Thoracic Outlet Syndrome

NONATHEROSCLEROTIC DISORDER

The thoracic outlet is the space through which the subclavian artery and vein and the brachial plexus pass from the neck into the upper extremity.

Its anatomic boundaries are the chest wall, the scalene muscles, the clavicle, and, potentially, a variety of anomalous, sometimes compressive structures such as fibrous bands or cervical ribs

Proper treatment of thoracic outlet syndrome (TOS) requires a detailed history and physical examination, appropriate diagnostic tests, and understanding of the intricate anatomic relationships in this area.

AKA: Neurovascular Compression Syndromes

Classic Presentation: Diffuse arm symptoms, numbness, tingling; typically down medial arm to 4th and 5th digits.

Symptoms are worse with overhead activity.

THORACIC OUTLET SYNDROME

Generalized Symptoms: Pain in the upper extremity, paraesthesia, numbness, weakness, skin discolorations, swelling, Raynaud s Phenomenon.

Arterial Component
The arterial complications of TOS are caused by a bony cervical rib or an anomaly of the first rib. Patients may present with an asymptomatic pulsatile cervical mass with upper-extremity ischemia ranging from unilateral Raynaud's phenomenon to acute ischemia with absent pulses. Symptoms are caused by atheroemboli from a poststenotic dilatation or true aneurysm (rarely thrombosis) of the subclavian artery. The evaluation should include cervical x-rays, noninvasive vascular testing, and arteriography when appropriate.

Treatment requires removal of the embolic source, resection of the bony anomaly, reperfusion of the ischemic extremity.

The subclavian artery aneurysm

is best approached through a supraclavicular incision with or without removal of the medial half of the clavicle. The aneurysm is resected and replaced with an interposition saphenous vein graft.
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The cervical and first ribs can be excised through the same approach, or the patient can be repositioned and the operation completed through the axilla.

If the artery is dilated but not aneurysmal, resection is not indicated, because bony decompression is sufficient to prevent further atheroemboli in most instances. In this situation the transaxillary approach is preferred, because it simplifies removal of the first rib.

Any distal embolic material that must be removed should be approached through separate arteriotomies in the arm.

Sympathectomy can be a useful adjunct when distal emboli are irretrievable

Venous Component
Venous obstruction of the upper extremity is caused by a narrowing of the costoclavicular space between the medial aspect of the first rib and the clavicle. This is the site where the axillary vein passes over the rib and under the clavicle to join the internal jugular vein. Both hyperabduction of the arm and hyperextension of the shoulders can narrow this space, causing venous obstruction. Venous obstruction takes one of three forms: intermittent obstruction, acute thrombosis, and postthrombotic intermittent obstruction.

Intermittent Obstruction
These patients present with arm swelling, cyanosis, and pain when the arm is abducted or the shoulders hyperextended. The diagnosis can be made by phlebograms with the arm in both the relaxed and symptomatic positions. A positive examination shows a beaklike appearance in the vein proximal to the first rib when the arm is stressed and a normal venous anatomy with the arm in a neutral position. Venous pressure measurements also can be made in the same arm positions. Treatment consists of transaxillary first rib resection or medial subtotal claviculectomy.

Acute Thrombosis

Patients usually are young and healthy and present with the sudden onset of arm pain, swelling, and cyanosis. The problem often follows some repetitive activity, such as throwing a ball, house painting, paper hanging, swimming, or rowing a boat, and has been called the Paget-Schroetter syndrome or effort thrombosis. Phlebograms show a complete obstruction of the subclavian vein, often with thrombus distally in the axillary vein.

Treatment
elevation and heparinization, venous thrombectomy, and local thrombolysis; Local thrombolysis: has gained much support in recent years. Once the diagnosis is confirmed, a coaxial catheter is inserted into the basilic vein and placed directly into the thrombus. Thrombolytic infusion is begun and its progress monitored with serial venography. If successful thrombolysis uncovers an underlying stenotic lesion, decompression of the thoracic outlet should be undertaken (usually clavicular resection), with simultaneous surgical repair of the venous lesion (patch angioplasty or venous bypass). The results of percutaneous balloon dilation of these lesions have been unsatisfactory. Stents should almost never be used in this group of patients, because they may be compressed between the first rib and clavicle. The patient is discharged on warfarin, which is continued for 3 months.

Postthrombotic Intermittent Obstruction Patients with acute obstruction and unsuccessful clot removal, whether chemical or mechanical, have a 50 percent chance of developing residual symptoms of venous obstruction. Venograms usually demonstrate an occluded vein with large collateral vessels around the first rib. Hyperabduction of the arm results in compression of these collateral veins. Either first rib resection or a medial claviculectomy will relieve these symptoms in some patients. Direct repair of the chronically occluded subclavian vein may be preferable and can be achieved by mobilizing the internal jugular vein and turning it down for anastomosis into the divided patent axillary vein.

Neurologic Component
The subjective nature of the symptoms and the lack of objective diagnostic criteria make the management of the neurologic component of TOS potentially very difficult. Some would restrict this diagnosis to only those patients with symptoms and signs limited to the T1 nerve root (ulnar nerve), while others would broaden it to include any neurologic symptoms of the neck, upper back, and upper extremity. These symptoms are exacerbated by elevation and abduction of the arm. Trauma may precipitate the symptoms in a susceptible individual.

An accurate and complete history is important, because the diagnosis is often one of exclusion. Most elements of the differential diagnosis have reliable diagnostic tests. All these patients should have cervical spine films to identify any bony anomalies and to rule out cervical disc protrusion or spondylitis. Nerve conduction studies are indicated to rule out carpal tunnel syndrome and ulnar nerve compression at the elbow. Orthopaedic and neurologic consultations may be necessary to rule out specific pathologic conditions of the shoulder, multiple sclerosis, and spinal cord tumors.

Physical examination :

Blood pressure measurements in both arms. The hands are examined for signs of atrophy of the ulnar nerve innervated interosseus muscles and the median nerve innervated thenar muscles. Percussion over the median nerve (Tinel's test) and rapid wrist flexion (Phalen's test) are performed to further evaluate the median nerve. A complete neurologic examination of the neck and upper extremity is performed, including the application of pressure in the supraclavicular space over the brachial plexus. The traditional Adson's test is totally unreliable in detecting brachial plexus compression and is of no use in making the diagnosis of neurologic TOS. The elevated arm stress test (EAST) described by Roos has the patient raise the arm to 90 degrees and open and close the hands for 3 min. This may reproduce the patient's symptoms but is unfortunately also positive in 90 percent of patients with carpal tunnel syndrome.

When neurologic TOS is the considered diagnosis and treatment is indicated, a conservative approach should always be followed. Patients with severe pain and cervical muscle spasm are initially treated with physical therapy directed at relieving the muscle spasm. Peets' shoulder strengthening exercises are started as the pain subsides. Methods of opening the costoclavicular space by hunching the shoulders upward and forward are used when the patient first feels symptoms recurring.

Indications for operation 1. failed physical therapy, 2. intractable pain, 3. progressive neurologic dysfunction.

Technique of First Rib Resection

Clagett suggested in 1962 that the first rib was the common denominator in the various compression syndromes of the thoracic outlet and recommended its resection in appropriate cases. In 1966 Roos described the technique of transaxillary first rib resection, which, because of its cosmetic appeal, simplicity, and safety has become the most frequently performed operation for neurologic TOS.

With the patient in the lateral decubitus position with the arm elevated, a skin incision is made in the axillary hair line between the pectoralis major and latissimus dorsi muscles. The first rib is reached by blunt dissection in the axillary tunnel, taking care to avoid the intercostobrachial nerve. The subclavian artery and vein are identified and the subclavius muscle tendon divided. The anterior scalene muscle can now be identified and divided at the point where it inserts on the first rib anterior to the artery. At this time a digital search for anomalous bands is performed. These may originate from the C7 transverse process, from an incomplete cervical rib, from attachment to two places on the first rib, or from the middle scalene muscle. After any bands have been divided, the middle scalene muscle and the intercostal muscle attachments are pushed off the first rib. When all muscle fibers are cleared and the T1 nerve root is visualized and protected, the rib is divided and removed. The wound is irrigated with saline to detect any pneumothorax, which, if present can be treated by inserting a small chest tube into the pleural space. The tube can be removed in the recovery room if the lung is fully expanded and there is no air leak. A number of brachial plexus injuries have been reported with this approach, and there are proponents of a supraclavicular approach that avoids any traction on the brachial plexus.