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 syndromes

Thoracic outlet syndrome (TOS) is no longer considered to be a single entity. The syndromes are venous (V-TOS), arterial (A-TOS) and neurological (N-TOS), but may co-exist. The end stage of VTOS (Paget Schroetter syndrome or effort thrombosis of the subclavian vein) should be recognized early so that younger sportsmen and musicians in particular can be offered the opportunity of thrombolysis, decompression surgery and balloon venoplasty. Most uncomplicated cases of A-TOS and N-TOS can be treated conservatively with posture, diet, physiotherapy advice and reassurance. Complicated arterial TOS, with aneurysm or embolization, should be treated expeditiously by cervical rib excision and arterial reconstruction. Double crush syndromes are relatively common in patients with TOS. It is easier to treat carpal tunnel syndrome than N-TOS. Muscle wasting and pain are an indication for surgery in N-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.     

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.     

Surgical management of thoracic outlet syndrome: a 10-year experience

BACKGROUND: Thoracic Outlet Syndrome (TOS) refers to compression of the neurovascular structures in the region between the scalene muscles and the first rib, or by anatomical abnormalities such as cervical rib, fibrous bands and other variations in the scalene musculature. METHODS: Our experience with 63 consecutive operations for TOS, over a period of 10 years, has been reviewed. Preoperative symptoms and signs, investigations, surgery done, complications and the outcome of surgery are analysed. RESULTS: A total of 60 patients underwent 63 operations for decompression of TOS. All the 63 first ribs, were excised by the transaxillary approach. In seven patients (16%), a combined transaxillary and supraclavicular approach was used. There was no operative mortality in this series. The operative complications included pneumothorax in four patients (6.3%), which was treated by insertion of chest drain, and lower brachial plexus neuropraxia in two patients (3%), which improved with conservative management. The mean duration of postoperative hospital stay was 3.6 days. At 12 months following surgery, 56 patients (93%) had complete or partial relief of symptoms and only four patients (6.6%) had no relief of symptoms. CONCLUSION: The results of the present study confirm that transaxillary excision of the first rib is a surgical procedure associated with very low morbidity and excellent relief of symptoms. It can therefore be offered as an early option for patients with thoracic outlet syndrome. It may be combined with the supraclavicular approach if exposure of the subclavian artery is required for vascular reconstruction.     

A rare cause of thoracic outlet syndrome

First rib pathology can narrow the thoracic outlet thus producing compression of the brachial plexus and subclavian vessels. There have been only three case reports of neurogenic thoracic outlet syndrome (TOS) caused by a nonunion of the first rib and there have been no reports of a first rib malunion causing TOS. A rare case of TOS caused by a malunion of the first rib is presented. This work has not received financial support and the authors declare no conflict of interest.     

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.     

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.     

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     

颈肋综合征13例分析

目的探讨颈肋综合征的特点和治疗方法。方法回顾分析13例颈肋综合征的临床表现、手术探查所见和手术方法。本组臂丛下干受压型8例,臂丛中、下干受压型3例,全臂丛受压型2例。13例均有下颈部肿块,全部采用手术治疗。术中见不完整颈肋4例,完整颈肋7例,颈肋由两个节段组成2例;同时合并前、中、小斜角肌异常和纤维索带,共同构成对臂丛特别是下干的卡压。结果随访6个月～5年3个月,手术疗效优6例,良5例,可2例。结论颈肋综合征和颈肋两者内涵不同。颈肋可分为横突增长、不完整颈肋、完整颈肋和特殊形态等4种。而臂丛下干支配区的运动和感觉障碍以及下颈部肿块是颈肋综合征的重要特点,臂丛下干受压型是其主要临床类型。手术是主要的治疗措施,应将颈肋等卡压组织逐一切除或切断。建议将颈肋综合征作为胸廓出口综合征的特殊类型加以研究。     

胸廓出口综合征的新认识——解剖学与临床观察

目的探讨胸廓出口综合征的病因。方法对３０具６０侧经福尔马林固定的成人尸体小斜角肌及前中斜角肌的起始部进行解剖研究;对５３例胸廓出口综合征手术患者（１９６６～１９９４年４５例,１９９６～１９９７年８例）随访情况进行总结分析。结果解剖研究发现小斜角肌的出现率为８８３％,Ｔ１神经根或其下干在小斜角肌近段起源的腱性组织上跨过;前中斜角肌在颈椎横突的前后结节均有起点,Ｃ５、Ｃ６神经根从前中斜角肌的交叉腱性起点中穿过。４５例１９６６～１９９６年手术者中,有颈肩痛症状者３４例,术后１７例颈肩痛症状仍存在,其中７例加重;８例１９９６～１９９７年手术者中,７例有颈肩痛,术中切断前中斜角肌在Ｃ５～６神经根旁的腱性纤维组织,术后仅有１例仍有颈肩部不适。结论小斜角肌的腱性纤维是臂丛神经下干或Ｔ１神经根受压的原因;前中斜角肌在Ｃ４～５横突前后结节的交叉腱性起点是压迫Ｃ５～６,有时包括Ｃ７神经根或臂丛神经上（中）干的原因     

Arterial complications associated with thoracic outlet compression syndrome

Six patients with major arterial lesions were encountered in a group of 40 patients undergoing operation for thoracic outlet compression syndrome. In each instance a bony abnormality was present: either a fully articulating cervical rib (Gruber type III) or an anomalous first rib articulating with the second rib at the site of the scalene muscle insertion. Two patients had brachial artery embolism, and another had a cerebrovascular accident secondary to retrograde vertebral artery embolism and associated with subclavian artery thrombosis. Two patients had subclavian artery aneurysms, one of which proved to be a difficult surgical problem.A brief discussion of each patient is given, with emphasis on the importance of distinguishing between patients who have osseous abnormalities and those who do not when patients are evaluated for operation for thoracic outlet syndrome.     

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.     

Role of anterior scalene muscle hypertrophy in thoracic outlet syndrome

A case of hypertrophic anterior scalene muscle surgically treated is reported. The patient suffered from upper limb intermittent claudication at any sustained upper extremity activity such as lifting a weight or opening and closing the hand with the arm abducted. Doppler and angiographic study showed significant compression of subclavian artery with hyperabduction and Adson manoeuver. Simple anterior scalenotomy was followed by prompt recovery of symptoms. The results of scalenotomy and other surgical approaches to thoracic outlet syndrome are reviewed in the literature. The most common anomalies of anterior scalene muscle in the TOS are also described. Doppler and arteriographic study in different functional positions are necessary in the evaluation of subclavian artery compression by osseous or muscular structures. In the reported case scalenotomy was at least as effective as 1st rib resection.     

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.     

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.     

Management of vascular complications in thoracic outlet syndrome

Arterial complications of thoracic outlet syndrome (TOS) were surgically treated in 11 patients (12 limbs) and venous complications in five (6 limbs). Arteriography showed total occlusion or significant stenosis of the subclavian artery in eight patients (bilateral in 1), with complicating peripheral thrombosis in three. Two patients had unilateral subclavian artery aneurysm: One was the patient with bilateral subclavian occlusion, and the other also had brachial artery embolism. Yet another patient had brachial thrombosis. Treatment included reconstructive surgery (3 limbs), thoracic sympathectomy (3) or decompression alone (6). Of the five patients with venous TOS complications, four were found at phlebography to have subclavian thrombosis and one had significant bilateral subclavian obstruction. Treatment was transaxillary first-rib resection (4 cases) or division of soft-tissue bands and hypertrophied anterior scalene muscle (1 case). After follow-up averaging 9 years, eight of the nine survivors in the arterial group were working and seven were asymptomatic. All five in the venous group were working and only two had slight, strain-related symptoms. Impaired arterial flow in TOS can usually be managed with decompression, but direct surgery (bypass or thrombectomy) or thoracic sympathectomy is required in cases with severe ischemia with proximal occlusion and after resection of a subclavian aneurysm or in cases with unilateral Raynaud's phenomenon or thrombosis of small arteries. For venous symptoms decompression alone suffices.     

Pseudarthrosis of cervical rib: an unusual cause of thoracic outlet syndrome

Thoracic outlet syndrome is uncommon in adolescence. Cervical rib fracture is an extremely rare cause of thoracic outlet syndrome in this age group. We report an unusual case of thoracic outlet syndrome in a 14-year-old girl caused by pseudarthrosis of the cervical rib. A magnetic resonance imaging scan showed significant compression of the brachial plexus by the pseudarthrosis mass. Excision of the cervical rib through a supraclavicular approach gave excellent results in this case.     

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。     

Supraclavicular Approach for Thoracic Outlet Syndrome

The authors' experience with the supraclavicular approach for the treatment of patients with primary thoracic outlet syndrome (TOS) and for patients with recurrent TOS or iatrogenic brachial plexus injury after prior transaxillary first rib resection is presented. The records of 33 patients (34 plexuses) with TOS who presented for evaluation and treatment were analyzed. Of these, 12 (35%) plexuses underwent surgical treatment, and 22 (65%) plexuses were managed non-operatively. The patients who were treated non-operatively and had an adequate follow-up (n = 11) were used as a control group. Of the 12 surgically treated patients, five patients underwent primary surgery; four patients had secondary surgery for recurrent TOS; and three patients had surgery for iatrogenic brachial plexus injury. All patients presented with severe pain, and most of them had neurologic symptoms. All nine (100%) patients who underwent primary surgery (n = 5) and secondary surgery for recurrent TOS (n = 4) demonstrated excellent or good results. On the other hand, six (54%) of the 11 patients from the control group had some benefit from the non-operative treatment. Reoperation in three patients with iatrogenic brachial plexus injury resulted in good result in one case and in fair results in two patients; however, all patients were pain-free. No complications were encountered. Supraclavicular exploration of the brachial plexus enables precise assessment of the contents of the thoracic inlet area. It allows for safe identification and release of all abnormal anatomical structures and complete first rib resection with minimal risk to neurovascular structures. Additionally, this approach allows for the appropriate nerve reconstruction in cases of prior transaxillary iatrogenic plexus injury.