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.     

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.     

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

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.     

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.     

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.     

Proximal ulnar nerve compression. Cubital tunnel syndrome.

Ulnar nerve compression about the elbow is common. If diagnosed and treated early, satisfactory results can be expected. Severe chronic nerve compression may lead to permanent nerve damage. The diagnosis can be made by careful history, physical examination, knowledge of the nerve anatomy, and sometimes electrodiagnosis. Cubital tunnel syndrome must be differentiated from TOS and ulnar tunnel syndrome. Double-crush syndrome should be ruled out. Nonoperative treatment must be attempted first, whereas surgical treatment is indicated in severe and chronic cases. Satisfactory results can be achieved after surgery if nerve damage is absent and careful attention to technical details and gentle handling of the nerve are exercised.     

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.     

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.     

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.     

双神经卡压综合征

目的：研究双神经卡压征的病因及手术治疗方法。方法：分析了自１９８８年以来同时诊断为腕管综合征和肘管综合征２６例３４侧的临床资料。全部患者均作两处神经松解术，平均随访１７个月。疗效评定标准，根据术后症状、体征的改善程度分优、良、可和无效四级。结果：２５侧术后疗效优良，占７３．６％（２５／３４）。结论：双神经卡压征手术治疗效果较好。当双神经卡压同时合并颈部神经卡压时，建议优先考虑远端的神经减压。当远端神经减压后未能改善近端神经卡压症状时，才考虑近端神经减压     

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.     

Management of thoracic outlet syndrome

The experience with transaxillary first-rib resection and scalenotomy reported herein shows these to be safe and effective treatments for patients with thoracic outlet syndrome (TOS). The former operation usually offers the best possibility for complete resection of the first rib and all anomalous congenital bands, and is curative in most cases, regardless of the mechanism of the compression. Scalenotomy, or Powers' operation, is also helpful, in particular for cases of TOS with a vertebral arterial insufficiency. Accurate diagnosis of TOS and selection for surgery after a detailed history and proper physical examination will result in gratifying relief of symptoms in almost all patients with TOS.     

Management of thoracic outlet syndrome

Summary The experience with transaxillary first-rib resection and scalenotomy reported herein shows these to be safe and effective treatments for patients with thoracic outlet syndrome (TOS). The former operation usually offers the best possibility for complete resection of the first rib and all anomalous congenital bands, and is curative in most cases, regardless of the mechanism of the compression. Scalenotomy, or Powers' operation, is also helpful, in particular for cases of TOS with a vertebral arterial insufficiency. Accurate diagnosis of TOS and selection for surgery after a detailed history and proper physical examination will result in gratifying relief of symptoms in almost all patients with TOS.     

Diagnosis and treatment of thoracic outlet syndrome

Patients who develop symptoms of thoracic outlet syndrome (TOS) have a predisposing anatomic abnormality. In most patients with TOS, the symptoms are caused by entrapment of the brachial plexus and they do not arise from compression of the subclavian artery, as was previously thought. The tests advocated for diagnosing this common syndrome (i.e., evaluating the positional compression of the artery when the arms are raised, the neck is turned, or the shoulders are braced) cannot accurately diagnose this syndrome. There are two reasons for this. The symptoms of TOS are not related to the compression of the artery in the outlet in 98% of patients, and 75% of normal individuals without symptoms show diminished radial pulse on various provocation tests. We employed four timed provocation tests (minute tests) to diagnose TOS: the timed Morley test, timed Wright test, timed Eden test, and elevated arm stress exercise, all of which are very sensitive. In normal individuals without symptoms, 20% experience transitional symptoms such as slight pain and tiredness, on these tests indicating a subclinical state. TOS is treated by keeping the thoracic outlet wide, this being done either conservatively or surgically. In 1993 and 1994, we conservatively treated 418 of 422 patients with TOS by means of active exercise, a brace, and by block therapy. These measures did not reduce the symptoms in 23 of these patients, so surgical treatment was indicated. In the remaining 4 of the 422 patients, conservative treatment was not indicated and surgery was performed directly. All the patients showed significant clinical improvement of varying degree. Presented at the 69th Annual Meeting of the Japanese Orthopaedic Association, Tokyo, April 12, 1996     

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.     

Epidemiology of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) describes a complex disease process with three anatomic variations each with their own individual characteristics. Understanding the prevalence, diagnosis, and treatment of TOS is challenging for many providers. For this reason, the establishment of comprehensive care models and expert leadership by dedicated vascular surgeons with TOS experience has been invaluable.     

胸廓出口综合征非手术和手术治疗的长期随访

目的 了解胸廓出口综合征的解剖学基础，分析颈神经根受压的临床特点、诊断和治疗。方法 对1995—1999年间的18例胸廓出口综合征患者作平均6．9年的随访，其中8例作手术治疗，10例作非手术治疗（局部封闭为主）。胸廓出口综合征的特点是颈神经根在椎间孔外受压，以颈肩痛、手麻痛为主要表现，可伴有上肢的酸痛及功能障碍。结果 治疗后颈肩痛消失或明显缓解，并有较大的功能改善。非手术治疗和手术治疗的疗效分别为60％和75％。结论 胸廓出口综合征的非手术治疗和手术治疗均有效，并都有一定的反复，需长期反复治疗，应严格掌握手术指征。     

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.     

The history of surgery for thoracic outlet syndrome

The history of surgery for thoracic outlet syndrome (TOS) is examined, ranging from the earliest recorded reference of TOS in the anatomic recognition of cervical ribs by Galen and Vesalius, to the current research on the diagnosis and treatment of TOS. The author discusses various cases that helped advance the use of surgery in treating TOS, tracing the years of progress that led to the present day understanding of the disease.