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.     

Diagnosis, treatment, and complications of thoracic outlet syndrome

New concepts regarding the diagnosis and treatment of thoracic outlet syndrome, double crush syndrome related to thoracic outlet syndrome, and minor traumatic dystrophy related to thoracic outlet syndrome are explained. Received for publication on May 22, 1998     

Embolic brain infarction: a rare complication of thoracic outlet syndrome. A report of two cases

The thoracic outlet syndrome is known to cause brachial neuropathy. Pressure on the subclavian artery causing post-stenotic dilatation with intraluminal thrombosis is not a common complication. This may lead to antegrade embolisation and ischemic changes in the upper limb. In right sided thoracic outlet syndrome the thrombus may extend retrogradely. From this an embolus may detach to the right hemisphere of the brain resulting in left sided hemiplegia. This is a rare but serious complication from a neglected, relatively benign, curable condition. This report describes two cases of a right sided thoracic outlet syndrome due to cervical rib compression with retrograde embolisation.     

First rib resection in thoracic outlet syndrome

Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement.     

The Paget-Schroetter syndrome

Primary axillo-subclavian venous thrombosis is pathology of the young working man. It affects above all the main upper limb and arises during a physical activity of the shoulder. Its aetiology is complex and multifactorial. It is most often the consequence of a chronic compression of the subclavian vein at the level of the thoracic outlet. Clinical presentation can be confirmed with a duplex scan investigation.Early diagnosis offers the opportunity for rapid venous recanalisation with an anticoagulation treatment. A fibrinolytic therapy can be started in the same session of the phlebography. In case of success, a dynamic phlebography is performed to confirm the existence of a venous thoracic outlet syndrome. Even if indications for surgical management of primary subclavian vein thrombosis are still controversial, it is actually clear that this multidisciplinary management of these patients has to be as early as possible. Decompression of the thoracic outlet can be performed secondarily using various techniques including first-rib resection. Should this approach fail to re-establish patency, leaving some residual disabling of the arm, axillo-subclavian vein revascularization can provide good mid-term results.     

Facial pain and headache associated with brachial plexus compression in the thoracic inlet

Among the sources for confusion related to brachial plexus compression in the thoracic inlet are the name for this clinical entity (thoracic outlet syndrome) and the fact that some of its associated symptoms occur outside the upper extremity, such as face and neck pain (FP) and occipital headaches (OH). With the realization that scalenus anticus (SA) contraction is the primary source of brachial plexus compression, it is possible to understand the occurrence of both FP and OH in this syndrome. It was hypothesized that SA contraction compresses the cervical plexus as it exits deep to this muscle. Furthermore, it was hypothesized that tension on the origin of this muscle from the transverse cervical processes causes compression of the occipital nerves. To evaluate this, a consecutive series of 32 patients who had resection of the SA between January 2004 and December 2007 were evaluated to determine prevalence of FP and OH, and the extent to which these symptoms were relieved postoperatively after SA resection. It was found that 25% of the patients had FP and that 50% had OH. Postoperatively, for those patients with neck pain, with or without facial pain, 75% were completely relieved, 18% were partially relieved. OH was completely relieved in 81% and partially relieved in 13% of the patients. In conclusion, symptoms of FP and OH associated with brachial plexus compression is due to cervical plexus compression by SA muscle, and symptoms can be relieved by resection of the SA.     

The Paget-Schroetter Syndrome

Primary axillo-subclavian venous thrombosis is pathology of the young working man. It affects above all the main upper limb and arises during a physical activity of the shoulder. Its aetiology is complex and multifactorial. It is most often the consequence of a chronic compression of the subclavian vein at the level of the thoracic outlet. Clinical presentation can be confirmed with a duplex scan investigation. Early diagnosis offers the opportunity for rapid venous recanalisation with an anticoagulation treatment. A fibrinolytic therapy can be started in the same session of the phle-bography. In case of success, a dynamic phlebography is performed to confirm the existence of a venous thoracic outlet syndrome. Even if indications for surgical management of primary subclavian vein thrombosis are still controversial, it is actually clear that this multidisciplinary management of these patients has to be as early as possible. Decompression of the thoracic outlet can be performed secondarily using various techniques including first-rib resection. Should this approach fail to re-establish patency, leaving some residual disabling of the arm, axillo-subclavian vein revasculariza-tion can provide good mid-term results.     

Bilateral pain relief after unilateral thoracic percutaneous sympathectomy

PURPOSE: To present a case of unexpected bilateral pain relief following unilateral thoracic percutaneous sympathectomy. CLINICAL FINDINGS: We present a case report where severe ischemic pain due to paraneoplastic Raynaud's syndrome with distal gangrene was successfully treated by means of percutaneous thoracic sympathectomy. A unilateral T2, T3 radiofrequency sympathectomy combined with small volume phenol injection resulted in unexpected bilateral pain relief. CONCLUSION: Our observations from this case report suggest a possible crossover of sympathetic innervation at the cervical and thoracic levels. Percutanenous thoracic radiofrequency sympathectomy is a feasible option for the treatment of refractory ischemic upper limb pain.     

Thoracic outlet syndrome--a myofascial variant: Part 1. Pathology and diagnosis

Four cases of thoracic outlet syndrome are described, with observations to support a primary myofascial etiology involving the scalene and smaller pectoral muscles. It is believed that thermography can be extremely helpful as an aid in diagnosis of thoracic outlet syndrome and, when combined with Doppler blood flow studies and photoplethysmography, can help localize the site of the pathosis. Thermography is a sensitive, non-invasive test that most clearly demonstrates pathology in the hand views. Global changes throughout the entire hand suggest vascular or reflex autonomic involvement, while a more dermatomal distribution suggests specific neurologic involvement. Vigorous stretching and a unique form of myofascial release manipulation has been successful in rapidly treating patients with thoracic outlet syndrome. Follow-up thermography (perhaps hand and forearm views only) can be used to monitor response to treatment and to objectively document improvement.     

Thoracic outlet syndrome of pectoralis minor etiology mimicking cardiac symptoms on activity: a case report

Thoracic outlet syndrome is the result of compression or irritation of neurovascular bundles as they pass from the lower cervical spine into the arm, via the axilla. If the pectoralis minor muscle is involved the patient may present with chest pain, along with pain and paraesthesia into the arm. These symptoms are also commonly seen in patients with chest pain of a cardiac origin. In this case, a patient presents with a history of left sided chest pain with pain and paraesthesia into the left upper limb, which only occurs whilst running. The symptoms were reproduced on both digital pressure over the pectoralis minor muscle and on provocative testing for thoracic outlet syndrome. The patient’s treatment therefore focused on the pectoralis minor muscle, with a complete resolution of symptoms. This illustrates that not all cases of chest pain with associated arm symptoms that occur on physical activity are of cardiac origin.     

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.     

Sudeck's dystrophy following arthroscopy of the knee joint--a case report

Many studies and publications have been devoted to Sudeck's syndrome. A much more rare occurrence is described here, namely, after a lesion affecting the lower extremity and knee joint. The case report concerns the typical course of a reflex dystrophy of the knee joint after a mild interior lesion of the knee followed by arthroscopy.     

Herniated thoracic disc at T1-2 level associated with Horner's syndrome. Case report

A case of symptomatic herniation at the first thoracic disc level is reported. The patient presented with hand weakness, Horner's syndrome, and pain radiating along the medial aspect of the upper extremity. Myelography demonstrated a smooth lateral defect at T1-2. Three sequestrated epidural disc fragments were removed with postoperatvie relief of pain. A slightly miotic pupil remains.     

An unusual case of neurogenic thoracic outlet syndrome

IntroductionNeurogenic thoracic outlet syndrome (nTOS) is the most common manifestation of thoracic outlet syndrome (TOS), accounting for more than 95% of cases. It is usually caused by cervical ribs, anomalies in the scalene muscle anatomy or post-traumatic inflammatory changes causing compression of the brachial plexus.Case presentation: We present an unusual case of nTOS caused by a cystic lymphangioma at the thoracic outlet, with only one case reported previously in the literature. We used a combined supraclavicular and transaxillary approach for complete removal, which resulted in excellent recovery of the patient.DiscussionThough lymphatic cysts may be commonly encountered in surgical practice, compression causing nTOS is extremely rare. The location of the lymphatic cyst with compression of the brachial plexus may provide a challenge for treatment. Surgical excision is the preferred method of management, with higher success rates than sclerotherapy.ConclusionSurgical excision to ensure complete removal of the cyst is recommended. Sclerotherapy may be used in cases where complete excision of the cyst wall may not be possible.     

Thoracoscopic sympathectomy

The objective was to evaluate the safety and effectiveness of endoscopic thoracic sympathectomy (ETS) for treatment of a variety of sympathetic disorders, including hyperhidrosis, splanchnic pain, reflex sympathetic dystrophy, and Raynaud upper extremity ischemia. Sixty-three ETS procedures were performed in 34 patients at the University of Maryland Medical System between March 1992 and August 1999 (14 male patients, 20 female patients; mean age 22 years). The indications for surgery were hyperhidrosis in 26 patients, upper extremity ischemia in 3 patients, splanchnic pain and reflex sympathetic dystrophy in 2 patients each, and facial blushing in 1 patient. Preoperative symptoms resolved completely or improved significantly in 97.1% (33/34) of patients. One patient with left reflex sympathetic dystrophy had symptoms that recurred shortly after surgery. There were no major complications; one patient with hyperhidrosis reported significant compensatory hyperhidrosis. These findings suggest that ETS is a safe and effective procedure for treatment of a variety of sympathetic disorders. Its application for hyperhidrosis is very effective, and its treatment of splanchnic pain, reflex sympathetic dystrophy, and Raynaud syndrome are rewarding. With increasing experience, ETS should become established in the repertoire of the thoracic surgeon.     

The relationship between dead arm syndrome and thoracic outlet syndrome

A relationship exists between anterior shoulder subluxation and thoracic outlet syndrome that is responsible for the more florid symptoms of dead arm syndrome (DAS) in some patients. This relationship was demonstrated in eight of 27 patients (30%) in a consecutive series of Bankart operations for treatment of subluxation. The mechanism is associated with a disturbance in the kinesiology of the shoulder-joint complex that alters the position of the scapula relative to the rib cage and neurovascular supply to the upper limb. Therapy is directed toward restoration of the stability of the glenohumeral joint so that normal biomechanics can be reestablished. In advanced stages of thoracic outlet syndrome, however, DAS may initially require surgical decompression of the nerves and vessels. Careful attention to postural mechanics is essential for rational diagnosis and treatment of DAS.     

History of thoracic outlet syndrome

Thoracic outlet syndrome (TOS), a condition in which neurovascular structures in the thoracic outlet region are compressed, can be caused by anatomical abnormalities or acquired changes in the soft tissues and bony structures in the region. The brachial plexus is the most frequently affected structure. TOS is one of the most difficult neurovascular compressions in the upper extremity to manage because of the variability of complaints and the high risk associated with surgical treatment.     

Percutaneous transluminal angioplasty and transaxillary first rib resection. A multidisciplinary approach to the thoracic outlet syndrome

A 33-year-old man with the thoracic outlet syndrome complicated by recurrent upper extremity deep venous thrombosis underwent venographic and dynamic venous pressure studies that suggested both extrinsic and intrinsic venous obstruction. The patient was treated with transaxillary first rib resection and percutaneous transluminal angioplasty of the involved subclavian vein stenosis and is symptom-free at 16 months follow-up. To our knowledge this is the first case in which such a multidisciplinary approach to the thoracic outlet syndrome has been performed.     

Ultrasonography-guided osteopathic manipulative treatment for a patient with thoracic outlet syndrome

Patients with thoracic outlet syndrome can be treated with osteopathic manipulative treatment (OMT) to alleviate dysfunction and restriction of the pectoralis minor muscle (PMM) and the resulting compression of the brachial plexus. Neuromuscular ultrasonography (US) can demonstrate abnormalities in the thoracic outlet that are amenable to OMT and can be used to monitor intervention. The present report identifies PMM deformation and brachial plexus compression in a 32-year-old woman with thoracic outlet syndrome who was treated successfully with OMT. Neuromuscular US results were used to measure the degree of PMM deformation with the pectoral bowing ratio and confirm the diagnosis. Osteopathic manipulative treatment was applied and monitored using neuromuscular US to confirm that the operator's manipulating hand had direct contact with the PMM. Symptoms abated immediately after treatment. Results of a second neuromuscular US examination showed that the pectoral bowing ratio decreased into the normal range and thus confirmed that PMM deformation had resolved.     

小针刀定点松解法治疗上干型胸廓出口综合征

目的：观察小针刀定点松解治疗上干型胸廓出口综合征的疗效及探讨其作用机制。方法：共治疗32例上千型胸廓出口综合征患者,其中女22例,男10例;年龄25-55岁。病程1个月～3年,均为单侧发病。采用小针刀对C。关节突关节及冈下窝痛性条索定点快速松解,每周1次,治疗1-4次。结果：所有患者术后即刻都有不同程度的颈肩部主观症状缓解,26例术前有肌力下降的患者中术后即刻测试有20例肌力明显增加;18例术前有皮肤痛触觉减弱的患者中术后即刻测试痛触觉有8例感觉明显改善。随访1年,根据Wood评价标准,优19例,良7例,可3例,差3例,其中1例转为手术治疗,无并发症发生。结论：小针刀定点松解法治疗上干型胸廓出口综合征操作安全简便,疗效确切,并同时具有肌松和镇痛作用。