgical
field
Vascular reconstruction
possible
70.
71.
72.
73.
74.
75.
76.
77.
78.
79. Trans axillary approach :
Transaxillary incision is performed
through 2nd intercoastal space
84. • VATS first rib resection forTOS provides,
• unlike the classic approaches, a superior, magnified, and well-illuminated
view of the thoracic inlet.
• It allows good posterior trimming of the first rib, release of brachial plexus,
and an aesthetically pleasing result, especially in female patients
• Totally Endoscopic (VATS) First Rib Resection forThoracicOutlet Syndrome
• Presented at the GeneralThoracic Surgical Motion Picture Matinee of the Fifty-second
Annual Meeting ofThe Society ofThoracic Surgeons, Phoenix,AZ, Jan 23–27, 2016.
85. • Following intubation with double lumen tube,
• patients are placed in the lateral decubitus position with the arm abducted to 90 degrees and
held by a traction strap wrapped carefully around the forearm and attached to an overhead bar.
• The third to fifth ribs are marked and two 10-mm working ports are placed in the anterior third
and the lateral fourth intercostal spaces in alignment with the anterior axillary line to facilitate
conversion in case of bleeding.
• The third scope port is placed laterally in the fifth intercostal space .
• .
86. • While on single lung ventilation, the first rib is identified
• the parietal pleura and periosteum overlying it are stripped off using the harmonic scalpel
• Using the harmonic scalpel, both intercostal muscles are separated from the rib and the
scalenae muscles are dissected
• The first rib is then transected anteriorly near the costochondral junction and posteriorly as
close to the transverse process as possible using the modified endoscopic rib cutter
• The neurovascular bundle is gently retracted using a peanut to allow sliding of the edge under
the rib.
• Once the rib is engaged in the cutter’s groove the peanut is removed and the blade is
introduced to cut the rib
• Once the rib is cut it is removed through one of the ports