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Chapter 41 - Thoracic Outlet Syndrome

Scalenus anticus syndrome
Cervical rib syndrome
First thoracic rib syndrome
Costoclavicular syndrome
Subcoracoid-pectoralis minor syndrome
Hyperabduction syndrome[1]
ICD-9 Code
Brachial plexus lesions (cervical rib syndrome, costoclavicular syndrome,
scalenus anticus syndrome, thoracic outlet syndrome)
Thoracic outlet syndrome (TOS) remains a contentious area in medicine. The term is
used to describe a number of conditions attributed to a compromise of the
brachial plexus (typically the lower trunk), subclavian/axillary artery or vein, or both at
one or more points between the base of the neck and the axilla. Because of the
controversy and confusion surrounding this entity it is helpful to further subclassify the
condition based on the neurovascular structure that is compromised: neurologic
(axonal) TOS, vascular TOS, and disputed/symptomatic TOS.[2]
Vascular TOS refers to compromise of the subclavian/axillary artery or vein. Both are
very rare and usually affect young to middle-aged persons. Vascular
compromise may develop from trauma, thrombi, or congenital anomalies, such as a
fully formed cervical rib or abnormal first thoracic rib. Traumatic causes such as
midclavicular fractures may present acutely or as a late effect secondary to non-union
or excessive callus formation. Repetitive trauma has also been implicated, such
as that seen in throwing sports. Intimal damage to vascular structures may lead to
thrombus or aneurysm formation.
Neurologic (axonal) TOS refers to true compression of the brachial plexus with
resultant axonal damage, particularly to the lower trunk. This condition is also very
rare, affecting young to middle-aged women more than men. Although many
conditions may contribute to brachial plexus injuries (e.g., trauma, tumor, infections),

Presence of cervical rib. 220 Physical Examination Physical examination should include an extensive evaluation of the patient's neck. cyanosis.) Symptoms Patients typically report pain along the distal and ulnar aspects of their forearm and hand as well as sensory symptoms such as numbness. It is a diagnosis of exclusion. C. (From DePalma AF: Surgery of the Shoulder. It is defined more as a symptom complex rather than a true anatomic pathologic process. especially those involving overhead work. the distal C8 anterior primary rami. Compression by pectoralis minor during hyperabduc tion. and atrophy are consistent with a true neurologic deficit. coldness. although it appears to affect women more than men.term "neurologic TOS" is used to describe a condition believed to be caused by the compression of the distal T1 and. Physical examination should reveal normal neurologic and vascular findings. Because of the difficulties in defining this condition. Lippincott. may reveal atrophy of the thenar greater than hypothenar . 2nd ed. 219 Figure 41-1 Areas of compression of the neurovascular bundle. A. pp 511–520. Subjective complaints of weakness or of dropping objects should be verified by physical examination. Abnormal reflexes. by a taut band that extends from a rudimentary cervical rib or elongated C7 transverse process to the first thoracic rib. Presence of a fibrous band." or "symptomatic. affecting primarily the lower trunk of the brachial plexus. D. with particular attention to the neurologic and vascular examinations. Careful attention to the neck range of motion and a positive Spurling's test may reveal a cervical root lesion. J. to a lesser extent. The patient should be undressed in order to assess any postural abnormalities or side-to-side atrophy. B. Neurologic TOS. and upper extremities." TOS refers to a condition that occurs more commonly than both the vascular and true neurologic types. shoulders. Hypertrophy of scalene muscles. "Disputed. tingling. Philadelphia. and burning. These symptoms are often aggravated by certain positions or activities. Those with vascular compromise may present with swelling. weakness. 1973. or even Raynaud's type symptoms. accurate etiologic data is not available.B. and therefore other conditions must be excluded prior to making the diagnosis. with permission.

especially if a patient reports nonspecific decreased sensation or weakness associated with pain or "give-way" effort. [5] Diagnostic Studies Cervical spine x-rays are helpful to identify an elongated C7 transverse process or a rudimentary cervical rib. however. followed by keyboard instrumentalists and flutists. These patients often present with a "droopy shoulder" posture. discoloration.[3] These patients may also have a diminished radial pulse. oblique films of the cervical spine are helpful . especially after exercise. [4] Some patients may have tenderness in the supraclavicular fossa overlying the anterior/middle scalenes. prominent dilated veins. trapezius. such as a Tinel's sign at the elbow or wrist and a positive Phalen's maneuver. This finding would be more consistent with a diagnosis of myofascial pain syndrome. such as Adson's. Special tests. have normal neurologic and vascular examinations. Careful palpation to the scalene. and often protracted shoulders. and sloping. Patients with disputed/symptomatic TOS. subungual hemorrhages. and ulcerations of the fingertips.eminence in the hand. typing. may be helpful when considering the diagnosis of cubital or carpal tunnel syndrome. and sensory abnormalities of the medial forearm and hand. particularly when their arms are in the overhead or abducted positions. such as groceries. impairing their ability to perform fine motor activities such as writing. In addition. and working a cash register. This. Other special tests advocated in evaluating TOS. have disputed results. with horizontal clavicles. Patients with vascular compromise to their upper extremity may have upper extremity swelling. when a downward load is applied to the upper extremities causing additional stretch to the plexus and vessels. rounded. levator scapulae. buttoning a shirt. Patients with more advanced disease may have significant weakness and numbness of the hands. or supraspinatus muscles may reveal identifiable trigger points. weakness of the hand intrinsic muscles. Patients most affected were reported to play the violin or viola. as discussed earlier. the patient may report difficulty carrying heavy objects. TOS has been reported in a subsection of patients who are instrumental musicians. Functional Limitations Patients with all forms of TOS typically have difficulty with upper extremity function. characterized by a long thin neck. may be difficult to establish. Allen's. reproducing the patient's symptoms. In addition. and costoclavicular tests. hyperabduction.

to evaluate for significant neuroforaminal stenosis. such as a tumor or hematoma. If the clinician has a high suspicion of cervical radiculopathy.[6] Abnormal ulnar motor conduction velocity studies across the "thoracic outlet" should be interpreted with skepticism. plexus. they are typically done at the discretion of a vascular surgeon. or peripheral nerve (median or ulnar). Hallmark findings of neurologic (axonal) TOS include abnormal needle EMG activity in the C8/T1 myotomes as well as decreased amplitudes of the median greater than ulnar compound motor action potential (CMAP) and ulnar sensory nerve action potential (SNAP) with preservation of the median SNAP. which may be compromising the plexus. as these recordings have been shown to be of no use. 221 Electrodiagnostic testing (e. Differential Diagnosis Cervical radiculopathy Carpal tunnel syndrome Traction plexopathy Thrombophlebitis Vasculitis Myofascial pain syndrome Neuralgic amyotrophy . Arteriography and venography are indicated for further evaluation of possible vascular compromise. EMG and nerve conduction studies) may be extremely helpful in determining the presence of true neurologic insult as well as localizing the injury to the root.. magnetic resonance imaging (MRI) should be performed to rule out a possible herniated nucleus pulposus.g. given the risk of potential complications from these more invasive procedures. which may be more consistent with a cervical radiculopathy. [7] Normal electrodiagnostic testing is expected in both vascular and disputed/symptomatic TOS. An MRI of the brachial plexus may be particularly helpful in identifying a possible soft tissue lesion. however. even in the face of normal cervical spine x-rays. Chest x-rays or clavicular films may reveal a possible pancoast tumor or an undiagnosed clavicular fracture.

Rehabilitation Considerations . costoclavicular. Some key components to this treatment program include postural training and awareness.. correction of muscle imbalances through appropriate stretching and strengthening. especially when there is a large component of neuropathic pain. Patients may benefit by utilizing a cervical roll or wearing a soft cervical collar when sleeping. should be treated conservatively. and subcoracoid areas. nortriptyline) as well as anticonvulsant medications (e. Initial treatment involves activity modification and pain management.g. True neurologic compromise to the brachial plexus. weight reduction. where no identifiable structural lesion can be identified. including cyclooxygenase-2 (COX-2) inhibitors. carbamezepine). Poor sleep secondary to soft tissue pain or depression may greatly improve with the use of a low-dose antidepressant medication. warrant further evaluation by a neurosurgeon or a thoracic surgeon. The vast majority of patients with disputed/symptomatic TOS.[8] [9] Some important points listed in Table 1 .Ulnar neuropathy Mass lesion (tumor. 222 TABLE 41-1 -. amytryptiline.g. Symptoms of sleep apnea should be addressed. where structural lesions can be identified.. gabapentin. tricyclic antidepressants (e. including the interscalene. thereby helping to minimize any potential compression of the plexus or vascular structures at the various sites between the neck and the axilla. and aerobic conditioning. Medications that may be helpful include nonsteroidal anti-inflammatory drugs (NSAIDs). Rehabilitation Rehabilitation regimens attempt to normalize the neck and upper trunk relationships. Significant sleep disturbances should be addressed and treated appropriately. Vascular compromises warrant immediate consultation with a vascular surgeon. hematoma) Arteriosclerosis Multiple sclerosis Syringomyelia Treatment Initial Initial treatment starts with an accurate diagnosis.

Improving respiratory efficiency may be achieved by introducing aerobic conditioning and chest expansion exercises. however. 5. which may contribute to TOS symptoms. may benefit greatly from local trigger point injections. such as the serratus anterior and pectoralis major and minor. and should remind themselves during the day to avoid "slouching.1. thereby reducing lumbar lordosis. Patients who perform most of their activities at a desk. Having the patient lower the keyboard may be an effective way to improve posture and decrease muscle effort in the upper extremity and minimize irritation of the cervicoscapular region. 2. therefore. Obesity may be a contributing factor to TOS symptoms. and sternocleidomastoid. . increasing thoracic kyphosis. an exercise program emphasizing stretching of the anterior muscles. coupled with strengthening of the lower scapular stabilizers and thoracic extensors may offer significant benefit. Aerobic conditioning may be helpful in managing patients' chronic pain symptoms. who can assist with establishing an appropriate weight loss program. have a tendency to slide forward in their chair. using visual aides such as mirrors. and increasing cervical lordosis and head forward postures. A figure-of-eight harness may be used to help correct this posture. In addition. it is typically poorly tolerated by most patients. 4. upper trapezius. patients with decreased respiratory efficiency tend to utilize their accessory respiratory muscles more. Patients with identifiable trigger points. spray and stretch treatments. Postures that tend to exacerbate symptoms of TOS include when the head and cervical spine are anterior to the thorax and protraction of the scapulae. including the scalenes. 3. Procedures Patients with neurologic symptoms attributed to other causes such as radiculopathy or peripheral nerve entrapment should be treated in the appropriate manner for such conditions. Patients should be made aware of their posture. Women with breast hypertrophy may benefit from a more supportive brassier with wider straps across the back. especially those who use a keyboard." In addition. or other myofascial release techniques. consistent with myofascial pain syndrome. overweight patients should be referred to a nutritionist. [9] Further ergonomic assessments of patients' work or home environments may be warranted by an occupational therapist or other skilled provider.

This may involve thrombolytic therapy. hepatic. cervical rib removal. Potential Disease Complications Potential complications from unrecognized or undiagnosed vascular or neurologic TOS include progressive and irreversible loss of limb function by either ischemia or nerve damage. Patients who are prescribed carbamezipine should receive liver function and complete blood count tests.Surgery Prompt surgical evaluation and treatment is indicated for patients with vascular TOS. although one should not expect significant improvement of hand intrinsic muscle atrophy. Patients with true neurologic TOS often benefit from surgical sectioning of the congenital band between the tip of the cervical rib or elongated C7 transverse process and the first thoracic rib via a supraclavicular approach. Patients with known cardiac disease should not be prescribed TCAs without a cardiologist's approval. proximal embolization into the carotids and brain is unlikely but has been reported. and urinary retention. dry mouth. constipation. per Federal Drug Administration (FDA) recommendations. and COX-2 inhibitors have well-known side effects that most commonly affect the gasdtric. depending on the extent of damage. NSAIDs. [10] Because of the potential risk of serious complications and inconsistent results. or bypass grafting. Potential complications . Patients undergoing this procedure typically experience improved sensory symptoms and some improved hand strength. Occasionally the use of medications such as tricyclic antidepressants (TCAs) and anticonvulsants for neuropathic pain is limited by their side effects. Surgery should be reserved for patients with identifiable structural lesions or patients with intractable pain and/or significant functional impairment unimproved by conservative treatment. [11] 223 Potential Treatment Complications Analgesics. surgery should be considered as a last resort for patients in whom no structural lesion is identified on imaging and/or no objective abnormalities are noted on physical examination or electrodiagnostic testing. Most common side effects include drowsiness. In cases of thrombus formation. Great care must be advocated with any surgical intervention because of the potential for grave harm to the patient. and renal systems. aneurysm repair.

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