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.

1. Thoracic outlet
syndrome
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2. Introduction
Definition
• 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

3. Anatomy
Thoracic outlet
• The thoracic outlet is defined as the interval from the
supraclavicular fossa to the axilla that passes between
the clavicle and the first rib

4. Common Compression sites
1. Interscalene triangle
2. Costoclavicular space
3. Retropectoralis minor
space

5. Anatomy -
Scalane triangle

6. Anatomy of
the
costoclavicular
space
Subclavian vein
Subclavian artery
Brachial plexus
Clavicle
1st Rib

7. Pectoralis
minor space
• Located inferior to the coracoid
process
• anterior to the second through
fourth ribs
• posterior to the pectoralis minor
muscle
• Contents
1. The cords of the brachial
plexus
2. Axillary artery
3. Axillary vein.

8. Etiology
Soft-tissue Causes (70%)
Scalene muscle
• Variations in insertion
• Hypertrophy
• Accessory scalenus minimus muscle
Anomalous ligaments or bands
Soft-tissue tumors

9. Etiology
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

10. Etiology
Other causes
Poor posture
 Drooping the shoulders
 Holding the head in a forward position
Repetitive activity
 Athletes and swimmers
Obesity
Pregnancy

11. Classification
Neurogenic T. outlet syndrome
(NTOS) – 90%
Venous Thoracic outlet syndrome
(VTOS) - 3-5%
Arterial Thoracic outlet syndrome
(ATOS) – 1%

12. 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

13. 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.

14. 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

15. Venous TOS
Causes
1.Hypertrophy of the
subclavius muscle,
2.Chondroma formation

16. 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

17. 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.

18. Arterial TOS
Rare but has more devastating consequences
Caused by
1. Intermittent subclavian arterial compression - Costoclavicular compression with normal
anatomy.
2. Prolonged subclavian arterial compression - Always associated with a bony abnormality
A-TOS often coincides with minor paraesthesia in the C8/T1 distribution because the
lowest trunk of the brachial plexus lies alongside the subclavian artery and is subject
to the same compressive mechanisms.

19. Clinical features
• Pallor that worsens in cold temperatures
• Non radicular pain
• Coolness
• Numbness
Compression over time leads to intimal damage, eventual aneurysm formation,
thrombosis, embolic events, and even potentially limb-threatening ischemia

20. Physical
examination &
Provocative tests

21. Physical examination
• Comparing the upper extremity with cotra lateral limb
1. Skin colour – Cyanosis
2. Temperature
3. Hair distribution
4. Muscle atrophy
5. Odema
• Palpation of the supraclavicular region - Mass
• Quality and location of pain with movements of the neck, shoulder, and upper limb
should be recorded
• The vascular examination documents the presence and quality of the radial pulse
with the arm in different positions
• Listen for bruits
• Should include evaluation of shoulder, cervical spine and upper extremity

22. The Adson test
• Bringing the arm into extension turning
the head toward the affected side and
taking a deep breath.
• The test is positive if there is a marked
decrease, or disappearance, of the radial
pulse.
• It is important to check the patient's radial
pulse on the other arm to recognize the
patient's normal pulse

23. Provocative
tests
A decrease in the radial pulse with the arm in
hyperabduction
and external rotation, with the head turned in the opposite
direction.
With this maneuver, the radial pulse dampens or
obliterates
But in up to 7% of the normal population shows positive
finfing

24. Roos test / The
elevated arm
stress test
The patient places both arms in the 90 abducted position with the elbows flexed to 90. The
hands are then opened and closed for a 3-minute period.
Normal persons may have minor discomfort due to muscular fatigue, but patients with TOS
have more discomfort
• Carpal tunnel syndrome,
• Ulnar neuropathy fibromyalgia

25. Differential diagnosis
Pancoast’s syndrome
• Due to apical carcinoma of the bronchus with
infiltration of the structures at the root of the neck
pain, numbness and weakness of the hand.
• A hard mass may be palpable in the neck
• X-ray of the chest shows a characteristic opacity
Cervical spondylosis –
• Constant neck and shoulder pain presents in a
radicular distribution
• Pain aggravated by position of the neck

26. Differential diagnosis…..
Rotator cuff lesions
• Sometimes cause pain radiating down the arm
• There are no neurological symptoms
• Shoulder movement is likely to be abnormal.
Distal compression neuropathies ( carpal tunnel cubital tunnel syndrome)
• Symptoms isolated to nerve distributions
• Pain aggravated by position of the wrist or elbow

27. Investigations
Imaging
Chest and cervical spine radiographs
1. Cervical ribs
2. Prominent C7 transverse processes
3. Low-lying shoulder girdles
CT and MRI - has not been well studied, it may be effective in the setting of
1. Identifiable congenital anomaly
2. A space-occupying lesion (eg, a pancoast tumor)
3. Metastatic disease
4. Malunited fractures of ribs or the clavicle

28. Investigations ……
Angiography -
• CTA / MRA or traditional angiography can be utilized to identify more clearly the
• Occlusion
• Aneurysm
• Distal embolization.
Nerve conduction study, electromyography
• Confirm neurogenic TOS
• Localize the area of compression- r/o CTS

29. Management
Nonsurgical Management
• Initial treatment strategy for Neurogenic TOS
Surgical management
• Arterial and venous TOS
• Pt with resistant neurogenic TOS

30. Nonsurgical
Management
1. Activity Modifications
1. Avoid aggravating activities.
2. Avoid repetitive upper extremity mechanical work
and muscular trauma.
2. Pain control Medications
1. Analgesics
2. muscle relaxants
3. Antidepressants.
4. TENS
3. Physiotherapy
1. Posture improving exercises.
2. Breathing exercises.
4. Patient education
1. Weight reduction

31. Botulinum toxin A
• Botulinum toxin A (botox) can be used for temporary symptom relief.
• Botox takes two weeks to work but can last three months and can help patients
progress with physical therapy.
• Botulinum toxin injection with ultrasound guidance is safe and well tolerated in
subjects with suspected nTOS .

32. Surgical
Management
Indications:
 Symptoms persists with non operative
treatment.
 Associated vascular compression.
 Progression of neurological symptoms.
 Nerve conduction velocity < 60m/s

33. Surgical options and Approaches
• First rib resection
• Anterior scalenectomy
• Cervical Rib/fibrous band resection
• Costoclavicular ligament resection
• C7,C8 and T1 root neurolysis
Trans axillary approach
Commonly performed approach
Provides superior exposure for
first rib resection, as well as for
removal of cervical ribs and
fibrous bands, with a more
cosmetic scar.
Supraclavicular approach
Favorable exposure for upper
brachial plexus
Posterior approach
Favorable exposure for upper
brachial plexus

34. Thank you