Thoracic outlet syndrome

(Scalenus syndrome, 1st rib syndrome, Thoracic inlet syndrome)

Introduction:
It is a clinical syndrome(group of disorder) characterized by
neurological and vascular symptom & sign in the upper limbs produced
by compression of lower trunk of the brachial plexus (C8 – T1) and
subclavian vessels in the neck region.

Sites of compression (Anatomical location)

1. Supra clavicular : Interscalene triangle between the insertion of
anterior and middle scalene muscles & base is formed by 1 st rib –
Scalenus anticus syndrome
2. Subclavicular : Interval between 1st thoracic rib posteriorly and
clavicle and subclvius muscles anteriorly – Costoclavicular syndrome
3. Infraclavicular: An enclosure formed by the coracoid, the pectoralis
minor tendon and costocoracoid membrane – Hyperabduction
syndrome
4. Rarely – A scissor like encirclement of the axillary artery by the heads
of the median nerve.

Contributing factor:
A) Dynamic factor : When the arm is hyperabducted the clavicle rotate
and
narrows the retroclavicular space
B) Static factors : Increased muscle bulk reduce the space and Lack of
muscle mass and tone causes sagging shoulders which
angulate and compress the neurovascular structure
(hypertrophy of scalene, old age – muscle wasting)
C) Congenital factor : 1. A cervical rib or its fibrous extension
2. Bifid 1st rib
3. Anomaly of the clavicle
D) Traumatic factor : Malunion or nonunion of clavicle with excessive callus
Single or repeated subacromial destruction of humeral
head
E) Arteriosclerotic factors : Atherosclerotic changes in the vessels
F) Miscellaneous : Apical lobe tumor of lung (Pancoast tumor)
Cervicothoracic scoliosis
 Long neck (high neck) – Modiglianis painting like

C/F Causes
1. cervical rib
Patient usually women in her30s, often long necked 2. scalenus anticus muscle
A) Neurological manifestations: anomaly
i. Pain & paresthesia 3. costoclavicular
ii. Extending from shoulder syndrome/compression
down the ulnar aspect of arm & 4. wide 1st thoracic rib
forearm into the medial 2 finger 5. # 1st rib or clavicle
iii. Worse at night
iv. Aggravated by bracing the shoulder (wearing ofProvocative
back
pack) test
v. 1. Adson’s test
Relieved by changing the position of the arm temporaliy
vi. + ve
Mild clawing of ulnar 2 fingers with wasting of intrinsic
muscles 2. Wright test +
vii. There is a sensory impairment ve
B) Vascular manifestations: usually rare
i. There may be cyanosis, coldness of finger & increased
sweating
ii. Unilateral Raynaud’s phenomenon should make one think
‘ thoracic outlet’

Investigation
1. X –ray: a) cervical spine – to see cervical rib & abnormally long
C7cervical process
b) Chest – to exclude pancoast tumor
c) Shoulder – to exclude rotatory cuff tear
2. Arteriography & venography – for vascular symptom
3. Electrodiagnostic test – Nerve conduction study for peripheral nerve
lesions

D/D – D/D
1. Ulnar nerve compression 1. Cervical disc herniation – symptom along
2. Cervical spondylosis median nerve distribution (Turek 980p)
2. Central lesion – tumor involving spinal cord
3. Pancoast’s tumor
and its root
4. Rotator cuff lesions 3. cervico spondylolisthesis
4. pl ______ lesion –
Treatment: i. Pancoast tumor
ii. Cervical spondylosis
A) Conservative – Rest, Analgesic,5. Distal nerve lesion
Physiotherpay i. Friction nuritis of ulnar nerve
B) Operative treatment – ii. Carpal tunnel syndrome
i. Indication – 6. Raynaud’s disease
a. Severe7.pain
Amyotrophic lateral scoliosis
b. Obvious muscle wasting
c. Vascular disturbance
ii. Procedure – Removing of cervical rib, 1st rib either a
supraclavicular or transaxillary approach care must be taken to
brachial plexus, subclavian vessels or perforation of pleura
Short case
1. Name, age
2. What is your problem – if pain – character,
radiation, any night pain
3. occupation – painter, tuck driver, heavy load carrier
4. মমাথমার উপর হমাত ররখখ কমাজ করখত রকমান সমসসমা হয়?
5. Pancoast tumor এ রচমাখখর দদিখক তমাকমাখত হয়

Look Exposure upto wrist

1. wasting of hand muscles or sensory change
2. sign of ischemia in one hand – coldness, discolouration, trophic
change
3. supraclavicular swelling

Feel
1. if supraclavicular swelling exam from behind
2. confirmation of wasting
3. sensory exam of lower trunk of brachial plexus
4. muscles power specially ulnar nerve
5. vascular status
6. if there is any excessive sweating – sympathetic irritation
7. Special test –
a. Adson’s test – extended neck + turns towards affected
side + deep breath
b. Wright’s test – arms abducted and externally rotated
c. Roos’s test – (intermittent claudication test) surrender
position

Auscultation
Bruit over subclavian artery
Complication -
Subclavian artery compression → Post stenotic dilation → formation and
dislodgement of thrombosis → embolization → gangrene

Q. From where arise

Ans – Supranumerary rib arise usually from C7 vertebra, rarely C6 & C5
Frequently bilateral

Development
In the embryo, the nerves are much larger in proportion to the
ribs than they are in the fully developed animal. When nerves are
unusually large, as they are in cervical region they interfere with the
development of costal process. So it in the prefixed brachial plexus it is
more common and rare in post fixed plexus.

Erb’s point
It is situated in the supraclavicular fossa
Is at the angle formed by the clavicle and posterolateral fibers of
the sternomastid muscle ( junction of upper trunk and
suprascapular nerve)
Brachial plexus stimulated by this angle