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 Thoracic Outlet Syndrome

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

Includes:

  • 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.

References

1. Cheng SWK, Reilly LM, Nelken NA, Ellis WV, Stoney RJ. Neurogenic thoracic outlet decompression: rationale for sparing the first rib. Cardiovasc Surg 1995;3:617 - 623

2. Thompson JF, Jannsen F. Thoracic outlet syndromes (Editorial) Br J Surg 1996;83:435 - 436

3. Mingoli A, Feldhaus RJ, Farina C, Cavallari N, Sapienza P, di Marzo L. Cavallaro A. Long - term outcome after transaxillary approach for thoracic outlet syndrome. Surgery 1995;118:840 - 844

4. Sanders RJ, Cooper MA. Surgical management of subclavian vein obstruction, including six cases of subclavian vein bypass. Surgery 1995;118:856 - 863

5. Juvoen T. Satta J, Laitala P, Luukkonen K, Nissinen. Anomalies at the thoracic outlet are frequent in the general population. Am J Surg 1995;170:33 - 37

6. Lindgren KA, Oksala I. Long - term outcome of surgery for thoracic outlet syndrome. Am J Surg 1995;169:358 - 360

7. Moore WAS, Machleder HI, Poeter JM, Roos DB. Thoracic outlet syndrome (Symposium). Contemp Surg 1994;45:99 - 111

8. Cina C., Whiteacre L, Edwards R, Maggisano R. Treatment of thoracic outlet syndrome with combined scalenectomy and transaxillary first rib resection. Cardiovasc Surg 1994;2:514 - 518

9. Baker MD, Lamerton AJ. Outcome of surgical management of the thoracic outlet compression syndrome in a district general hospital. Ann Royal Coll Surg Eng 1993;75:172 - 174

10. Green RM, McNamara J, Oriel K. Long - term follow - up after thoracic outlet decompression: An analysis of factors determining outcome. J Vasc Surg 1991;14:739 - 46

11. Sanders RJ, Haug C. Review of arterial thoracic outlet syndrome with a report of five new instances. Surg Gynecol Obstet 1991;173:415 - 425

12. Lord Jr, JW. Critical reappraisal of diagnostic and therapeutic modalities for thoracic outlet syndromes. Surg Gynecol Obstet 1989;168:337 - 340

13. Sanders RJ, Jackson CGR, Bancher N, Pearce WH. Scalene muscle abnormalities in traumatic thoracic outlet syndrome. Am J Surg 1990;159:231 - 236

14. Machleder HI. Thoracic outlet syndromes: New concepts from a century of discovery. Cardiovasc Surg 1994;2(2):137 - 145

15. Durham JR, Yao JS, Pearce WH, Nuber GM, McCarthy WJ III. Arterial injuries in the thoracic outlet syndrome (see comments). J Vasc Surg 1995;21(1):57 - 69;discussion 70 Comment in: J Vasc Surg 1995;22(1):124 - 125

16. Jamieson WG, Chinnick B. Thoracic outlet syndrome: Fact or fancy? A review of 409 consecutive patients who underwent operation. Can J Surg 1996;39(4):321 - 326

17. Roos DB. Historical perspectives and anatomic considerations. Thoracic outlet syndrome (Review article). Sem Thoracic Cardiovasc Surg 1996;8(2):183 - 189

Posted June 2010