Dynamic neuromusculoskeletal ultrasound documentation of brachial plexus/thoracic outlet compression during elevated arm stress testing

Background

The diagnosis and validation of thoracic outlet syndrome/brachial plexopathy (TOS) remains a difficult challenge for surgeons, neurologists, and radiologists. This is due to the fact that the responses of standard elevated arm stress tests can be considered somewhat subjective and can vary. Therefore, non-vascular TOS cases are presently diagnosed clinically, and any objective diagnosis has been controversial.

Methods

This is a technique paper describing the use of dynamic neuromusculoskeletal ultrasound to assist in the diagnosis of thoracic outlet/brachial plexus pathology. We propose a new way to observe the brachial plexus dynamically, so that physical verification of nerve compression between the anterior and middle scalene muscles can be clearly made at the onset of clinical symptoms. This gives a way to objectively identify clinically significant brachial plexus compression.

Results

Dynamic testing can add objective analysis to tests such as the elevated arm stress tests and can correlate the onset of symptoms with plexus compression between the anterior and middle scalene muscles. With this, the area of pathologic compression can be identified and viewed while performing the dynamic testing. If compression is seen and the onset of symptoms ensues, this is a positive confirmatory test for the presence of TOS and a clinically significant disease.

Conclusions

This paper offers a simple, objective, and visual diagnostic test that can validate the presence or absence of brachial plexus compression during arm elevation in patients with brachial plexus injury and thoracic outlet syndrome.     

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。     

Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina)

Forty-four patients presenting with chest pain suggesting coronary artery disease had normal exercise stress tests and selective coronary angiography and subsequently were found to have an unsuspected thoracic outlet syndrome. Thirteen additional patients had both significant coronary artery disease and thoracic outlet syndrome. Esophageal and pulmonary disease were ruled out and the diagnosis of brachial plexus compression in the thoracic outlet established by a reduction of the ulnar nerve conduction velocity (UNCV) below normal, the normal value being 72 meters per second. Clinical improvement from thoracic outlet compression resulted either from physical therapy if the UNCV's were above 55 m./sec, or from transaxillary surgical extirpation of the first rib if the UNCV's were below 55 m./sec. Thirteen patients with coronary artery disease and thoracic outlet syndrome required therapy for both problems before improvement ensued. Although the usual symptomatology for thoracic outlet syndrome involves pain and paresthesias of the shoulder, arm, and hand, the chest wall is frequently involved. If the chest pain is predominant with minimal shoulder-hand symptoms, the diagnosis is not suggested clinically and can only be established by the high index of suspicion, positive UNCV reduction, and a normal coronary angiogram. Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm.     

An osteopathic approach to conservative management of thoracic outlet syndromes

Thoracic outlet syndromes (TOS) are a group of disorders in which there is compression of the brachial plexus or the subclavian artery or vein or both as they pass through the thoracic outlet. Most patients have neurologic symptoms of the arm and hand. These syndromes are generally named according to the site of compression or the compressing structures. There are many factors that predispose patients to the development of TOS. The differential diagnosis includes many diseases that can add to or imitate TOS symptoms. Diagnosis is based mainly on the findings of the history and physical examination. Most patients respond well to a conservative care regimen, which should be tailored to the individual patient's needs. In most instances, surgery should be reserved as a treatment of last resort.     

Anomalous vasculature as direct cause of upper brachial plexus thoracic outlet syndrome

Direct vascular etiologies of upper plexus thoracic outlet syndrome (TOS) other than the subclavian vessels are exceptional. This is a unique case of an anomalous artery and its accompanying vein causing direct compression to the upper brachial plexus causing TOS. All symptoms resolved after successful treatment consisting of ligation and resection of the vessels. This case demonstrates that although direct vascular etiologies causing upper plexus TOS are extremely uncommon, they should be considered in the differential diagnosis.     

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.     

New approaches in diagnosis and therapy of the thoracic outlet syndrome]

The results of diagnosis and treatment of the thoracic outlet syndrome (TOS) in 35 patients have been analysed. Compression of the subclavicular neurovascular bundle at the site of its outlet from the thoracic cavity was most frequent cause of TOS development. A degree of compression was assessed quantitatively by the data of a modified functional dynamic test. The modified operation, including resection of the I rib (and of a cervical one in its presence), scalene muscle, musculus pectoralis minor, periarterial sympathectomy of the subclavicular artery, was performed. In narrow (less than 1.5 cm) costoclavicular space, the II rib was additionally resected. An excellent long-term result is indicative of the effectiveness of the method.     

Doppler Adson’s Test: Predictor of Outcome of Surgery in Non-Specific Thoracic Outlet Syndrome

Introduction Outcome of surgery in non-specific thoracic outlet syndrome (TOS) is variable. Duplex imaging of the subclavian artery during Adson’s maneuvre may help predict outcome. Patients and methods A retrospective study of 16 cases of non-specific TOS who had pre-operative duplex imaging of the subclavian artery during Adson’s maneuvre was done and their outcomes following surgical decompression of the thoracic outlet studied. Results Of the eight cases with a positive Adson’s test, seven (87.5%) had a complete response of symptoms following surgery while in the eight cases with a negative test, only four (50%) had a favorable response to surgery. Conclusion Duplex scanning of the thoracic outlet during Adson’s maneuvre may help predict outcome of thoracic outlet decompression surgery in cases of non-specific TOS. Funding, sponsorship or conflict of interest: None.     

Resection of the first rib, following deep arm vein thrombolysis in patients with thoracic outlet syndrome

In order to evaluate, the prophylactic effect of first rib resection in patients with fibrinolytic recanalised deep arm vein thrombosis, we present our experience with 21 patients. After recanalisation 12 had phlebographic signs of venous compression in the costoclavicular space, with the arm in the normal position. This fulfills the requirements for thoracic outlet syndrome (TOS). In 60 normal persons without symptoms of TOS none had phlebographic signs of venous compression with the arm in normal position. This difference is significant. In the 12 patients TOS was suspected was to be the underlying cause of rethrombosis and first rib resection was performed. Two patients with TOS had rethrombosis before first rib resection could be performed. At follow up 1 to 6 years after the thrombosis no rethrombosis was found. TOS and deep arm vein thrombosis is rare. Controlled studies are not available. We advocate first rib resection in patients with successful fibrinolysis and TOS in order to avoid rethrombosis.     

Computed tomography angiography to evaluate thoracic outlet neurovascular compression

The objective was to evaluate the efficacy of computed tomography angiography with upper extremity hyperabduction to diagnose thoracic outlet syndrome. Over 5 years, 21 patients were treated surgically for neurogenic symptoms of thoracic outlet syndrome. For patients whose diagnosis was unclear after history and physical examination, adjunctive tests (duplex, magnetic resonance angiography, or computed tomography angiography) were performed to help establish the diagnosis. Five of the 6 computed tomography angiograms were positive. The sixth computed tomography was deemed to be an incomplete study. With mean follow-up of 9.4 months, 95% (n = 19) of patients with a positive hyperabduction test on physical examination were free of symptoms postoperatively. All patients with a positive computed tomography angiogram, with their neurovascular compression localized to the thoracic outlet, had successful operative decompression. Computed tomography angiogram with abduction of the arm can be used as an adjunct to confirm the diagnosis of neurovascular compression and then predict successful operative decompression.     

Thoracic outlet and pectoralis minor syndromes

Compression of the neurovascular bundle to the upper extremity can occur above or below the clavicle; thoracic outlet syndrome (TOS) is above the clavicle and pectoralis minor syndrome is below. More than 90% of cases involve the brachial plexus, 5% involve venous obstruction, and 1% are associate with arterial obstruction. The clinical presentation, including symptoms, physical examination, pathology, etiology, and treatment differences among neurogenic, venous, and arterial TOS syndromes. This review details the diagnostic testing required to differentiate among the associated conditions and recommends appropriate medical or surgical treatment for each compression syndrome. The long-term outcomes of patients with TOS and pectoralis minor syndrome also vary and depend on duration of symptoms before initiation of physical therapy and surgical intervention. Overall, it can be expected that >80% of patients with these compression syndromes can experience functional improvement of their upper extremity; higher for arterial and venous TOS than for neurogenic compression.     

A neurophysiologic investigation of thoracic outlet syndrome

Earlier reports have been conflicting as regards the value of neurophysiologic measurements in the diagnosis of thoracic outlet syndrome (TOS), presumably due to differences in selection of patients and in selection and standardization of neurophysiologic tests. The object of the present study was to assess the value of extensive conventional neurophysiologic measurements for the diagnosis of brachial plexus compression in patients with clinical TOS as determined from standardized criteria. The results are discussed in the light of expected neurophysiologic findings at different degrees of brachial plexus compression.     

Diagnosis of patients with thoracic outlet syndrome (TOS) using physiological measures of the medial antebrachial cutaneous nerve

The diagnosis of thoracic outlet syndrome (TOS) remains difficult; therefore, reliable and objective tests are required. We examined the process to diagnose TOS, and assessed the validity of measuring the medial antebrachial cutaneous nerve (MAC), also the ulnar nerve (UN) as a diagnostic tool. Between 2008 and 2011, 86 sides in 73 patients admitted to our hospital for the treatment of TOS were analyzed. In the process for the diagnosis as TOS, the narrow parts of the subclavian artery that was compressed by the anterior scalene muscle were confirmed with a three-dimensional CT angiography. All patients were taken a brachial plexus anesthesiological block to aim at both for diagnosis and treatment of TOS. For the diagnosis of TOS, measurements of latency (LT) and sensory nerve action potential (SNAP) of MAC and UN were analyzed between the TOS side and the non-TOS side and separated into traumatic type or disputed type. In our research, the LT of MAC and UN did not differ much between the TOS side and the non-TOS side; however, the amplitude of SNAP of MAC and UN were lower on the TOS side, especially in traumatic TOS. We concluded that comparison of the amplitude of SNAP of MAC on the injured or non-injured side was comparatively helpful for the diagnosis of TOS.     

Neurovascular compression in the thoracic outlet: changing management over 50 years.

SUMMARY BACKGROUND DATA: During the past five decades, significant improvements have been made in the diagnosis and treatment of thoracic outlet syndrome (TOS) secondary to sports activities, breast implants, or median sternotomy. METHODS, RESULTS, AND CONCLUSIONS: Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular decompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurysm or occlusion was treated successfully in 240 patients. Dorsal sympathectomy was performed concomitantly in 71 patients for occlusion or embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained pain syndrome and causalgia that did not improve with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal sympathectomy. The use of hyaluronic acid significantly reduced recurrent scarring.     

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.     

Upper extremity arterial injury in athletes

Between 1983 and 1986, 23 athletes were evaluated for arm and hand complaints. Eleven players had symptoms of thoracic outlet compression. Severe arm fatigue (eight patients) and finger ischemia (three patients) were the presenting symptoms. In the remaining 12 athletes, symptoms of hand ischemia were predominant. Noninvasive testing with Doppler ultrasonography and duplex scanning (positional testing and finger systolic pressure recording) and cold immersion were used to aid in diagnosis. In the 11 athletes with thoracic outlet compression, arteriography confirmed the finding with compression of the subclavian artery in five, the axillary artery in one, both subclavian and axillary arteries in two, posterior humeral circumflex artery in one, and subclavian aneurysm in two. Compression of the suprascapular artery was identified in four, the subscapular artery in two, and the posterior humeral circumflex artery in one. Thrombosis of a first baseman's ulnar artery and occlusion of the palmar arch in a frisbee player were documented by arteriography. Decompression of the thoracic outlet consisted of anterior scalenectomy in five, pectoralis minor muscle division in one, and resection of both muscles in two. Removal of cervical rib with interposed vein graft was performed in the two players with arterial aneurysm. Hand ischemia in the remaining athletes was treated conservatively with Dextran-heparin infusion for acute ischemia. Repeat noninvasive study of all players demonstrated absence of compression in their playing position, and all have resumed their playing careers. Hand ischemia in athletes can be evaluated noninvasively and treated conservatively. Resection of hypertrophied muscles to decompress the thoracic outlet together with release of branch artery compression in selected athletes promotes perfusion to arm and shoulder muscles and helps to avoid the catastrophic complication of repetitive trauma leading to sudden arterial thrombosis.     

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.     

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.     

Complete cervical rib. Possible neurovascular implications of the upper limb

The thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus or subclavian artery or vein in the region of the neck and shoulder girdle. The neurovascular bundle may be compressed at multiple sites: costoclavicular space, interscalene triangle, insertion of the pectoralis minor into the coracoid process. More than 90% of the patients present with neurologic symptoms: pain, paraesthesias or arm and hand weakness and 10% also have vascular problems. The diagnosis of TOS is always difficult and depends on careful clinical study of patients. For the neurological type of TOS, electromyograms, arteriograms and venograms are not helpful. The value of Doppler study and of arteriography is demonstrated in the present case of a woman with a five month history of pain and paraesthesias of the arm and hand, who shoved sudden occlusion of left humeral artery. Roentgenograms showed the presence of a well developed left cervical rib. Doppler study and arteriography showed the compression of subclavian artery with the arm abduction manoeuver. After first rib resection and humeral artery thrombectomy there was a complete return of humeral artery flow and of all neurologic functions. Thus the role of first cervical rib or other bone and muscular structures must be emphasyzed both in the brachial and in the subclavian artery or vein compression. Embolization of the axillary or humeral artery should be corrected as soon as possible when the cervical rib is corrected.     

Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients.

OBJECTIVE: To evaluate the diagnostic usefulness of provocative tests, Doppler ultrasonography, electrophysiological investigations, and helical computed tomography (CT) angiography in thoracic outlet syndrome (TOS). PATIENTS AND METHODS: We prospectively evaluated 48 patients with a clinical suspicion of thoracic outlet syndrome. Standardized provocative tests, an electromyogram and somatosensory evoked responses, a Doppler ultrasonogram, and a helical CT arterial and/or venous angiogram with dynamic maneuvers were done on each patient. The final diagnosis was established by excluding all other causes based on all available data. The agreement between the results of each investigation and the final diagnosis was evaluated. RESULTS: Provocative tests had mean sensitivity and specificity values of 72% and 53%, respectively, with better values for the Adson test (positive predictive value [PPV], 85%), the hyperabduction test (PPV, 92%), and the Wright test. Using several tests in combination improved specificity. Doppler ultrasonography visualized vascular parietal abnormalities and confirmed the diagnosis in patients with at least five positive provocative tests. Electrophysiological studies were useful mainly for the differential diagnosis or for detecting concomitant abnormalities. Although helical CT angiography provided accurate information on the location and mechanism of vascular compression, the usefulness of this investigation for establishing the diagnosis of TOS and for obtaining pretherapeutic information remains unclear.