Thoracic Outlet Syndrome and Dorsal Sympathectomy.pptx

1. Thoracic Outlet Syndrome
and Dorsal Sympathectomy

2. Introduction
• An umbrella term for conditions involving the compression of
neurovascular structures
- Brachial plexus
- Subclavian artery / vein
• Causes :
- Trauma
- Tumors
- Cervical ribs

3. • The thoracic outlet is the area between the collarbone (clavicle)
and the first rib.
• It contains the brachial plexus (nerves), subclavian artery, and
subclavian vein.
• Compression of these structures can lead to TOS symptoms.

5. Clinical Features
Compression of parts of the brachial plexus
Sensory loss : follow the distribution of ulnar nerve
Pain : neck and arm
Gilliatt-Sumner Hand : Atrophy of instrinsic hand musles
( thenar , hypothenar , lumbrical , interossei muscles )
Compression of subclavian vein ( 3% of cases )
Swelling
Venous distension
Diffuse hand or arm pain
Heaviness
Risk of thrombosis of the arm ( Paget-Schroetter disease )

6. • Compression of the subclavian artery (<1% of cases)
• Arm ache , fatique
• 5P’s
• Low BP in the affected arm (>20mmHg)
• Ischemia can lead to ulcer and gangrene

8. Diagnostic
• Provocation tests
• Adson test
• Wright test
• Roos stress test

9. Imaging
• Radiographs – spine / shoulder / collarbone : bony abnormalities
• CT / MRI – to exclude other conditions ( rotator cuff tear , Pancoast
syndrome , Cervical disc disorder / Fibromyalgia )
• Others :
• Neurogenic TOS : Electromyography / Nerve conduction studies
• Venous TOS : Duplex USG
• Arterial TOS : MR Angiography

10. Radiographic film showing bilateral
cervical ribs

11. Phlebogram showing total occlusion (arrow) with minimal collateral circulation of the left
subclavian vein resulting from thoracic outlet compression. At operation, no thrombus was
present in the vein, and obstruction was relieved by removing the first rib.

12. Treatment Options for Thoracic Outlet
Syndrome
• Conservative treatment includes physical therapy to improve
posture and strengthen muscles, as well as medication for pain
relief.
• Surgical options may be considered for patients who do not
respond to conservative treatment, including dorsal
sympathectomy and first rib resection.

13. What is Dorsal Sympathectomy?
• Dorsal sympathectomy is a surgical procedure used to treat
neurogenic TOS by disrupting the sympathetic nerve fibers in
the thoracic outlet.
• This procedure aims to reduce pain and improve blood flow to
the arm by interrupting the sympathetic signals that may
contribute to TOS symptoms.

14. Indications for Dorsal Sympathectomy
• Severe and persistent symptoms of neurogenic TOS that do not
respond to conservative treatment.
• Presence of neurological symptoms such as weakness, muscle
atrophy, or sensory deficits.
• Vascular symptoms such as arm swelling, discoloration, or cold
intolerance.

15. Surgical Procedure of Dorsal
Sympathectomy
• The principal physiologic effect expected of sympathectomy is the
release of vasomotor control and hyperactive tone of the arterioles
and smaller arteries that have a muscular element in the vessel wall.
• The circulation to the skin, peripheral extremity, and bone are vastly
improved, but the effect on the skeletal muscle of the arm is minimal.

16. Surgical Approaches for Dorsal
Sympathectomy
• Historically the anterior cervical approach has been used, with division of the scalenus-
anticus muscle employed as the approach to the cervical sympathetic chain.
• The stellate ganglion lies on the transverse process of C6.
• The most common current approach is the transaxillary transthoracic one, which is
performed through the second or third interspace using the transverse subhairline
incision.
• The approach most frequently employed when combined with relief of a TOS is the
transaxillary approach, and includes resection of the first rib, retraction of the pleura
caudad, and a dorsal sympathectomy.

17. 1. Incisions in each approach of
thoracic outlet syndrome treatment.
A Transaxillary approach (①) and
endoscopic-assisted transaxillary
approach (①þ②, ②: endoscopic
portal).
B Supraclavicular approach (①),
infraclavicular approach (②), and
combined supra- and infraclavicular
approach (①þ②).
C Posterior approach.
D Video-assisted thoracoscopic
approach with a few portals.

18. Transaxillary approach.
The incision for this approach is made between the PM and LD muscles.
IBN, intercostobrachial nerve; LD, latissimus dorsi; PM, pectoralis major.

19. Supraclavicular approach.
A Macroscopic appearance of supraclavicular structures.
B Exposure of the first rib after scalenectomy. ASM, anterior scalene muscle; BP, brachial plexus; PN,
phrenic nerve.

20. Infraclavicular approach.
A Macroscopic appearance of infraclavicular structures.
B Exposure of the SV after resection of the SM, anterior scalene muscle, and first rib. SM, subclavian
muscle; SN, supraclavicular nerve; SV, subclavian vein

25. Recovery and Complications
• Postoperative care includes pain management, wound care,
and physical therapy to regain strength and mobility.
• Complications of dorsal sympathectomy can include infection,
bleeding, nerve injury, and recurrence of symptoms.
• Most patients experience improvement in symptoms after
surgery, but outcomes can vary.

26. Conclusion
• TOS is a complex condition that requires a multidisciplinary
approach to diagnosis and treatment.
• Dorsal sympathectomy is a surgical option for neurogenic TOS
that can provide relief for patients with severe and persistent
symptoms.
• It is important for patients to work closely with their healthcare
providers to develop a personalized treatment plan.