This document describes a case of thoracic outlet syndrome caused by a cervical rib in a 22-year old male patient who presented with numbness, pain, discoloration, and swelling in his right arm. Imaging revealed a cervical rib compressing the brachial plexus. The patient underwent surgery to remove the cervical rib, which relieved his symptoms. The document then provides an overview of thoracic outlet syndrome, including its causes, types, symptoms, diagnostic techniques like physical exams and imaging, and treatment options like physical therapy, medications, and surgical decompression.

1. Thoracic Outlet Syndrome
Muhammad Ammar Shafique
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

2. Case Presentation
• 22 years old male presented in emergency
department with
Following Complaints :
Numbness of right hand and forearm from
last 2 weeks
Pain right hand and forarm
Discoloration of right hand and forearm
Swelling of right hand and forearm

3. Non smoker
Family history of IHD and Dibetes Mellitus

4. Examination
• Radial and brachial pulses were palpable in
left arm but absent in right arm
• Capillary refill was more than 2 seconds in
right hand.
• Distal pahlanges were cyanosed.
• Hypothermia.
• Sensory and motor system were intact.
• Left hand was normal.

5. Workup
• Doppler Scan showed thrombosed brachial
artery at midarm.
• Normal CBC ,caogulation profile,LFT’s, RFT’s.
• ECG was normal.

6. • Embolectomy was done in emergency
operation theater. Thrombus was removed
from brachial artery.
• Patient was admitted in ward.
• Clexane and analgesics were given.
• Despite embolectomy patient arm was still
cold ,pale and radial and brachial pulses were
absent.

8. Workup
• CT Angiogram
Showed Partial thrombosis of brachial artery
with absent contrast.
Distal subtle opacification of radial artery
noted which is because of collateral flow.
Ulnar artery seen opacified in its entire
course.No evidence of external compression
seen.

9. • X-RAY Thoracic Inlet
Showed right sided cervical rib
Which was the actual cause of all his
symptoms

10. X-ray Thoracic Inlet

11. X ray Cervical Spine

12. Treatment
• Surgery was planned
• Supraclavicular approach
• Cervical rib was identified and divided
• Compression was relieved
• Patient symptoms were settled
• Discharged on anticoagulants and analgesics

13. Thoracic Outlet Syndrome
• History
• Galen – 2nd century – first description of
cervical ribs in medical literature
• Vesalius – 1543 – Belgian anatomist described
cervical ribs
• Gruber – 1842 – 4 types of cervical ribs
• Coote - 1861 – first cervical rib resection
• Paget – 1875 – subclavian vein thrombosis

14. • Peet – 1956 – “thoracic outlet syndrome”
• Clagett – 1962 – posterior approach to first rib
resection
• Roos – 1966 – transaxillary first rib resection
• Gol – 1968 – infraclavicular approach

15. TOS
Combination of anatomic anomalies, physical
activities, and life events
• Constellation of upper extremity symptoms
• Compression of neurovascular bundle at
thoracic outlet
– Brachial plexus (C5-T1)
– Subclavian vein
– Subclavian artery

16. Anatomy
• Scalene triangle
• Costoclavicular space
• Pectoralis minor space

17. Anatomic Variations
• Scalene Muscles
– Wide vs narrow triangle
– Congenital bands/ligaments
• Cervical ribs
– Incidence 0.74%
– Female:male ratio 7:3
– Complete vs incomplete
– More common on left
• Anomalous 1st ribs
– Incidence 0.76%
– Equal occurrence in men and women

18. Epidemiology
• 20-50yo
– <5% teenagers
– 10% over 50
– Rarely >65
• 70% female
– 70% cervical ribs occur in females

19. Types of TOS
• Neurogenic TOS – 95%
– Most difficult to diagnose and treat
• Venous TOS – 2-3%
• Arterial TOS - <1%

20. Neurogenic TOS
– Etiology
– Hyperextension neck injury (whiplash)
– Repetitive stress injuries (typing, assembly lines)
– Falls on slippery floors/ice

21. Neurogenic TOS
• Predisposing Factors
– Scalene muscle anomalies
– Narrow scalene triangles
– Congenital ligaments/bands
– High plexus roots
– Cervical ribs

22. Neurogenic TOS
• Symptoms
– Pain, parasthesias, numbness, weakness
– Throughout affected hand/arm
• Not necessarily localized to peripheral nerve distribution
– Extension to shoulder, neck, upper back not
infrequently
– “Upper plexus” disorders – radial and
musculocutaneous nerve distributions
– “Lower plexus” disorders – median and ulnar nerve
distributions

23. Neurogenic TOS
• Symptoms
– Occipital headaches
– Perceived muscle weakness
• Actual weakness and atrophy are rare
– Vasomotor symptoms
• Vasospasm, edema, hypersensitivity

24. Venous TOS
• Etiology
– Developmental anomalies of costoclavicular space
– Repetitive arm activities – throwing, swimming,
overhead activities

25. Venous TOS
• Predisposing Factors
– Relationship of vein to subclavius tendon and
costoclavicular ligament
– Dimensions of costoclavicular space
• Repetitive trauma to vein causing fibrosis,
stenosis, thrombosis

26. Venous TOS
• Acute occlusion
– Pain
– Tightness
– Discomfort during exercise
– Edema
– Cyanosis
– Increased venous pattern
– Tenderness over the axillary vein
– Gangrene

27. Venous TOS
• Physical activities
– Lifting or pulling heavy objects, basketball,
baseball, painting, tennis, raquet ball, football,
golf, wrestling, weightlifting, scrubbing, shoveling
snow, swinging rifle
• Up to 40% had residual symptoms after
treatment

28. Arterial TOS
• Etiology
– Cervical or anomalous first rib
– Anomalous anterior scalene insertion

29. Arterial TOS
• Pathophysiology
– Arterial compression resulting in post-stenotic
dilatation or aneurysm
– Distal embolization of thrombus

30. Arterial TOS
• Symptoms
– Digital or hand ischemia
– Cutaneous ulcerations
– Forearm pain with use
– Pulsatile supraclavicular mass/bruit

31. Diagnosis
• “the most accurate diagnosis of TOS…must
rely on a careful history and thorough,
appropriate physical examination”
• No single diagnostic test has sufficient
specificity to prove or exclude the diagnosis

32. Physical Exam
• Pulse exam
• Listen for bruits
• Edema/cyanosis/collateral veins
• Tenderness over scalene muscles (trigger
points) or pectoralis minor
• Reduced sensation to very light touch in
fingers
• Provocative maneuvers

33. Adson Test
• With the patient seated, arms at the sides, the
radial pulse is palpated and the examiner
listens for bruits above the clavicle
• Elevate arm and turn the chin both toward
and away from the involved side
• A positive test results in diminished radial
pulse, bruit, and numbness and tingling
• Up to 50% of healthy volunteers have a
positive test – unreliable for diagnosis of TOS

34. EAST
• Elevated arm stress test
• Most accurate clinical test (Roos)
• Hold “surrender” position for 3 minutes while
opening/closing hands

35. EAST
• nTOS
– Heaviness, progressive weakness, numbness
– Tingling in fingers, progressing up arm
• vTOS
– Cyanotic arm with distended forearm veins
• aTOS
– Ischemic, cramping pain

36. Upper Limb Tension Test
• Positive response indicates compression of
cervical roots or brachial plexus
• Negative response is usually adequate to rule
out nTOS

37. Imaging
• Xrays
– Cervical rib
– Elongated C7 transverse process
– Hypoplastic 1st rib
– Callous formation from clavicle or 1st rib fracture
– Pseudoarthrosis of 1st rib
• Unable to image soft tissue anomalies and
fibromuscular bands – seen only at time of
surgery

38. Imaging
• CT/MRI usually negative but can rule out other
pathologies
• MR neurography – newer technology to
detect localized nerve function abnormality

39. Imaging
• aTOS
– Segmental arterial pressures
– Angiography
• vTOS
– Duplex U/S
– Venography
• Use positional maneuvers during the studies
• Consider bilateral studies

40. EMG/NCS
• Positive results
– Aid in evaluation of other conditions
– Poor prognostic factor if truly nTOS – indicate
advanced neural damage
• Negative results
– Exclude other conditions
– May still be nTOS

41. Scalene muscle block
• Most useful when diagnosis is unclear
• Correlation between relief of symptoms after
block and successful outcome after surgical
decompression

42. Treatment nTOS
• Physical therapy
– Therapist must have experience in evaluation and
treatment of nTOS
– 20-30% of patients respond, do not require
surgical treatment

43. Treatment nTOS
• Neck stretching
• Posture correction
• Avoid neck traction, weights, resistance
exercises, strengthening exercises

44. Treatment nTOS
• If no improvement after several months
– Live with symptoms
– Surgical decompression

45. Treatment vTOS
• Catheter-directed thrombolysis
• Anticoagulation
• Surgical decompression with intraoperative
venography and subclavian vein
PTA(percutaneous transluminal angioplasty)

46. Surgical Treatment
• Transaxillary approach
– Advantages
• Limited field of operative dissection
• Cosmetically placed incision
• Sufficient exposure (for 1 person)
• Achieve 1st rib resection and anterior scalenectomy
• Removal of anomalous ligaments and fibrous bands
– Disadvantages
• Incomplete exposure of entire scalene triangle
• Difficulty achieving brachial plexus neurolysis
• Limited if vascular reconstruction is needed

47. Surgical Treatment
• Supraclavicular approach
– Advantages
• Wide exposure of all anatomic structures
• Permits complete resection of anterior and middle
scalenes as well as brachial plexus neurolysis
• Allows resection of cervical ribs and anomalous 1st ribs
• Vascular reconstruction is possible

48. Surgical Treatment
• Adjunctive procedures
– Pectoralis minor tenotomy
– Cervical sympathectomy

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

50. Outcomes
• No difference in long term results between
the 2 approaches
• No difference in outcome based on
– Presence of any particular provocative test results
– Experience of operating surgeon
• Predictors of ongoing disability
– Amount of work disability preop
– Longer intervals between injury and diagnosis
– Older age at time of surgery

51. Outcomes
• Associations between preexisting
psychological factors and socioeconomic
characteristics have been examined
• Independent risk factors associated with
persistent disability
– Major depression
– Single

52. Outcomes
• Results vary by etiology of symptoms
– Failure in 42% with symptoms after a work-related
injury or repetitive stress
– Failure in 26% with symptoms after auto accident
– Failure in 18% with nonspecific etiology

53. Conclusion
• “A surgeon recognizing nTOS should not be
dissuaded by the impression that these
problems are frequently associated with
psychiatric overtones, dependency on pain
medications, and ongoing litigation”

54. THANK YOU