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Thoracic outlet syndrome
- 1. THORACIC OUTLET SYNDROME Anything that narrows Costoclavicular space
- 2. DEFINITION Thoracic outlet syndrome(TOS)- a collection of symptoms brought about by abnormal compression of the neurovascular bundle by bony, ligamentous or muscular structures in the narrow space between clavicle and 1st rib – the thoracic outlet.
- 3. Thoracic outletis bounded Anteriorly: Manubrium Sterni Posteriorly: Spine Laterally: First Rib
- 6. ANATOMY • The thoracicoutlet is composed of five successive spaces the vascular and nervous elements go through : o The inter costo scalenic defile o The prescalenic defile o The costoclavicular space o The sub-pectoral tunnel o The humeral space
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- 10. Cervico axillarycanal divided into PROXIMAL COSTOCLAVICULAR SPACE DISTAL AXILLA.
- 11. Costoclavicular spaceis bounded by Superiorly: Clavicle Inferiorly: First Rib Antero medially: Costo clavicular Ligament Postero laterally: Scalenus medius muscle
- 13. Scalenus Anticusmuscle divides costoclavicular space into 2 compartments Anteriorly: Subclavian vein Posteriorly: Subclavian Artery and Brachial Plexus Posterior compartment is called Scalene triangle bounded Anteriorly: Scalenus Anticus Posteriorly: Scalenus Medius Inferiorly: 1st Rib
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- 18. Pectoralis minor muscleand coracoid process
- 19. First clinical descriptiongiven by A.Cooper 1821 W H Willshire described about cervical rib H Coote first resection of cervical rib. In 1956 Peet introduced the term thoracic outlet syndrome.
- 20. contents • viscera – thymus –trachea – oesophagus – lung apices • vessels, nerves and lymphatics – common carotid arteries – confluences of internal jugular and subclavian veins – phrenic nerves – vagus nerves – recurrent laryngeal nerves – thoracic duct • prevertebral fascia • muscles – sternocleidomastoid muscle – anterior and middle scalene muscles – sternohyoid muscle – sternothyroid muscle
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- 22. • Race No racialpredilection exists. • Sex Thoracic outlet syndrome is traditionally more common in women than in men, with a female-to-male ratio as high as 3:1. • Age Thoracic outlet syndrome is most common in people aged 10-50 years
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- 24. Subgroup 1 -(neurologic) –95% of cases This type is secondary to compression of the brachial plexus caused by various soft tissue and bony abnormalities at the point where the nerves pass between the anterior and middle scalene muscles
- 25. Subgroup 2 -(venous type) 3-4% of cases. Venous thrombosis may be categorized into primary and secondary thrombosis based on the etiology. Primary venous thoracic outlet syndrome, or primary venous thrombosis, is also called Paget-Schrötter syndrome named after the 2 individuals who first described this entity: Paget, who described it in 1875, and von Schrötter, in 1884.
- 26. Subgroup 3 (arterialtype): 1-2% of cases. This type is associated with the most serious complications, including limb ischemia (which may result in the loss of the affected upper extremity).
- 27. Neurogenic TOS Etiology Hyperextensionneck injury (whiplash) Repetitive stress injuries
- 28. Predisposing Factors Scalenemuscle anomalies Narrow scalene triangles Congenital ligaments/bands Cervical ribs
- 29. Pathophysiology Neck traumastretches and tears scalene muscle fibers Swelling of muscle belly pain, parathesias, numbness, weakness Scarring/fibrosis of muscle belly occipital headaches.
- 30. Symptoms Pain, parathesias,numbness, weakness throughout affected hand/arm Not necessarily localized to peripheral nerve distribution Extension to shoulder, neck, upper back Upper plexus” disorders “Lower plexus” disorders Occipital headaches Perceived muscle weakness Actual weakness and atrophy are rare Vasomotor symptoms Vasospasm, edema, hypersensitivity (CRPS)
- 31. Neurologic compression Pain and/or parasthesia of the neck, shoulder region, arm or hand, depending on the root involved Often bilateral Difficulty with fine motor tasks of the hand Examination reveals :sensitive disorders muscle weakness muscle atrophy (long fingers flexors) Palpation of subclavicular area may cause pain
- 32. Pectoralis minor syndrome Compression of neurovascular bundle under the pectoralis minor Pain over anterior chest and axilla Fewer head/neck symptoms
- 33. Venous TOS Etiology Developmentalanomalies of costoclavicular space Repetitive arm activities – throwing, swimming, overhead activities.
- 34. Predisposing Factors Relationshipof vein to subclavius tendon and costoclavicular ligament Decrease in dimensions of costoclavicular space Repetitive trauma to vein causing stenosis, thrombosis
- 35. 1. Acute occlusion Pain Tightness Discomfort during exercise Edema Cyanosis 2. Increased venous pattern Swelling Feeling of heaviness Easily fatigued arm and hand Superficial vein distension Thrombophlebitis of the upper limb Tenderness over the axillary vein ,Gangrene rarely Venous compression
- 36. Interscalene triangle Artery, Nerves VeinCostoclavicular space Subcoracoid area Artery, Vein , Nerves
- 37. Arterial TOS Etiology Cervicalor anomalous first rib Anomalous anterior scalene insertion
- 38. Symptoms Digital orhand ischemia Cutaneous ulcerations Forearm pain with use Pulsatile supraclavicular mass/bruit Arterial compression : Easily fatigued arms and hands Rest pain of hand and fingers Paleness – coldness of the hand Raynaud’s phenomenon Ischemic signs, distal gangrene due to repeated embolization, or to subclavian artery thrombosis
- 39. DIAGNOSIS Clinical maneuvers Radiography Ultrasonography Magnetic resonance(MR) angiography Computed tomographic (CT) angiography Angiography and venography
- 40. Adson maneuver Patientis instructed to take and hold a deep breath and extend his neck fully and then asked to turn his head towards the side being examined. Obliteration or diminuation in the radial pulse suggest compression.
- 41. The Roos test The patient repeatedly clenches and unclenches the fists while keeping the arms abducted and externally rotated (palms forward and upward). The elbows are braced slightly behind the frontal plane for 3mins The test is positive when symptoms are reproduced with this maneuver A positive test is very suggestive of the thoracic outlet syndrome.
- 43. Hyperabduction maneuver Evaluatescompression of the neurovascular bundle between the coracoid process and the pectoralis minor muscle. The patient externally rotates the shoulders and extends the arms out from the chest and then above the head.
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- 45. Halsted's Costoclavicular maneuver •Evaluates compression of the neurovascular bundle between the clavicle and the first rib. • The patient assumes an exaggerated military position with shoulders pushed backward and pressed downward.
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- 48. Diagnosis • “the mostaccurate 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
- 49. DD nTOS Carpaltunnel syndrome Ulnar nerve compression or neuritis Rotator cuff tendinitis Cervical spine strain/sprain Fibromyositis Cervical disk disease Cervical arthritis Brachial plexus injury
- 50. DD aTOS Othersources of emboli: Cardiac and aortic arch arch causes Coagulopathies Vasculitis Radiation induced arteritis Connective tissue Disorders Arterial dissection Atherosclerotic disease Traumatic
- 51. IMAGING X-rays Cervicalrib 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
- 52. CT/MRI canrule out other pathologies Magnetic resonance (MR) angiography computed tomographic (CT) angiography of the thoracic inlet, especially with recently devised techniques and protocols, are noninvasive modalities that provide image quality comparable to that of angiography and venography
- 53. • Angiography andvenography remain the criterion standards for the radiologic diagnosis of these conditions, and they have the added benefit of enabling potential endovascular treatment. • MR neurography – newer technology to detect localized nerve function abnormality
- 54. • aTOS – Segmentalarterial pressures – Angiography • vTOS – Duplex U/S – Venography – Consider bilateral studies •
- 55. EMG Reduction inNCV and low amplitude motor responses Positive results Confirms the clinical diagnosis Poor prognosis if true neural damage present Negative results Does not exclude TOS Both EMG/NCV have lo sensistivity for TOS
- 56. Electrophysiology Testing Medialantebrachial cutaneous nerve (MAC) Lowest branch of inferior trunk of brachial plexus More sensitive to compression than other branches Higher sensitivity and specificity with EMG/NCS
- 57. Scalene muscle block Most useful when diagnosis is unclear Patient in supine position with neck hyperextended and turned to opposite side. Lateral border of sternocledomastoid is palpated andabout 1.5 inches above the clavicle anterior scalene muscle is palpated 5- 7ml of plane bupivacaine and 1ml of betamethasone is injected. Relief of symptoms ranging from few days to weeks. Good relief of symptoms confirms the diagnosis. 2-3 injections can be given.
- 58. Treatment Conservative managementaims to increase the space in the thoracic outlet area and to relieve compression on the neurovascular structures. Step 1 proper postural changes and correct faulty postures. Step 2 manipulate and mobilize and relax 1st rib and clavicular, scapular, pectoral muscles. Step 3 strengthen the shoulder girdle muscles and stretch scalene muscles
- 59. Pain control • Musclerelaxants • NSAIDS • Ultrasonography with ionatophorosis • Transcutaneous electric nerve stimulation. (TENS) • Local anesthetic injections.
- 60. Edema control • gloves •Compressive garments • Elevation of limb • Active range of motion exercises • Retrograde massages • Phonophoresis controls pain and edema
- 61. Ergonomics Work posturerelated changes Relative adjustment of chair height so that forearm restscomfortably and without shoulders being elevated or depressed. Avoid carrying heavy weights on effected side Avoid hyperextension of neck and hyperabducting postures
- 62. PHYSICAL THERAPY Is thekey of T.O.S. treatment Its purpose : open the costo-clavicular space fight against physiological shoulders falling attitude Has to be progressive, painless, bilateral Average duration : 3 to 6 months If properly executed : 70 to 90% of good results
- 63. Exercises Involves relaxingshoulder girdle and stretching the scalene and pectoral muscles. Neck : neck side bending exercises neck rotation neck flexion exercises Shoulder : shrugging of shoulders pendulum exercises
- 64. TREATMENT OF T.O.S. •PHYSICAL THERAPY (2) • Muscular relaxation
- 65. TREATMENT OF T.O.S. •PHYSICAL THERAPY (3) • Correct shoulder falling attitude
- 66. TREATMENT OF T.O.S. •PHYSICAL THERAPY (4) • Reinforce muscles that ‘‘open’’ the costo- clavicular space
- 67. TREATMENT OF T.O.S. •PHYSICAL THERAPY (5) • Respiratory reeducation
- 68. Treatment nTOS • Neckstretching • Posture correction • Avoid neck traction, weights, resistance exercises, strengthening exercises
- 69. •SURGICAL TREATMENT OFT.O.S. Surgical treatment is indicated: • after failure of physiotherapy • in T.O.S. with venous or arterial complications (thrombosis, aneurysms…) • in case of nervous compression • in case of symptomatic cervical rib
- 70. Surgical decompression Symptoms persistsbeyond 2 months of conservative management. Associated vascular compression with poststenotic dialatation. Complete occlusion of a large vessel. P rogression of neurological symptoms. Nerve conduction velocity < 60m/s
- 71. • 1strib resectionand scalenectomy are standard procedures for TOS • 1strib resection is recommended for lower type TOS • Scalenectomy is recommended for upper type TOS • Best results and less chance of recurrence with combined 1strib resection and scalenectomy.
- 72. Scalenectomy • Incision :8cmsincision, 1.5cm above middle third of clavicle. • 80-90% of scalenus anterior muscle and 40-50% of scalenus medius muscle removed. Protect long thoracic nerve and phrenic nerve. Complications : neck hematoma, chylus drainge, dyspnea due to phrenic nerve irritation.
- 73. 1st rib resection 1.Transaxillary approach 2. Supraclavicular approach 3. Infraclavicular approach 4. Posterior approach.
- 74. Transaxillary approach (Roos approach) • Transverse Incision at the level of third rib just below the axillary hair line. – Advantages • Limited field of operative dissection • Cosmetically placed incision • Achieve 1strib resection and anterior scalenectomy • Removal of anomalous ligaments and fibrous bands. • Less blood loss, no muscles are divided.
- 75. • Incomplete exposureof entire scalene triangle • Difficulty achieving brachial plexus neurolysis • Limited if vascular reconstruction is needed Disadvantages
- 76. • 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
- 77. Infraclavicular approach • ADVANTAGES •Ideal for venous and arterial obstruction. • Venous embolectomy. • Arterial reconstruction. • DISADVANTAGES • Poor view of thoracic outlet. • Poor excision of posterior part of the rib.
- 78. Posterior approach • Advantages •cervical rib can be easily resected. • Sympathetectomy can be done • Disadvantages • Vascular reconstruction can not be performed.
- 79. Thoracoscopic First RibResesction • Three 10mm portal are made -1st anterior 3rdICS -2ndlateral 5th ICS - 3rdlateral wall of 6thICS Endoscopic drill is used to dissesct the rib
- 80. Adjunctive procedures – Pectoralisminor tenotomy. – Sympathectomy :
- 81. Treatment vTOS • Anticoagulationtherapy with heparin and oral anticoagulants. • Fibrinolytics • Catheter-directed thrombolysis. • Thrombosis is < 3days old : Thrombectomy • Chronic thrombosis : Venous Bypass
- 82. Complications • Nerve injury bracialplexus injury Long thoracic nerve of bell Phrenic nerve Intercostobrachial nerve. Vagus and Reccurent laryngeal nerve Vascular injury Subclavian vein and artery
- 83. Thoracic duct injury •Lymphatic fistula • Lymphocele • Chylothorax Pleural complication pleural damage Pneumotharax Pleural effusion
- 84. Recurrent nTOS • Postoperativescarring most common cause. • Recurrence usually is seen within 3months. • To minimize scar tissue formation patient is instructed to perform active range of motion exercises beginning the day after surgery. Performed every 3-4 hrs for atleast 6 months.