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Review Article

Thoracic Outlet Syndrome

John E. Kuhn, MD Thoracic outlet syndrome is a well-described disorder caused by
George F. Lebus V, MD thoracic outlet compression of the brachial plexus and/or the
subclavian vessels. Neurogenic thoracic outlet syndrome is the most
Jesse E. Bible, MD
common manifestation, presenting with pain, numbness, tingling,
weakness, and vasomotor changes of the upper extremity. Vascular
complications of thoracic outlet syndrome are uncommon and include
thromboembolic phenomena and swelling. The clinical presentation is
highly variable, and no reproducible study exists to confirm the
diagnosis; instead, the diagnosis is based on a physician’s judgment
after a meticulous history and physical examination. Both
nonsurgical and surgical treatment methods are available for thoracic
outlet syndrome. Whereas nonsurgical management appears to be
effective in some persons, surgical treatment has been shown to
provide predictable long-term cure rates for carefully selected
patients. In addition, physicians who do not regularly treat patients
with thoracic outlet syndrome may not have an accurate view of this
disorder, its treatment, or the possible success rate of treatment.

P eet etal1 first used the term thoracic
outlet syndrome (TOS) in 1956 to
describe the constellation of symptoms
fossa to the axilla that passes between
the clavicle and the first rib (Figure 1).
It contains three important struc-
caused by compression of the neuro- tures that may be subjected to
From the Division of Sports Medicine, vascular bundle at the thoracic outlet. compression: the subclavian artery,
Department of Orthopaedics, TOS describes a wide spectrum of the subclavian vein, and the bra-
Vanderbilt University Medical Center, clinical presentations with a variety chial plexus. Compression may
Nashville, TN.
of etiologies, all with the common occur at three distinct points in the
Dr. Kuhn or an immediate family thread of neurovascular compression thoracic outlet: the interscalene
member serves as a board member,
in the thoracic outlet region. As our triangle, the costoclavicular space,
owner, officer, or committee member
of the American Orthopaedic Society understanding of this condition has and the retropectoralis minor
for Sports Medicine and American improved, treatment has evolved but it space2 (Figure 2). The interscalene
Shoulder and Elbow Surgeons. remains controversial. The mainstay of triangle consists of the anterior
Neither of the following authors nor
management is nonsurgical in most scalene muscle, the middle scalene
any immediate family member has
received anything of value from or patients; however, surgery is indicated muscle, and the first rib, and it
owns stock in a commercial company for recalcitrant cases and for vascular contains the subclavian artery and
or institution related directly or involvement. Although TOS is a chal- the upper, middle, and lower
indirectly to the subject of this article:
lenging diagnosis, proper evaluation trunks of the brachial plexus. The
Dr. Lebus and Dr. Bible.
and treatment leads to symptom relief costoclavicular space is made up
J Am Acad Orthop Surg 2015;23: for most patients.
222-232 anteriorly by the clavicle, the sub-
clavius muscle, and the costocora-
JAAOS-D-13-00215 Anatomy coid ligament, posteriorly by the
first rib and the anterior and middle
Copyright 2015 by the American
Academy of Orthopaedic Surgeons. The thoracic outlet is defined as the scalene muscles, and laterally by
interval from the supraclavicular the scapula. This space contains the

222 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Whereas our be organized into soft-tissue and is implicated in venous compression understanding has evolved.3 abnormalities encompass the other vulnerability to compression. the cervical transverse processes and development of symptoms only after gest that this lack of demographic inserts into the first rib between the injury.8 scarring may produce delayed symp- vascular compression with any fur. Hooper et al2 sug. exostoses. Soft-tissue causes in Paget-Schroetter syndrome. After the fascia splits to encompass the subclavius muscle. . repetitive stress. Most 30%9 (Table 1). or they may develop scalenus minimus. Anecdotally. it originates from with TOS and cervical ribs show the widely reported. an accessory mus. transverse processes. Although cervical ribs acute trauma. and posterior to the pectoralis minor muscle. the typ. vertebral column grows faster than the upper extremity in youth. et al subclavian vessels and the divisions Figure 1 of the brachial plexus. thin musculature or congenital anomalous bands and ligaments are implicated.10 The costocoracoid ligament ther scapular descent. No 4 223 Copyright ª the American Academy of Orthopaedic Surgeons. may cause TOS symptoms in the insidiously because of chronic stress. this osseous categories. whereas osseous thrombosis.7. Finally. The prior trauma. either Soft-tissue Abnormalities include cervical ribs.3. original insight is valuable because it are associated with to up to 70% of a manifestation of TOS that leads to highlights this anatomic region’s cases of TOS. ante- rior to the second through fourth ribs. this structure invests the pectoralis minor muscle and ulti- mately becomes the suspensory ligament of the axilla. Vol 23. prominent C7 from a single acute incident or from Variation in scalene origin and inser. MD. Osseous Abnormalities cases of TOS are now thought to stem from an anatomic predisposition with Bony findings associated with TOS superimposed neck trauma. shoulders.5 Symptoms may be tion may cause compression within tumor in the region. Kuhn.3 Etiology and Pathology In 1912. Deep cervical fascia invests the neurovascular structures during their course from the first rib to the axilla. this space houses the cords of the brachial plexus and the axillary artery and vein.6 cle. the costocoracoid fascia thins to become the clavipectoral fascia. 80% of patients Epidemiologic data for TOS are not patients with TOS. John E. thus causing the scapula to descend and female with a long neck and drooping ligaments or bands. Unauthorized reproduction of this article is prohibited. When the ribs themselves do not for the disease. Trauma and later leading to a susceptibility for neuro. or callus from delayed several weeks or longer after the interscalene triangle. it comes back together to form the costocoracoid ligament (Figure 3).5 April 2015.6 a large cervical rib fused to the first the definition and diagnostic criteria Symptomatic compression may result rib. The anatomic causes of TOS may toms. Caudal to the subclavius muscle. Todd4 suggested that the Normal thoracic anatomy. their associated ical patient with TOS is a young. the retropectoralis minor space is located inferior to the coracoid process.11 These patients often have information is due to disagreement in subclavian artery and the T1 root. from hypertrophy of the scalene cause compression. can be found in 30% to 50% of absence of trauma.

the clinical impression from fingers (58%). supraclavicular pain (76%). and retropectoralis space. trapezius pain (92%). and to upper or lower plexus compres- Often. are that . altered biomechanics from and some have been told that their activities as well as during sleep. stellation of upper extremity weak. Patients are fre. neck Presentation artery or vein is involved. Mani.12 symptom distribution in subclassified as arterial or venous. classify neurogenic TOS as secondary quently young. whereas because of the varied clinical pre.12 data to support a diagnosis. condition is psychosomatic. and third fingers (14%). caused by compression of the ties. et al. ponent in differentiating TOS from Neurogenic TOS presents as a con. costoclavicular space. TN = thoracic nerve Similarly. occipital headache sentation and the lack of objective and . numbness. and paresthesias in all five a result. In most patients. chest approximately 3% to 5% are venous pain (72%).1% are arterial. Symptoms are present during daily combined plexus pathology is seen 224 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Estimates pain (88%). Symptom patterns can further other conditions.90% of all TOS cases are shoulder and/or arm pain (88%). sion. ness. sec- examination remains a crucial com. Syndrome ond.Thoracic Outlet Syndrome Figure 2 Three regions of potential neurovascular compression: interscalene triangle. . undergone misdiagnosis. acromioclavicular and sternocla. and vascular TOS. Upper extremity heaviness is com- vicular injuries are also noted in festations of TOS include neurogenic mon with above-the-shoulder activi- some patients with TOS. or the first. the fourth and fifth a thorough history and physical Neurogenic Thoracic Outlet fingers only (26%). Diagnosis of TOS is challenging of neurogenic origin. and healthy. active. paresthesias.2 TOS. As (76%). neurogenic TOS included upper Clinical History and depending on whether the subclavian extremity paresthesia (98%). lower and physicians. Unauthorized reproduction of this article is prohibited. they have seen multiple pain in a nonradicular distribution. In a systematic review by Sanders brachial plexus.

embolic events. April 2015. leads to intimal damage. The patient may have or prolonged arterial compression of genic TOS must be differentiated cyanotic discoloration of the the subclavian artery. venous and arterial clinical subtypes.13 A well-known of C8 and T1. It is caused by intermittent index finger and thumb. Venous TOS is characterized by sig- presents as pain in the supra. but it has potentially devastating nificant swelling of the upper clavicular region that may radiate consequences. after activity. it may be compressed at limb-threatening ischemia. Often. coolness. lying etiology. involves the C5-C7 nerve roots. chest. and shoulder. clavicular junction where it passes aneurysm formation. No 4 225 Copyright ª the American Academy of Orthopaedic Surgeons. and manifests as subtype of venous TOS is Paget- symptoms in the area of the ulnar Vascular Thoracic Outlet Schroetter syndrome. eventual cervical nerve root compression. Upper plexus compression tively young and healthy persons. It presents as non- extremity. extremity. Compression over time such as carpal tunnel syndrome and commonly compressed at the costo. and Arterial TOS is a rarer condition. and even potentially the wide anatomic distribution and however.2 Neuro. along with and pallor that worsens in cold tem- nerve distribution to the dorsal a feeling of heaviness that is worse peratures. described as forearm and hand and possibly the Syndrome thrombosis of the subclavian vein axillary and anterior shoulder caused by repetitive injury in rela- Vascular TOS consists of both region. Unauthorized reproduction of this article is prohibited. thrombosis. (85% to 90%). chest. Kuhn. typically by from other compression syndromes. face.9 Lower plexus the nonradicular nature of symp. MD. et al Figure 3 Fascial layers of the cervicothoracic region. numbness. . Vol 23. radicular pain. John E. other areas depending on the under- involvement represents compression toms in TOS. The subclavian vein is a cervical rib. Such a distinction may be made by anterior to the anterior scalene. or radial ity. periscapular region. upper with deep pain in the upper extrem. it is commonly associated into the ipsilateral head.

Anomalous ligaments or bands neck.6 The symptoms of episodic pallor. 226 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. in arterial TOS.6 The Adson test describes pression. and paresthesias may also be by arm. pulse with the arm in hyper- a combination of neurologic and such as carpal and cubital tunnel abduction and external rotation. neck. In addi. Thus. Early fatigue may vical spine problems are more often clavicular region may reveal tender- occur with exercise. ranging from mild posi. pain aggravated by the position of and upper limb should be recorded. syndromes. shoulder. intrinsic shoulder prominent superficial veins in circulation of the hands or fingers in dysfunction. radiate into the upper arm. and cyanosis with a distribu. ciated finding. Shoulder position this context are shown in Figure 4. collagen vascular disease or other radicular and anatomically wide- Distal skin changes. Scalene muscle hypertrophy Attention should be directed toward Accessory scalenus minimus muscle evaluating the position of the head. Comparing the upper Prominent C7 transverse process extremity with the contralateral arm Displacement or callus from first rib fracture yields information regarding skin Malunited clavicle or first rib fracture color. by the position of the shoulder or ulation. vascular components. and which symptoms difference of 20 mm Hg between the TOS. More described as a decrease in the radial that are related to compression of distal compression neuropathies. which symptoms are vas. a charac- teristic finding of neurogenic TOS. spread symptoms that are influenced coldness. neck. tion. masses. the examiner and are aggravated more by the radial pulse dampens or obliterates must distinguish which symptoms position of the wrist and elbow than in up to 7% of the normal pop- are related to brachial plexus com. Intrinsic shoulder pathol. and vascular disorders. Osseous tumor The Gilliatt-Sumner hand. Differential Diagnosis the neck. the hypothenar musculature and the interossei. ulcerations. to a lesser degree. but radial pulse with the arm in different tional discomfort to severe limb. The Wright test was originally lateral or bilateral signs or symptoms tures aggravate symptoms. have symptoms isolated with the head turned in the opposite cular TOS is more easily diagnosed to predictable nerve distributions direction. The vascular examination docu- The clinical presentation of TOS var. ery.or numbness is not a commonly asso. The Osseous Causes (30%) patient’s overall posture should be Cervical rib assessed. is AC = acromioclavicular. Signs that point to arterial TOS have no relationship with thoracic upper extremities is a significant but include unilateral Raynaud-type outlet pathology. Scalene muscle variations in insertion shoulder. or other abnormalities. and upper extremity. hair distribution. the the absence of any other cause. temperature. Isolated vas. SC = sternoclavicular described as atrophy of the abductor pollicis brevis and.Thoracic Outlet Syndrome Table 1 Physical Examination Common Abnormalities Causing Thoracic Outlet Syndrome9 Soft-tissue Causes (70%) Physical examination should include an evaluation of the cervical spine. can help narrow the differential upper extremity and chest wall may thema.2 Cer. warrant a suspicion for TOS.14 Palpation of the supra- embolic disease. Non- upper extremity may appear pale. looking for the Soft-tissue tumors presence of thoracic kyphosis. and other peripheral venous TOS.6 bringing the arm into extension. shoulder pain that presents in Quality and location of pain with a radicular distribution. and shoulder. ogy causes shoulder pain that may ments the presence and quality of the ies widely. and shoulder position signs of microembolic events are rare present with long-standing micro.8.7. such as compression neuropathies. Chronic pain. Several provocative tests in life-threatening symptoms.15 A blood pressure arterial TOS coexists with neurogenic cular in nature. diagnosis. .14 characterized by constant neck and ness. Unauthorized reproduction of this article is prohibited. with the movements of the neck. The clinical history rare finding of vascular TOS. positions. With this maneuver. the but is rare. patients may present with uni. AC or SC joint injury or dislocation muscle atrophy. and nail changes. findings. and direct palpation on joint struc. which includes cervical be congested and edematous with tion of symptoms to the distal spine pathology.

9 Provocative testing for TOS has been criticized for leading to a high number of false positives. MD. A. Aralasmak et al22 a statistically significant decrease in the setting of an identifiable con. and the reproduc.18 the specificity for the Adson Clinical photographs demonstrating provocative physical tests for thoracic outlet test and for the Roos test was 76% syndrome. using ultrasonographic methods in of embolic disease. The Roos test.6 symptoms. or malunited frac. et al turning the head toward the affected Figure 4 side. . John E. the authors could not distinguish Although some authors have pro. tures of ribs or the clavicle. and taking a deep breath. performing multiple tests in conjunction and considering their results together may increase their specificity. such as junction with MRI or CT. Normal persons may have minor discomfort due to muscular fatigue. lesion (eg. the patient places both arms in the 90! abducted position with the elbows flexed to 90!. Conventional arteriog- Chest and cervical spine radio. or the elevated arm stress test. Kuhn.8. compression. but this measure in this context. a pancoast tumor). B. Unauthorized reproduction of this article is prohibited. showing CT and MRI. Braun which may contribute to thoracic Angiography et al19 used pulse oximetry to outlet compression20 (Figure 5). met. showed that magnetic resonance pulse oximetry readings. but patients with TOS have more dramatic symptoms that replicate their usual discomfort such that they may not be able to complete the test. The hands are then opened and closed for a 3-minute period. Gergoudis et al16 challenged the clinical utility of this test by showing that 66 of 130 normal persons (51%) had a diminished pulse with the Adson maneuver. however. No 4 227 Copyright ª the American Academy of Orthopaedic Surgeons. has not been well technology’s role in diagnosis re- that provocative exercise led to studied. when both tests were positive. patients with known TOS. astatic disease. Roos test. arm in a neutral position. nor could they corre- ited in the diagnosis of TOS because late imaging findings with clinical Imaging the area of interest is obscured. uate the neurovascular bundle in tion of symptoms. an increase genital anomaly. however. respectively. Adson test. Longley et al21 reported 92% raphy is rarely useful in TOS and is graphs can identify cervical ribs. and 30%. Angiography may be used in con- attempt to provide a more objective Three-dimensional imaging. a bruit with the and low-lying shoulder girdles. In this maneuver. In a series by Gillard et al. suspicion April 2015. Wright test. however. all of the diagnosis of venous TOS. between physiologic and pathologic Diagnostic Studies posed that ultrasonography is lim. spec- ificity increased to 82%. specificity and 95% sensitivity only indicated in the circumstances prominent C7 transverse processes. C and D. Vol 23. rep- resents a more reliable diagnostic examination for TOS. a space-occupying angiography can dynamically eval- in the heart rate. Warrens et al17 showed that 58% of random volunteers had at least one positive test result with provocative maneu- vers. but it may be effective in mains unclear.

abductor pollicis brevis. genic TOS experienced symptomatic When an acute thrombosis is detected. and weight and ies were considered normal in cases of on history and physical examination. indicated by the white arrow. Torriani et al29 re- racic outlet compression in conjunction than 40 years. Clarifying goals of treatment is critical At the authors’ institution. A typical protocol consists early catheter-directed thrombolysis and surgical decompression may be Appropriately placed lidocaine or of education. Unauthorized reproduction of this article is prohibited. or differing blood in neurogenic TOS. Nonsurgical management is indicated first in most patients with neurogenic TOS. plain for patient outcome. Surgery is warranted in arterial or venous TOS and in patients with neurogenic TOS who have persistent Radiograph of a patient with a right cervical rib. tion may reliably improve symptoms upper extremities. Activity modifica- TOS unless the pathology was found followed by other diagnostic tests as tion includes limiting repetitive. Treatment Treatment strategy depends on the underlying etiology of TOS. muscle atrophy.26. a TOS thrombosis can represent a two. muscle arterial or venous thrombosis should prognostic benefits. however.6 trative points about different diag. it has shown good results in TOS. Lum et al24 relaxants.6 However. 69% of patients with neurogenic TOS. indicated to decrease the risk of botulinum toxin injections can and physical therapy.2 Despite several series 228 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. that 25 of 42 patients with neuro- eralization from nearby circulation. for when there is concern for a space- occupying lesion. with predominantly neurologic signs if necessary.27 arterial TOS are likely more positional antebrachial cutaneous nerve and Nonsurgical and are better diagnosed on physical the median motor nerve to the examination than with angiography. surgical outcomes in patients older num injections.Thoracic Outlet Syndrome Figure 5 uniformly dictate vascular imaging. and injections. transcutaneous electrical undergo coagulation studies because found that a successful block corre. patients with suspected TOS based postural mechanics. These changes patient population. Other cases of duction velocity studies of the medial and quality of life. nutritional control. Novak et al28 reported the subclavian vein as well as collat. symptoms. range-of-motion exercises. demonstrating compression of they are not shown as consistently as some series. or for a congenital or acquired deformity. activity modification. nerve stimulation. Physical therapy involves Tsao et al23 suggest that nerve fibers and symptoms often undergo neu. Patients head stress and changing employment had already occurred. Historically. and to a lesser rophysiologic testing early in their and tendon and nerve gliding tech- degree from C8. nostic techniques. lated with a 14% higher rate of good Using ultrasonography-guided botuli- hit phenomenon of mechanical tho. Patient education Neurophysiologic Studies radiographs are obtained initially for focuses on relaxation techniques. It is important relieve muscular contracture or pain control strategies include anti- to note that patients who experience spasm and have been shown to have inflammatory medications. TOS. over- late and permanent nerve damage dictated by their symptoms. nerve conduction velocity changes. derived from T1. Described a recurring thrombosis. . Table 2 depicts illus. neurophysiologic stud. or a pro- gressive deficit. stretching. ported short-term improvement in with underlying hypercoaguability. surgical interven- pressure measurements between the manifest as abnormal nerve con. relief after at least 6 months of physical Anterior Scalene Blocks therapy. venography is indicated ography may show fibrillations in tial treatment strategy for neurogenic in the workup of suspected venous T1 and C8 distributions. Three-dimensional imaging is reserved for surgical planning. may show changes workup. In the appropriate of an aneurysm. Electromy. Nonsurgical management is the ini- Conversely. Vascular manifestations niques.

describe the muscular or obese. TOS = thoracic outlet syndrome Surgical For any patient with vascular com- neurolysis. Posterior Table 3 summarizes some of the char. or patients with transaxillary approach as their ini. poorer exposure of the first rib TOS at the authors’ institution is scalenectomy. patients who are excessively TOS.9 Although the supra. who are on workers’ compensation. vides a more favorable exposure of The posterior approach. imaging posttraumatic deformity.8 Terzis et al32 reported pression or neurogenic TOS that has first rib resection can be accom. al- the first rib. the neck of described by Clagett38 in 1962. and posterior. Supraclavicular ences that are surgeon dependent. CT = computed tomography. (medial antebrachial cutaneous nerve)23 toms after 6 months. by surgeons who are performing iso. for removing rib remnants and for of cervical ribs and fibrous bands. Other Considerations which they perform first rib and clavicular approach may provide The favored surgical approach for costoclavicular ligament resection. ribs and prominent transverse processes20 Cervical spine agement is reported to be less suc- Chest cessful in obese patients. TOS over 50 years.34 supraclavicular. and T1 compared with the transaxillary similar to that described by Urschel April 2015. and C7. If the patients conduction velocities in C8 and T1 nerve roots show no improvement in their symp. surgical intervention is approach. the approach is the transaxillary approach is the lated scalenectomies and removal of more invasive and it can lead to most commonly performed approach cervical ribs for neurogenic TOS.28 At the au- Doppler ultrasonography May be useful in evaluating subclavian vein for thors’ institution. and the neurovascular lows better exposure of the proximal Transaxillary structures. as well as for removal plexus-type neurogenic TOS. rolysis for patients with recurrent Urschel et al. Vol 23. the supraclavicular approach is the thoracic outlet are transaxillary. originally acteristics of each surgical approach. neurolysis. good outcomes and fewer compli- failed to respond to nonsurgical plished via the supraclavicular cations with the supraclavicular management. If warranted. although there are many variations and prefer. all patients with obstruction or thrombosis21 suspected neurogenic TOS are coached Arteriography Often indicated in the workup of arterial aneurysms6 in lifestyle modification and are Venography Indicated in the workup of suspected subclavian/ referred for a trial of physical therapy axillary venous thrombosis6 that focuses on core strengthening and Neurophysiologic tests Often normal but can demonstrate abnormal nerve postural mechanics. . Anterior scalene blocks Blocks that relieve TOS symptoms may indicate a better chance of good surgical outcome24 uated and referred for surgical consideration if appropriate. recurrent TOS following prior first tial surgical approach through rib resection. arterial reconstruction is necessary. soft-tissue anatomic and in patients with double-crush CT anomalies25 neurologic pathology involving the MRI carpal or cubital tunnels. the upper brachial plexus. This approach is preferred elements of the brachial plexus for First described by Roos36 in 1966.37 in their review of ture. Kuhn. Diagnostic Modality Key Points lished due to a lack of randomized Radiographs Can identify bony abnormalities including cervical controlled trials.8 postoperative shoulder morbidity today. however. they are reeval. et al reporting positive results. C8. Nonsurgical man. visualization is inferior technique for first rib resection.31 absence of abnormal bony architec. The three main surgical and requires retraction of the neu. John E. They argue that while approach. No 4 229 Copyright ª the American Academy of Orthopaedic Surgeons. preferred. approaches for decompression of rovascular structures. in patients Three-dimensional May be effective in space-occupying lesions. Its proponents argue that it Scalenectomy in isolation can be and scapular winging.34 Urschel provides superior exposure for first considered in patients with upper et al37 reserve the posterior approach rib resection. The supraclavicular approach pro. pa. tients with TOS symptoms in the performing brachial plexus neu- with a more cosmetic scar.10. MRI = magnetic resonance imaging. Vanti et al30 Table 2 reviewed the literature and reported Common Diagnostic Tools for the Evaluation of Thoracic Outlet Syndrome that no definitive benefit of non- surgical management could be estab. Unauthorized reproduction of this article is prohibited. MD.

in the largest review. comes. initial man- congestion may be required. structures.13 TOS surgeries. theoretical complications proaches have led to improved out- Unique to surgery for arterial or are numerous and may be severe. saphenous vein one of the most common complica- approach for first rib resection. 3 of 5.008 procedures represented repeat symptoms reproducible to the sub- chronic venous occlusion. local wound infection and an incidence of the literature. vein thrombus (ie. or agement consists of nonsurgical care. Karamustafaoglu et al31 re- lenectomy. Atasoy39 reported that thrombectomy. Arte. neck of the first rib. 95% of patients had good outcomes whereas more distal and chronic No major vascular injuries occurred.Thoracic Outlet Syndrome Table 3 Common Surgical Approaches for Thoracic Outlet Syndrome Surgical Approach Characteristics/Proposed Advantages Disadvantages Transaxillary Most commonly used approach Risk of iatrogenic brachial plexus injury32 Allows more complete exposure of first rib More cosmetic scar No retraction of neurovascular structures necessary for first rib removal31 Supraclavicular Allows better exposure of the middle and Retraction of brachial plexus and vascular upper trunks. Acute. and neurolysis with vas.221 of the with neurogenic TOS and with require late vein reconstruction for 5. 1. Desai et al35 showed the utility of using a paraclavicular approach. Series the diagnosis is again firmly estab- presence of ischemic changes.35 Posterior Favored for recurrent TOS and in cases of Requires extensive muscle dissection that can prior anterior neck surgery lead to postoperative shoulder dysfunction May allow better exposure of proximal Risk of injury to the long thoracic. . particularly in the decompress the thoracic outlet. a synthetic tions. injury to the subclavian gery. coracoid space. for mild stenotic disease. Surgical strategies for treating rial repair strategies include resection associated with first rib resection is recurrent symptoms generally are 230 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. The vein or artery. Unauthorized reproduction of this article is prohibited. or recurrent symptoms following sur- and management of ischemia or mothorax.1% for lymphatic or nerve injury. arterial autograft. Long-lasting utility of performing an isolated local thrombolysis. The major complication pectoral minor tenotomy in patients thrombus. elements of the brachial plexus34 and accessory nerves34 et al. sca. and failure to fully followed by surgical measures when more urgent. Bleeding requiring anterior and middle scalenectomy. and anticoagulation.008 procedures. essentially adding an in- Complications Recurrent Thoracic Outlet fraclavicular incision to the supra- Syndrome clavicular approach. for more complete Because surgery for TOS involves first rib resections in patients with many complex and intimately related Although modern surgical ap- venous TOS. vascular reconstruction These complications include pneu. Some patients may seen was recurrent TOS.37 it consists of a transaxillary and primary repair. Urschel et al37 reported no major followed by immediate supraclavicular mia. prosthesis. and surgical nerve deficits occurred in only four decompression to prevent recurrent patients. with a combined approach consisting emboli mandate bypasses if the Likewise. Paget-Schroetter a second procedure occurred in only Vemuri et al40 demonstrated the syndrome) requires a venogram. and structure necessary for complete first rib anterior and middle scalene muscles32 removal31 May also allow effective first rib resection32 Allows vascular reconstruction33. . of transaxillary first rib resection. Other cular reconstruction if necessary.37 In these patients. some patients have persistent venous TOS. or an endovascular stent ported an incidence of 25%. dorsal scapular. timing of surgical intervention is thoracic duct. have shown that a pneumothorax lished. emboli are causing critical ische.14 Venous TOS with subclavian arterial injuries. complications in this series were low Various other modifications to proximal emboli may be treated and included an incidence of 3% for surgical techniques are described in with embolectomy catheters. graft. brachial plexus.

Brantigan CO. Mertens R. In this article. Gilliatt RW. Atasoy E: Thoracic outlet syndrome: patients with possible thoracic outlet ment. 9. syndrome. 22. Le Quesne PM. Anat Anz 1912. Yedlicka JW. management that includes education. magnetic resonance neurography 17. McGalliard MK. J Vasc Surg 2007. Gergoudis R. Such technology has the syndrome: A controversial clinical helical computed tomography in 48 patients. mainstay of treatment is nonsurgical (5):724-732. Huang JH.41(11): and vascular disorder. Cevikol C. syndrome. TOS remains a difficult diagnosis due 6. Marine L. References 4 and 38 (5):615-624. MD. Contribution of provocative tests. Zager EL: Thoracic outlet on the differential diagnosis for pa. et al: and corresponding increased signal Diagnosing thoracic outlet syndrome: 2. evidence are described in the table of 15. 113-118. surgi. Hachulla E. J Vasc Surg 2012. Ferrante MA. In cases of 12. Roos DB: Diagnosing Schwabacher S. Molina EJ. Likes K. 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