Diagnosis and treatment of thoracic outlet syndrome

TOS represents a spectrum of disorders encompassing four related syndromes: arterial compression, venous compression, neurogenic compression, and a poorly defined pain syndrome. Patients can present with signs of arterial insufficiency, venous obstruction, painless wasting of intrinsic hand muscles, and pain. History and physical examination are the most important diagnostic studies, and radiographs of the chest and cervical spine and electromyography/nerve conduction studies are useful to identify other causes of pain and disability. Surgical intervention is indicated for patients failing nonoperative maneuvers and can usually yield satisfactory results. TOS may also be the most underrated, overlooked, and misdiagnosed, and the most important and difficult to manage peripheral nerve compression in the upper extremity.     

Pectoralis minor syndrome: Report of two cases and review

Pectoralis minor syndrome (PMS) is an infrequent entity that mimics thoracic outlet syndrome. PMS is characterized by axillary vein stenosis/obstruction below the clavicle, due to compression by the pectoralis minor muscle. The typical clinical symptoms are pain, weakness, numbness, paresthesia, cyanosis and swelling of the upper extremity, aggravated by exercise. Two cases are presented here of right-sided PMS of symptomatic stenosis of the axillary vein. The importance is emphasized of diagnosis by dynamic venography imaging and treatment by surgery.     

Pectoralis minor obstruction of the axillary vein: report of six patients

PURPOSE: Although the usual site of nonthrombotic venous obstruction of the upper extremity is the subclavian vein, other sites may be the cause of such obstruction. This study describes the diagnosis and treatment of six patients with partial axillary vein obstruction by the pectoralis minor muscle, a condition that can mimic subclavian vein obstruction. METHODS: A chart review of patients undergoing pectoralis minor tenotomies (PMT) between 2004 and 2006 revealed six patients (3 men and 3 women), aged 17 to 39, who underwent seven PMT procedures for symptoms of arm swelling, cyanosis, and pain or tightness. Diagnosis was suggested by history and physical examination and was confirmed by dynamic venography. Patients with paresthesia suggesting associated neurogenic pectoralis minor compression were given a pectoralis minor muscle block. As an outpatient, PMT was initially performed with an infraclavicular approach but later through the transaxillary route. Follow-up was by phone interview in five patients and a physical examination in one. RESULTS: Venography demonstrated axillary vein compression under the pectoralis minor, which was more significant than the minor degree of subclavian vein compression seen on the same venogram. Follow-up was 1.5 years to 10 years in three patients and 3 months in the other three. All six patients experienced good-to-excellent relief of all symptoms. There were no surgical complications. CONCLUSION: Axillary venous obstruction by the pectoralis minor must be distinguished from subclavian vein obstruction, which presents with similar symptoms. PMT is a simple, risk-free, outpatient procedure that has produced uniformly good results.     

Thoracic outlet syndrome

Thoracic Outlet Syndromes (TOS) consists of a group of distinct pathologies arising from compression or impingement of structures at the thoracic outlet. The structures at risk are, from anterior to posterior, subclavian vein (venous — VTOS), subclavian artery (arterial — ATOS) and brachial plexus (neurogenic — NTOS). NTOS is the most common presentation, usually caused by compression of the brachial plexus at the scalene triangle or pectoralis minor space. Neurogenic compression syndromes at the carpal and cubital tunnels should be excluded. Management of NTOS is usually conservative, employing physiotherapy and postural exercises, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction, resulting in venous thrombosis (Paget—Schroetter syndrome) often as a result of exercise in fit young muscular people or musicians. Positional swelling of the upper limb without thrombosis is termed McCleery's syndrome. In acute thrombosis, clot lysis, first rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery at the scalene triangle, often in association with an anomalous bony structure, such as cervical rib, causing post-stenotic aneurysmal dilation of the artery, thrombosis and distal embolization. Acute upper limb ischaemia necessitates urgent cervical rib excision and arterial reconstruction.     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is an often misdiagnosed cause of neck, shoulder, and arm disability. Neurovascular compression may be seen in the interscalene triangle, costoclavicular space, or posterior to the pectoralis minor, although any cause of abnormalities of shoulder girdle alignment may cause a localized area of brachial plexus compression. Nerve compression in this way may lead to upper extremity weakness, pain, paresthesias, and numbness. A careful and detailed medical history and physical examination are essential to proper identification of thoracic outlet syndrome, which remains primarily a clinical diagnosis. Diagnostic testing may differentiate other causes of pain or neurologic symptoms of the upper extremity from TOS. Clinical management is often challenging.     

Diagnosis of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a nonspecific label. When employing it, one should define the type of TOS as arterial TOS, venous TOS, or neurogenic TOS. Each type has different symptoms and physical findings by which the three types can easily be identified. Neurogenic TOS (NTOS) is by far the most common, comprising well over 90% of all TOS patients. Arterial TOS is the least common accounting for no more than 1%. Many patients are erroneously diagnosed as "vascular" TOS, a nonspecific misnomer, whereas they really have NTOS. The Adson Test of noting a radial pulse deficit in provocative positions has been shown to be of no clinical value and should not be relied upon to make the diagnosis of any of the three types. The test is normal in most patients with NTOS and at the same time can be positive in many control volunteers. Arterial TOS is caused by emboli arising from subclavian artery stenosis or aneurysms. Symptoms are those of arterial ischemia and x-rays almost always disclose a cervical rib or anomalous first rib. Venous TOS presents with arm swelling, cyanosis, and pain due to subclavian vein obstruction, with or without thrombosis. Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesia, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds.     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) consists of a group of distinct pathologies arising as a result of compression of structures at the thoracic outlet. The structures at risk are, from anterior to posterior, the subclavian vein, subclavian artery and brachial plexus. Compression or impingement causes venous (VTOS), arterial (ATOS) or neurogenic (NTOS) TOS. NTOS is the most common presentation, caused by compression of the brachial plexus at the scalene triangle or pectoralis minor space. Other compression syndromes at the carpal and cubital tunnels should be excluded. Management is usually conservative, employing physiotherapy and postural exercises, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction, resulting in venous thrombosis, the Paget-Schroetter syndrome, often as a result of exercise in fit young muscular people or musicians. Positional swelling of the upper limb without thrombosis is termed McCleery's syndrome. In the presence of thrombosis, clot lysis, first rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery at the scalene triangle, often in association with an anomalous bony structure, such as cervical rib, causing post-stenotic aneurysmal dilation of the artery, thrombosis and embolization. Acute upper limb ischaemia necessitates urgent cervical rib excision and arterial reconstruction.     

Subclavian vein obstruction without thrombosis

BACKGROUND: Unilateral arm swelling caused by subclavian vein obstruction without thrombosis is an uncommon form of venous thoracic outlet syndrome (TOS). In 87 patients with venous TOS, only 21 patients had no thrombosis. We describe the diagnosis and treatment of these patients. MATERIAL AND METHODS: Twenty-one patients with arm swelling, cyanosis, and venograms demonstrating partial subclavian vein obstruction were treated with transaxillary first rib resection and venolysis. RESULTS: Eighteen (86%) of 21 patients had good-to-excellent improvement of symptoms. There were two failures (9%). CONCLUSIONS: Unilateral arm swelling without thrombosis, when not caused by lymphatic obstruction, may be due to subclavian vein compression at the costoclavicular ligament because of compression either by that ligament or the subclavius tendon most often because of congenital close proximity of the vein to the ligament. Arm symptoms of neurogenic TOS, pain, and paresthesia often accompany venous TOS while neck pain and headache, other common symptoms of neurogenic TOS, are infrequent. Diagnosis was made by dynamic venography. First rib resection, which included the anterior portion of rib and cartilage plus division of the costoclavicular ligament and subclavius tendon, proved to be effective treatment.     

Safety and efficacy of the supraclavicular approach to thoracic outlet decompression

BACKGROUND: Thoracic outlet syndrome (TOS) is a clinical diagnosis encountered by both thoracic and vascular surgeons. The goal of surgical therapy involves relieving compression of the neurovascular structures at the superior thoracic aperture. The traditional approach to thoracic outlet decompression has been transaxillary; however more centers are moving toward a more tailored approach through a supraclavicular incision. METHODS: The medical records of 67 patients who underwent surgical decompression between 1993 and 2001 for TOS were retrospectively reviewed. Patient demographics and early outcome were assessed through clinic follow-up. RESULTS: Seventy-two thoracic outlet decompressions were performed on 67 patients with the diagnosis of TOS. Five patients underwent bilateral thoracic outlet decompression. All operations in this time period were safely accomplished through a supraclavicular approach. The syndromes associated with thoracic outlet compression were neurogenic (n = 59), venous (n = 10), and arterial (n = 3). Forty-six of 72 (63.9%) operations resulted in complete resolution of symptoms, 17 cases (23.6%) had partial resolution, and 9 patients (12.5%) had no resolution. There were no deaths and morbidity was minimal with 6 complications (8.3%). CONCLUSIONS: The supraclavicular approach is a safe and effective technique in managing all forms of thoracic outlet compression.     

Thoracic outlet compression syndrome

In patients suffering from chronic, therapy-resistant shoulder and arm pains, the thoracic outlet compression syndrome (TOS) should be included in the differential diagnosis. It is very important to look out for neurogenic disorders as well as early signs of vascular compression in order to prevent ischaemic injuries. Although the initial complaints appear slight and can in some cases be treated successfully by conservative methods, neurogenic disorders due to TOS as well as arterial and venous manifestations of the syndrome should be treated by resection of the first rib. Only in this way can irreversible neurogenic lesions and arterial or venous complications be prevented.     

胸廓出口综合征的诊断治疗进展

胸廓出口综合征(thoracic outlet syndrome,TOS)是指臂丛神经或者锁骨下动脉或者锁骨下静脉在胸廓出口受到卡压而出现的一些列症状。可分为神经型TOS、静脉型TOS和动脉型TOS,其中神经型TOS最为常见。TOS的临床表现非常多样,并且缺乏确诊性的检查方法,因此诊断应结合详细的病史、查体及相关的辅助检查。保守治疗和手术治疗均适用于TOS,并且都能获得较好的预后。神经型TOS首选保守治疗,对于有症状的血管型TOS和保守治疗失败的神经型TOS,应尽早手术。     

Computer-assisted instrumentation during endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe alternate approach

The purpose of this article is to discuss the feasibility of using computer-enhanced instrumentation to improve visualization and therefore patient safety during transaxillary first rib resection. From November 1998 to July 2005, 105 patients who had failed conservative treatment underwent 131 procedures for thoracic outlet decompression. Eighty-nine endoscopic transaxillary first rib resections were completed using Aesop/Hermes integrated voice control instrumentation (Computer Motion, Goleta, CA). Since February 2003, dissection in 42 procedures was performed using the daVinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). The surgical findings with cervical bands correlated with the preoperative symptoms. One hundred percent of patients with a combination of neurogenic and arterial thoracic outlet syndrome (TOS) requiring cervical rib resection had Roos type I and/or II bands. Additional surgical findings included the following: combination of neurogenic and arterial TOS without cervical ribs or neurogenic TOS alone had type III, IV, or V bands, and patients with venous compression (100%) had type VII bands. No mortalities or permanent neurovascular injuries occurred. There was a 6.1% postoperative complication rate. Persistent myofibrositis was found in 34% of patients with ongoing symptoms. CONCLUSION: The daVinci three-dimensional optical imaging system enhances visualization, thereby promoting telemanipulation of soft tissue structures in a relatively inaccessible working space. Endoscopic computerized instrumentation in transaxillary first rib resection decreases the risk of neurovascular injury, promotes complete decompression, and therefore provides a safe alternative to standard first rib resections.     

Thoracic outlet syndrome in a patient with SAPHO syndrome – A case report

Introduction and ImportanceThoracic outlet syndrome (TOS) includes disorders caused by compression of the neurovascular structures in the upper thoracic outlet (Roos and Owens, 1996 [1]; Bürger, 2014; Curuk, 2020 [3]). Depending on the compressed structure, it is categorized into neurological, arterial and venous TOS.SAPHO syndrome (synovitis–acne–pustulosis–hyperostosis–osteitis syndrome) is a rare chronic inflammatory disease of unknown etiology. With its typical involvement of sternoclavicular joint and clavicle, complication due to hyperostosis in this region, leading to thrombosis of the subclavian vein have been reported in some cases of SAPHO syndrome.Between 2015 and 2019 488 patients, suffering from neurological, vascular or combined TOS presented at our department. Depending on clinical and diagnostic results surgical therapy was performed in 175 cases via the transaxillary approach, including complete first rib and/or cervical rib resection, neurolysis of plexus brachialis, thoracic sympathectomy and vascular reconstruction if indicated (Curuk, 2020). During this period, only one single patient presented with SAPHO syndrome with thrombosis of the subclavian vein and neurovascular TOS.Case presentationWe present a 50-year-old female patient, in line with the SCARE 2020 criteria (Agha et al., 2020 [12]) suffering from extremely rare combination of neurovascular TOS and SAPHO syndrome with thrombosis of the left subclavian vein due to hyperostosis of the left clavicle.ConclusionProgressive bone changes associated with SAPHO syndrome can lead to narrowing of the thoracic outlet. Pharmacological therapies to avoid the progression of the hyperostosis of the costoclavicular joint and the clavicle do currently not exist. First rib resection is a therapeutic option to widen the space in the upper thoracic region. Surely, it is a rare condition and more long-term follow-up data are required.     

Thoracic Outlet Syndrome Caused by a Pseudoaneurysm After Pseudarthrosis of the Clavicle

Clavicle fractures are common, with the majority treated conservatively. If treated conservatively, pseudarthrosis of the clavicle is reported in up to 3% of the cases. In rare cases, pseudarthrosis of the clavicle may cause pseudoaneurysm formation, resulting in compression of the brachial plexus and the adjoining vessels, which may produce neurological symptoms and circulatory disorders. Here, we describe two cases of the late onset of pseudoaneurysm formation after pseudarthrosis of the clavicle. Both cases were remarkable because they showed clinical symptoms of TOS. Therefore, surgical treatment was performed and included claviculectomy, resection of the pseudoaneurysm and interposition grafting with an artificial prosthesis. One year after the operation, both patients showed excellent upper extremity function without any deficit of vascular, sensorial or motorial function. Patient's history and radiological findings are the keys to diagnosis. Without treatment, the prognosis is poor with spontaneous development of bleeding or gangrene. Therefore, surgical treatment has to be performed, especially when neurological symptoms occur.     

Vascular thoracic outlet syndrome

Abstract The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib (n = 16), soft tissue anomalies (n = 12), and scar tissue after clavicle fracture (n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia (n = 11), transient ischemic attack (TIA) (n = 1), and claudication or vasomotor phenomena during the arm hyperabduction (n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision (n = 12), combined cervical and first rib excision (n = 4), and first rib excision (n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies. Electronic Publication     

Clinical presentation and management of arterial thoracic outlet syndrome

Objective

Arterial thoracic outlet syndrome (TOS) is a rare condition characterized by subclavian artery pathology associated with a bony abnormality. This study assessed contemporary clinical management of arterial TOS at a high-volume referral center.

Pediatric thoracic outlet syndrome: a disorder with serious vascular complications

Background

Thoracic outlet syndrome (TOS), caused by compression of the neurovascular structures between the clavicle and scalene muscles, typically presents with neurologic symptoms in adults. We reviewed our experience with 25 adolescents and propose a diagnostic/treatment algorithm for pediatric TOS.

Methods

From 1993 to 2005, 25 patients were treated with TOS. A retrospective chart review was performed with institutional review board approval. Demographics, clinical presentation, diagnostic studies, and treatment were evaluated.

Results

Seven male (28%) and 18 female (72%) patients presented between the ages of 12 to 18 years. Thirteen (52%) had vascular TOS (11 venous, 2 arterial), 11 (44%) had neurologic TOS, and 1 had both. Vascular TOS included subclavian vein thrombosis (7), venous impingement (4), and arterial impingement (2). Three patients had hypercoagulable disorders, and 6 had effort thrombosis. Venography was diagnostic in 10 cases. Neurogenic TOS was diagnosed by clinical symptoms. Five patients with subclavian vein thrombosis underwent thrombolysis, with 3 maintaining long-term patency. Of 25 patients, 24 underwent transaxillary first rib resection.

Conclusion

Vascular complications are more common in adolescents with TOS than in adults. A diagnostic/treatment algorithm includes urgent venography and thrombolysis for venous TOS and a workup for hypercoagulability. Neurogenic TOS is diagnosed clinically, whereas other studies are rarely beneficial.     

Thoracic-outlet-Syndrom

The thoracic outlet syndrome (TOS) is a disputed syndrome in the field of the so-called compression syndromes of the upper extremity. This is no surprise, as the TOS is a complex and multifactorial compression syndrome diagnosed by different medical specialities. On average 6.5 physicians of different specialities need 4.3 years to come up with the diagnosis of TOS. The correct diagnosis is of great importance and crucial for successful operative treatment. The necessary diagnostic tests can only be accomplished by team work, especially interdisciplinary cooperation. This expressly includes physiotherapy and not just the medical disciplines. This contribution presents a summary of the approaches and interactions involved in effective diagnosis and treatment of TOS.     

Recurrent neurogenic thoracic outlet syndrome

BACKGROUND: Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience "excellent" or "good" results after thoracic outlet decompression, recurrent symptoms may develop in certain patients. METHODS: This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed. RESULTS: Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had "excellent" or "good" results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these). CONCLUSIONS: Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.     

An unusual case of intermittent venous obstruction of the upper extremity.

The axillary vein can be subject to intermittent obstruction from numerous anatomic structures such as the pectoralis minor and the scalenus anterior muscles. The diagnosis can be readily made on history and physical examination of the upper extremity, but it can be difficult to confirm by routine venogram done with the arm in the standard position at the side with full extension at the antecubital fossa. Positional venography with the arm fully abducted and flexion of that antecubital fossa allows for better definition of this extrinsic compression. In the case presented, a fascial band arising from the medial head of the biceps was compressing the axillary vein and was suspected on history and physical examination; it was confirmed with positional venography as noted. As in this case, it is important to make the diagnosis early, before thrombosis of the vein occurs, to minimize the associated morbidity. Transaxillary exploration was performed with excision of the band and complete resolution of the symptoms. Subsequent noninvasive studies were performed that showed complete resolution of the extrinsic axillary vein compression. Having a high suspicion of intermittent venous obstruction with early diagnosis and surgical correction of any extrinsic compression are the keys to a successful outcome in these patients.