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 Thoracic Outlet Syndrome

Jonathan B. Towne, M.D., John Corson, M.D., Irving Kron, M.D.


  • Cervical Rib/Abnormal First Rib
  • Arterial Complications
  • Venous Complications
  • Neurogenic Complications

I. Anatomy and Pathophysiology

1. To understand the anatomy of the thoracic outlet to include anatomic variations in bones, muscles, and cervical ribs.

2. To recognize the origin of insertion of the musculoskeletal structures which surround the nerves and blood vessels that supply the arm.

3. To recognize the location of the costovertebral ligaments and the boundaries of the scalene triangle and the costoclavicular space.

4. To recognize the location and incidence of anatomic variations of the insertion of the cervical rib.

5. To recognize insertions of the anterior scalene and its relationship to the neurovascular structures.

6. To recognize the origin and insertion of the subclavius muscle and the possibility of encroaching the neurovascular structures in the costoclavicular triangle.

7. To recognize and define skeletal abnormalities, e.g. elongated C-7 transverse process, callous formation from a fractured clavicle or first rib, hypoplastic first rib, the anatomy of cervical nerves C-5, C-6, C-7, C-8, and T-1, and their relationships to the thoracic outlet.

II. Diagnostic Evaluation

1. To understand that pain is a principal symptom of neurologic type of thoracic outlet and that the distribution of pain which arises from the upper three nerves of the brachial plexus, C-5, C-6, and C-7, as distinct from the pattern of pain emanating from the lower nerves of the plexus, C-8 and T-1.

2. To recognize the arterial symptoms (embolization to hand and forearm, post stenotic dilatation, and subclavian artery occlusion) and venous symptoms (subclavian vein thrombosis for clinical diagnosis).

3. To understand this may present as spontaneous, related to injury (hyperextension, flexion injuries of the neck, blunt trauma), or that symptoms may occur with hyperadduction of the shoulder or arm exertion.

4. To define differential diagnoses of thoracic outlet to include cervical disc syndrome, carpal tunnel syndrome, orthopedic shoulder problems (shoulder sprain, rotator cuff injuries, tendonitis, cervical spondylitis, ulnar nerve compression at the elbow), Multiple Sclerosis, spinal cord tumor disease, angina pectoris, and Pancoast's tumor.

5. To understand the importance of obtaining blood pressure in both arms, clinical examinations of the hand, examination for muscle atrophy, and evaluation for muscle strain and percussion of the supra clavicular fossa.

6. To understand and have knowledge of tests used to evaluate thoracic outlet, i.e. Adson's test, hyperabduction test, and costoclavicular test.

7. To understand the role of vascular lab in the diagnosis using duplex evaluation to detect thrombosis of the subclavian vein and arterial studies of the upper extremity.

8. To define the physical findings of embolization to the digital vessels and occurrence of palpable aneurysm in the supraclavicular fossa.

9. To recognize the angiographic findings related to this syndrome including false aneurysm, post stenotic dilitation, and subclavian artery occlusion.

III. Treatment

1. To be familiar with surgical techniques and anatomy for first rib resection (transaxillary, supraclavicular, total anterior scalenotomy).

2. To define specific complications related to the surgical approach (traction injuries to the brachial plexus, pneumothorax, injury of the subclavian artery, injury to the subclavian vein, air embolus as a result of subclavian vein injury, nervous system injury, i.e. long thoracic nerve, intercostobrachial nerve, musculocutaneous nerve).

3. To be aware of the symptoms and incidence of these complications and nerve injuries.

4. To be familiar with the management of subclavian artery aneurysms including the use of graft materials and treatment of distal emboli.

5. To be familiar with thrombolytic therapy in the management of subclavian vein thrombosis.

6. To define the timing of a 1st rib resection with regard to subclavian vein thrombosis.

7. To be aware of the incidence of recurrence of thoracic outlet syndrome.

8. To be aware of the incidence of litigation pertaining to the diagnosis and treatment of thoracic outlet syndrome.

9. To have an understanding of the treatment options to include conservative approaches such as physical therapy and treatment of muscle spasm.


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Posted June 2010