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Thoracic Outlet Syndrome

Article  in  Neurosurgery · November 2004

DOI: 10.1227/01.NEU.0000137333.04342.4D · Source: PubMed

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 TOPIC REVIEW

THORACIC OUTLET SYNDROME

Jason H. Huang, M.D.
Department of Neurosurgery,
Hospital of the University of
Pennsylvania, University of
Pennsylvania Medical Center,
Philadelphia, Pennsylvania
Eric L. Zager, M.D.
Department of Neurosurgery,
Hospital of the University of
Pennsylvania, University of
Pennsylvania Medical Center,
Philadelphia, Pennsylvania
Reprint requests:
Jason H. Huang, M.D.,
Department of Neurosurgery,
3 Silverstein Pavilion,
3400 Spruce Street,
Philadelphia, PA 19104.
Email: huangj@uphs.upenn.edu
Received, May 2, 2003.
Accepted, May 24, 2004.
OBJECTIVE: Thoracic outlet syndrome (TOS) is one of the most controversial clinical
entities in medicine. We provide a review of this difficult-to-treat disorder, including
a brief overview, clinical presentations, surgical anatomy, treatment options, and
outcomes.
METHODS: TOS represents a spectrum of disorders encompassing three related
syndromes: compression of the brachial plexus (neurogenic TOS), compression of the
subclavian artery or vein (vascular TOS), and the nonspecific or disputed type of TOS.
Neurovascular compression may be observed most commonly in the interscalene
triangle, but it also has been described in the costoclavicular space and in the
subcoracoid space. Patients present with symptoms and signs of arterial insufficiency,
venous obstruction, painless wasting of intrinsic hand muscles, paresthesia, and pain.
A careful and detailed medical history and physical examination are the most impor-
tant diagnostic tools for proper identification of TOS. Electromyography, nerve con-
duction studies, and imaging of the cervical spine and the chest also can provide
helpful information regarding diagnosis. Clinical management usually starts with
conservative treatment including exercise programs and physical therapy; when these
therapies fail, patients are considered for surgery. Two of the most commonly used
surgical approaches are the supraclavicular exposure and the transaxillary approach
with first rib resection. On occasion, these approaches may be combined or, alterna-
tively, posterior subscapular exposure may be used in selected patients.
CONCLUSION: TOS is perhaps the most difficult entrapment neuropathy encountered
by neurosurgeons. Surgical intervention is indicated for vascular and true neurogenic
TOS and for some patients with the common or nonspecific type of TOS in whom
nonoperative therapies fail. With careful patient selection, operative intervention
usually yields satisfactory results.
KEY WORDS: Brachial plexopathy, First rib resection, Supraclavicular approach, Thoracic outlet syndrome,
Transaxillary approach

Neurosurgery 55:897-903, 2004 DOI: 10.1227/01.NEU.0000137333.04342.4D www.neurosurgery-online.com

T
horacic outlet syndrome (TOS) is one of the most con-
troversial clinical entities in medicine. Although it is
generally accepted that TOS is caused by compression of
brachial plexus elements or subclavian vessels in their passage
from the cervical area toward the axilla and proximal arm,
there is a great deal of disagreement among clinicians regard-
ing its diagnostic criteria and optimal treatment (7, 16, 18, 24,
36, 45). Some physicians even doubt the existence of TOS.
Because there is no objective confirmatory test for TOS, there
is also much disagreement among clinicians with regard to its
true incidence (31, 46), with reported incidences ranging from
3 to 80 cases per 1000 population. A variety of diseases can
mimic the presentation of TOS (Table 1), and in most situa-
tions, TOS is a diagnosis of exclusion. TOS is more commonly
observed in women, and the onset of symptoms usually oc-
curs between 20 and 50 years of age. From a practical stand-
point, we divide patients with TOS into three groups: 1) those
with compression of the brachial plexus, also called neuro-
genic TOS; 2) those with compression of the subclavian vessels
(either artery or vein), also called vascular TOS; and 3) those
with nonspecific-type TOS, sometimes referred to as the dis-
puted or common type of TOS, consisting poorly defined
chronic pain syndrome with features suggestive of brachial
plexus involvement (46). Occasionally, the neurological and
vascular components may coexist in the same patient. The
neurogenic type of TOS is more common clinically than vas-
cular TOS. The disputed or nonspecific-type TOS refers to a
large group of patients with unexplained pain in the arm,
scapular region, and cervical region. Their symptoms fre-
quently are triggered by a discrete traumatic event such as a

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HUANG AND ZAGER

TABLE 1. Differential diagnosis of thoracic outlet syndrome
Cervical disc or osteophyte
Pancoast tumor
Nerve sheath tumor
Ulnar and/or median nerve entrapment
Brachial plexitis
Syrinx or spinal cord tumor
Shoulder pathology (e.g., rotator cuff injuries)
Fibromyalgia
Multiple sclerosis
Raynaud disease
Acute coronary syndrome
Vasculitis
Vasospastic disorder
Complex regional pain syndrome
motor vehicle accident, and results of objective neurological
evaluation often are normal. The diagnosis of nonspecific-type
TOS depends on the presence of provocative reproduction of
symptoms as well as the absence of any other specific diag-
nosis. Unfortunately these provocative tests (e.g., Adson test)
are themselves nonspecific, and results of neurophysiological
tests that are useful in documenting true neurogenic TOS are
normal in the nonspecific disorder. Finally, there is consider-
able disagreement among clinicians regarding treatment of
TOS and debate regarding conservative treatment versus sur-
gical intervention (6, 13, 17, 18, 21, 22, 25). The choice of
surgical approach is also controversial; both of the two pop-
ular approaches, the transaxillary first rib resection and the
supraclavicular approach, have been used widely and provide
good outcomes, although major surgical complications also
have been reported (4, 6, 10, 16, 19, 20, 29, 32, 43, 45).
(Fig. 1). This triangle contains the trunks of the brachial plexus
and the subclavian artery. The subclavian vein crosses anterior
to the anterior scalene muscle. Just distal to the interscalene
triangle, the neurovascular bundle enters the costoclavicular
triangle, which is bordered anteriorly by the middle third of
the clavicle, posteromedially by the first rib, and posterolater-
ally by the upper border of the scapula. Finally, the neurovas-
cular bundle enters the subcoracoid space beneath the cora-
coid process just deep to the pectoralis minor tendon.
Compression or irritation of the brachial plexus elements
has been described in all three of these anatomic spaces, but
for practical purposes, the vast majority of cases of TOS in-
volve neural and/or vascular compression within the inter-
scalene triangle. This area may be small at rest and may
become even smaller with certain provocative maneuvers,
e.g., abduction and external rotation of the arm. Anomalous
structures such as cervical ribs, anomalous muscles, and fi-
brous bands may constrict this triangle further. Anomalous
fibrous bands are a more common cause of TOS than rib
anomalies (23, 30). The anomalous bands may originate from
a cervical or rudimentary 1st thoracic rib, C7 vertebra, Sibson’s
fascia (the suprapleural membrane) or the scalene muscles.
Pang et al. (23, 24) have presented a detailed description and
illustration of the cervical band syndrome associated with
TOS. Repetitive trauma to the plexus elements, particularly
the lower trunk and C8–T1 spinal nerves, is thought to play an
important role in the pathogenesis of TOS. This may occur in
a variety of occupations, sports, and hobbies. The disputed or
nonspecific-type TOS frequently is triggered by a discrete
traumatic event such as a motor vehicle accident.

SURGICAL ANATOMY
The term thoracic outlet has remained an unfortunate mis-
nomer for this anatomic region, which more properly should
be designated the thoracic inlet. The neurovascular bundle,
which contains the brachial plexus trunks and the subclavian
vessels, courses through three narrow passageways from the
base of the neck toward the axilla and the proximal arm. The
most important of these passageways clinically is the most
proximal, the interscalene triangle, which is bordered by the FIGURE 1. Illustration of the thoracic outlet anatomy showing the relation-
anterior scalene muscle anteriorly, the middle scalene muscle ship of the brachial plexus and subclavian artery to the clavicle and anterior
posteriorly, and the medial surface of the first rib inferiorly and middle scalene muscles.

898 | VOLUME 55 | NUMBER 4 | OCTOBER 2004 www.neurosurgery-online.com


CLINICAL PRESENTATION
AND DIAGNOSIS
In the three types of TOS, compression of the vascular
structures is relatively uncommon. It is usually easy to iden-
tify with objective vascular modalities such as venography
and arteriography (Fig. 2). Thrombosis of the subclavian vein
often is referred to as Paget-von Schrötter syndrome. It tends to
occur in younger men and often is associated with strenuous
work. Patients often present with edema and cyanosis of the
upper extremity or distended superficial veins of the shoulder
and chest. Color flow duplex ultrasonography, magnetic res-
onance venography, or venography is used to assist in the
diagnosis of subclavian vein compression and thrombosis.
Similarly, compression of the subclavian artery often occurs in
young adults with a history of vigorous arm activity. Patients
often present with pallor, pulselessness, and coolness of the
affected upper extremity. Decreased blood pressure greater
than 20 mm Hg in the affected arm compared with the con-
tralateral arm is often a reliable indicator of arterial involve-
ment. Rarely, patients can present with multiple small infarcts
of the hand and fingers owing to embolization. Duplex ultra-
sonography, magnetic resonance arteriography, computed to-
mographic angiography, and arteriography is used to confirm
the diagnosis. Definitive treatment involves prompt surgical
FIGURE 2. Schematic drawing showing proposed treatment algorithm for
TOS. APB, abductor pollicis brevis; MRI, magnetic resonance imaging;
MRA, magnetic resonance angiography; MRV, magnetic resonance venog-
raphy; CTA, computed tomographic angiography; BP, brachial plexus;
C-spine, cervical spine; CXR, chest x-ray; TP, transverse process.
NEUROSURGERY
THORACIC OUTLET SYNDROME
decompression of the subclavian artery or vein and recon-
struction of the damaged vessel if needed.
The true neurogenic and disputed types of TOS encompass
the vast majority of such patients evaluated by a surgeon. The
contrast between these two types of TOS syndrome may be
characterized by the relatively painless form, in which the
neurological and electrodiagnostic findings are quite dra-
matic, versus the type associated with chronic pain syndrome
and few definitive neurological or electrodiagnostic findings.
The classic finding in the patient with true neurogenic TOS is
the so-called Gilliatt-Sumner hand with the most dramatic
degree of atrophy observed in the abductor pollicis brevis,
with lesser involvement of the interossei and hypothenar mus-
cles (Fig. 3) (12). Sensory loss is restricted to the ulnar aspect of
the hand and forearm, as predicted by the known compression
of the lower trunk primarily. Upper trunk forms of TOS have
been described, but the reports are authored by non-
neurologists who evaluated patients with chronic pain syn-
dromes rather than true neurogenic TOS. The typical patient
with the true neurogenic form of TOS is a young, thin female
with a long neck and drooping shoulders (5, 24, 39, 47).
However, we have observed cases in men and even in body-
builders with overly developed scalene musculature. Dull,
aching pain in the lateral neck, shoulder, axilla, parascapular
region, and inner aspect of the arm and forearm is often
described, but pain is not the cardinal feature, unlike the
common or nonspecific neurogenic form of TOS. Discomfort
may be provoked by repetitive use of the extremity, particu-
larly with overhead activities. Pain is often diffuse and non-
dermatomal, and paresthesia is most often restricted to the
ulnar aspect of the hand and forearm. There are no reliable
provocative tests, but the 90-degree abduction and external
rotation test seems to have the best predictive value (11, 28).
Tinel’s sign over the supraclavicular fossa also seems to be
important.
FIGURE 3. Photographs showing Gilliatt-Sumner hand in a patient TOS.
Severe thenar wasting in the right (symptomatic) hand, mainly involving
the abductor pollicis brevis, is observed. A, side view of both hands. B,
frontal view of the right hand. The thenar eminence has typical “scal-
loped” appearance.
VOLUME 55 | NUMBER 4 | OCTOBER 2004 | 899
HUANG AND ZAGER

By far the most common patient to present to a surgeon’s

office with TOS has the nonspecific or common type. These
cases more often involve a traumatic event, e.g., a motor
vehicle accident or a work-related injury. Litigation often is an
important variable in these cases, and unfortunately it must be
included in the clinical decision-making equation. Physical
examination is difficult in these patients because of the ten-
dency to guard the extremity and to exhibit giveaway-type
weakness, and the sensory examination often is unreliable.
Atrophy is usually not observed except as a result of disuse in
truly chronic cases. Provocative maneuvers usually are posi-
tive in a wide anatomic area, often extending outside the
region innervated by the brachial plexus (Fig. 2). FIGURE 4. Anteroposterior x-ray of the cervical spine. The elongated
transverse process of the 7th cervical vertebra (dotted arrow) and a small
cervical rib on the left (solid arrow) are visible.
ELECTRODIAGNOSTIC AND
symptoms (e.g., tumors or degenerative disease of the cervical
IMAGING STUDIES spine) rather than to establish the diagnosis of TOS.
Nerve conduction studies and electromyography are often
helpful as components of the diagnostic evaluation of patients
with suspected TOS (35, 46). In advanced cases of neurogenic TREATMENT
TOS, nerve conduction studies commonly reveal the following
For most patients with TOS, common practice is to offer a
characteristics: 1) decreased amplitude in ulnar sensory action
course of conservative treatment. Conservative management in-
potentials; 2) decreased amplitude in median compound motor
cludes modification of behaviors by avoiding provocative activ-
action potentials; 3) normal or slightly decreased ulnar motor
ities and arm positions, in addition to individually tailored phys-
potentials; and 4) normal median nerve sensory potentials. Fi-
ical therapy programs that strengthen the muscles of the pectoral
brillation potentials (suggestive of active axonal loss) are most
girdle and help to restore normal posture (17, 22). The reported
pronounced in the median innervated abductor pollicis brevis
improvement with conservative management of TOS ranges
and less pronounced in the ulnar innervated first dorsal in-
from 50 to 90% (3, 13, 21, 22, 46). Only in extremely rare situations
terosseous and abductor digiti quinti. Electromyography often
is emergency surgery indicated, e.g., in patients with infarction
reveals severe abnormalities in the hand intrinsic muscles.
caused by vascular occlusion or recurrent embolism.
The electrodiagnostic findings described above can be ex-
Surgical intervention is indicated in the vascular forms of TOS,
plained by the pathogenesis of TOS. Although all three trunks of
which are usually resistant to conservative management. Surgi-
the brachial plexus enter the interscalene triangle, only the lower
cal treatment is also indicated in patients with the true neuro-
trunk (C8–T1), along with the subclavian artery, is in direct
genic form of TOS, in which conservative management most
contact with the tendinous portion of the scalene muscle and the
often is unhelpful. Many of these patients present with advanced
hard surface of the rib. All of the C8–T1 sensory fibers course in
atrophy. On the other hand, we offer surgery to patients with the
the ulnar nerve, which accounts for the decreased ulnar sensory
nonspecific or disputed type of TOS only as a last resort, after
potentials and normal median sensory potentials. The C8–T1
prolonged conservative management and a clear discussion em-
motor fibers are carried by both the median and ulnar nerves, but
phasizing the potential risks and complications of surgical explo-
the median motor fibers are preferentially injured as a result of
ration in this complex anatomic region.
their location within the lower trunk. Thus, the median motor
compound action potentials tend to reveal a greater degree of
abnormality than the ulnar motor potentials. SURGICAL APPROACHES
In addition to electrophysiological studies, imaging studies
can provide useful information in the diagnosis of TOS. Cer- The two most commonly used surgical approaches for treat-
vical spine and chest x-rays are important in the identification ment of TOS are the anterior supraclavicular and the transax-
of bony abnormalities, including cervical ribs or prominent, illary approach for resection of the first rib. Major neurovas-
often “peaked” C7 transverse processes (Fig. 4). Anomalous cular complications have been reported with both approaches.
cervical ribs are reported in approximately 10% of patients Surgeons typically use the approach with which they are most
with TOS (26, 30, 38). The estimated incidence of anomalous familiar to achieve the best outcome. A third approach, the
ribs as revealed by routine chest x-rays in the general popu- posterior subscapular approach, is used much less frequently.
lation varies from less than 0.01% to 0.5% (1, 2, 9, 27, 37, 40).
Most cervical ribs are not symptomatic, however. Magnetic Transaxillary Approach
resonance imaging and computed tomography are more use- The transaxillary approach with resection of the first rib is
ful for the identification of other conditions that might cause favored by most thoracic surgeons and many vascular sur-

900 | VOLUME 55 | NUMBER 4 | OCTOBER 2004 www.neurosurgery-online.com


geons (31, 32, 44, 45). It was first popularized by Roos in 1966
(29). With the patient in a posterolateral position and the arm
elevated above the head, an incision is made over the palpable
rib (usually the third rib) in the axillary fossa. The axillary fat,
lymph nodes, and vessels are dissected away, and the anterior
scalene and middle scalene muscles are divided. The first rib
is identified and resected. The advantage of this approach is
that it allows easy access through a hidden incision to almost
the entire first rib yet unhindered by the neurovascular struc-
tures. The shortcoming of this approach lies in its limited
exposure of the neural elements. Most congenital bands and
cervical ribs lie medial to the first rib and hidden behind the
neurovascular structures.
Anterior Supraclavicular Approach
The anterior supraclavicular approach is favored by most
neurosurgeons, who frequently use this exposure to treat neo-
plasms and trauma to the brachial plexus region. It allows wide
exposure of the supraclavicular plexus and middle two-thirds of
the first rib, where most of the potential congenital bands are
located. The incision is centered on the posterior triangle of the
neck and is either transverse or L shaped. During the exposure,
important landmarks include the sternocleidomastoid muscle,
the supraclavicular fat pad, the omohyoid muscle, the phrenic
nerve, and the anterior scalene muscle. Exposure can be achieved
with minimal morbidity when performed by a surgeon with
experience in brachial plexus operations (15, 18, 24, 34, 41). The
first rib also can be resected by use of this approach. After an
anterior approach, good to excellent results average approxi-
mately 80% (14, 23, 32, 42). In the series of 142 cases reported by
Pang (23), who used the supraclavicular approach, 85% had an
excellent outcome (defined as the total or near total disappear-
ance of pain and paresthesia and return to work); 13% had a
good result (significant improvement but some residual pain);
and only 2% had a poor outcome (no improvement and inability
to return to work). Infrequently, phrenic nerve paralysis may
occur; Sanders et al. (33) reported an incidence up to 7% in their
series. The paralysis is usually temporary and asymptomatic in
most patients. In the series presented by Pang (23) comprising
142 cases, there were 6 cases of transient brachial plexopathy
attributed to heat injury from the bipolar cautery. Small pleural
leaks also may occur, but most do not require chest tube
drainage.
Posterior Subscapular Approach
The posterior subscapular approach was popularized by
Kline et al. (8) at Louisiana State University, and it provides
excellent exposure of the C8 and T1 spinal nerves and the
lower trunk. We reserve this approach for patients who have
undergone prior anterior approaches or radiation therapy
with scarring. The posterior subscapular approach involves
extensive muscle dissection, and the nerves that are vulnera-
ble to injury during exposure include the long thoracic nerve,
the dorsal scapular nerve, and the accessory nerve. This ap-
proach has a 5% incidence of scapular winging as a result of
NEUROSURGERY
THORACIC OUTLET SYNDROME
long thoracic nerve injury or unsatisfactory healing of the
levator and rhomboid muscles (7, 8, 24).
CONCLUSION
TOS is perhaps the most difficult-to-treat entrapment neu-
ropathy encountered by neurosurgeons. Surgical intervention
is indicated for patients with vascular and true neurogenic
TOS and in those with the nonspecific or disputed type of
TOS, in whom nonoperative treatment fails. With careful pa-
tient selection, operative intervention usually can yield satis-
factory results.
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Acknowledgments
This work was supported in part by the American Association of Neurological
Surgeons Codman Award and David Kline Award (to JHH).
COMMENTS
T he authors have presented a review article on a complex and
challenging subject. They reviewed a literature that, at its
best, can be confusing and frustrating. It has always been my
902 | VOLUME 55 | NUMBER 4 | OCTOBER 2004
contention that there are, in fact, two thoracic outlet syndromes
(TOSs), the first, or “true,” syndrome being one where there is
clear-cut evidence of brachial plexus compression in the lower
trunk, and another where the reported symptoms largely consist
of pain in a widely distributed area around the neck, shoulder,
and arm, the latter having very few objective neurological or
electrodiagnostic findings. This is often referred to as the dis-
puted TOS. The authors make this distinction clearly.
Unfortunately, the nonspecific or disputed TOS is far more
common than the true syndrome. The true syndrome seems to
occur in approximately one person per million. A few points
deserve emphasis. There are a large number of anomalous bands
reputedly causing TOS. These bands have virtually all been
associated with studies detailing the experience of patients with
disputed TOS. There is one band stretching from the tip of an
abnormal C7 transverse process to the first rib that is clearly
implicated in true TOS. None of the other reputed abnormal
bands have ever been shown to cause a clearcut nerve root
compression syndrome. Virtually all patients with true TOS have
a cervical rib or an abnormal “beaked” and elongated C7 trans-
verse process. These abnormalities are best seen on apical lor-
dotic chest x-rays, although at times oblique cervical spine x-rays
may demonstrate them also. Cervical ribs are relatively rare in
patients with disputed TOS.
Separating the two types of neurogenic TOS can sometimes
be quite difficult. The authors have delineated the findings in
the true TOS: namely, atrophy of the intrinsic hand muscles,
especially the abductor pollicis brevis, the presence of a cer-
vical rib or abnormal C7 transverse process, and the typical
nerve conduction findings. When these are present, one can be
quite secure in diagnosing true TOS. There is little place for
conservative therapy in this diagnosis. Unfortunately, dra-
matic improvement does not seem to follow surgical plexus
decompression. The authors point out that one must be very
careful in performing surgery on patients with a less clearcut
TOS. The potential for serious complications, including dam-
age to the brachial plexus, is definitely present. The literature
supports a success rate of 70% at best. This percentage seems
to decrease fairly substantially over the years.
John E. McGillicuddy
Ann Arbor, Michigan
H uang and Zager have provided a review of TOS, includ-
ing its various forms and commonly accepted treatment
strategies. They present and discuss three syndromes: 1) com-
pression of the brachial plexus (neurogenic thoracic syn-
drome), 2) compression of the subclavian artery, and 3) com-
pression of the subclavian vein. They discuss in particular the
presentation and management strategies for neurogenic TOS,
commonly known to neurosurgeons as cervical band syn-
drome, which frequently is underdiagnosed. The authors have
raised our awareness of this entity and have provided a strat-
egy for diagnosis and management.
Edward C. Benzel
Cleveland, Ohio
www.neurosurgery-online.com

T he authors review the history and the current diagnostic and
surgical management options of TOS. This topical review
provides basic and standard information to the practicing neu-
rosurgeon in the area of TOS and serves as a reference guide for
researching this topic further. TOS is a complex problem, as is
delineated by the authors, in that it has multiple presentations.
The concern is with regard to the concept of neurogenic TOS
versus nonspecific arm and shoulder discomfort with extension
to the scapula. In these instances, the surgical indications become
unclear, as does whether decompression is indicated. Further
workup is lacking, and the results are often less satisfying in
these patients. The authors, however, provide a treatment algo-
rithm that would be very useful to a practicing neurosurgeon
with regard to diagnostic tests, differential diagnosis, and poten-
tial surgical treatment. Overall, this article provides a good re-
view, but is only a starting point for neurosurgeons who may be
further interested in this area.
P. David Adelson
Pittsburgh, Pennsylvania
T he authors have provided a succinct review of TOS. They
emphasize the difficulty in making this diagnosis, espe-
cially for disputed neurogenic TOS. This means that all other
possible differential diagnoses need to be excluded as much as
possible before this diagnosis is entertained. Also highlighted
by the authors is the need for a good trial of physical and
occupational therapy before resorting to surgery. Descriptions
of the operative approaches are brief, of necessity, and out-
Plaster cast of pregnant woman found on Via Stabiana in Pompeii. Her body, covered in a fine layer of ash, created a mold that was later filled with plas-
ter using the Giuseppe Fiorelli method, named after the archaeologist who led the official excavation of the site in 1860. (Photo courtesy of Electa, Milan.)
Please see de Divitiis et al., pp. 989–1006.
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THORACIC OUTLET SYNDROME
comes are not provided because it was the main intent of the
authors to discuss the entity and its clinical presentation.
Several additional observations are in order. Dr. Jim Camp-
bell and his group at Johns Hopkins favor transaxillary first
rib resection, and in their hands, this approach seems to work
well. Our group favors a supraclavicular approach or, in se-
lected cases, a posterior subscapular approach. This is in part
based on intraoperative nerve action potential recordings
found not only in Gilliatt-Sumner hand patients but also in
those with disputed TOS; the operative electrophysiological
findings are at a spinal nerve-to-trunk level, not more laterally
at a trunk-to-division level (1, 2; G Tender, A Thomas, N
Thomas, D Kline, in preparation). Thus, the problem, where
one exists, is a proximal one close to the spine, and indeed,
when we see anatomic correlates, such as a medial scalene
fibrous edge or band with or without cervical rib or elongated
C7 process, scalene minimus, or Sibson’s fascia entrapment,
those variants also are close to the exit of the spinal nerve from
the spine and do not occur more laterally.
David G. Kline
New Orleans, Louisiana
1. Kim D, Cho Y, Tiel R, Kline D: Outcomes of surgery in 1019 brachial plexus
lesions treated at Louisiana State University Health Sciences Center.
J Neurosurg 98:1005–1016, 2003.
2. Kline D, Hudson A: Nerve Injuries: Operative Results for Major Nerve Injuries,
Entrapments, and Tumors. Philadelphia, W.B. Saunders Co., 1995.