seminar tos thoracic outlet syndrome

THORACIC OUTLET SYNDROME

Thoracic outlet syndrome (TOS)- a collection of symptoms brought about by abnormal compression of the neurovascular bundle by bony, ligamentous or muscular obstacles in the narrow space between clavicle and 1st rib.

ANATOMY Interscalene triangle

Med : 1st rib Ant : clavicle, scaleneus

anterior Post : scaleneus medius

Costoclavicular space Med : 1st rib Ant : clavicle Post : scaleneus

anterior Lat : costoclavicular

ligament, subclavius muscle Subcoracoid tunnel

compressed by pectoralis minor tendon, head of humerus or coracoid process.

Subcoracoid tunnel

contents

Brachial plexus Subclavian artery Subclavian vein

Causes Cervical rib Long C7 transverse process Anomalous insertion of scalene muscles Scalene muscle hypertrophy Scaleneus minimus Abnormal bands, ligaments Fracture clavicle/ 1st rib Exostosis Tumours Brachial plexus trauma / diseases

Cervical rib

A cervical rib is a supernumerary (or extra) rib which arises from the seventh cervical vertebra.

Sometimes known as "neck ribs" Congenital abnormality located above the

normal first rib. A cervical rib is present in only about (0.2%) of

people. Half unilateral, common in right side. Usually asymptomatic

Types :1) Completely bony2) Completely

fibrous3) Combined 4) Bony swelling

Type 3 is most common. Type 3 – a band stretching from C7 vertebra to

Scalene tubercle on 1st rib. It elevates the neurovascular bundle compressing it in the interscalene triangle.

Cervical rib

Cervical rib

Clinical features

Most commonly seen in middle aged women Usually due to neural compromise.

Interscalene triangle

Artery , Nerves Scaleneus anticus syndrome

Costoclavicular space

Vein Edens syndrome

Subcoracoid area Artery, Vein , Nerves

Hyperabduction syndrome

Interscalene triangle

Costoclavicular space

Hyperabduction syndrome

Arterial compromise Fatigue Weakness Coldness Upper limb claudication Thrombosis Paraesthesia Gangrene Raynaud's phenomenon due to thrombosis with

distal embolisation

Venous compromise

Edema Venous distension Collateral formation Cyanosis Paget-Schroetter syndrome – effort thrombosis

"Effort" axillary-subclavian vein thrombosis (Paget-Schroetter syndrome) is an uncommon deep venous thrombosis due to repetitive activity of the upper limbs.

Neural compromise

Paraesthesia Pain in shoulder, arm, forearm and fingers Occipital headache – referred from tight

scalene muscles Weakness of forearm, hand.

Clinical tests

Roos Test

Hold both arms in surrendering position (90°overhead with shoulders in external rotation) – reproduction of symptoms within 1 minute . Arm collapses if continued.

modified Roos test / Elevated Arm Stress Test(EAST)– same as above. Symptoms precipitated by opening and closing fists continuously.

Elevated arms stress test

Adson's (Scalene) Test

Radial pulse diminishes and disappears on turning chin to same side.

Decreases space between scaleneus anterior and medius .

Adsons test

Halsted's costoclavicular compression test

45° abduction and extension of arm with downward pressure on shoulders –neck turned to opposite side- reproduce symptoms

Exaggerated military position

Patient shrugs shoulders with deep inhalation while drawing the shoulders backward in an exaggerated military position – radial pulse diminishes.

Military position

Wright's hyperabduction test

Arm hyperabducted to 180°-diminishing radial pulse.

Neurovascular structures compressed in subcoracoid region by pectoralis minor tendon, head of humerus or coracoid process.

Wright's hyperabdution test

Tinel sign – in supra and infraclavicular region Phalens sign – in carpel tunnel syndrome (CTS)

Differential diagnoses

Carpel tunnel syndrome Spinal canal tumors Shoulder myositis Angina pectoris Raynaud's disease Ulnar nerve compression - epicondylitis

Investigations

Chest x ray, cervical spine x ray MRI, cervical myelography

r/o narrowing of intrevertebral foramen, disc compression.

Doppler , vascular imaging(angiogram/venogram) r/o aneurism, thrombosis

Nerve conduction study, electromyography confirm neurogenic TOS, localise the area of

compression- r/o CTS

Double crush syndrome – TOS with other peripheral sites of nerve compression(CTS)

Treatment

Non operative treatment

Posture improving exercises. Breathing exercises. Avoid aggravating activities. Avoid repetitive upper extremity mechanical

work and muscular trauma. Analgesics,muscle relaxants, antidepressants. Physiotherapy .

Surgical treatment

Indications: Symptoms persists with non operative

treatment. Associated vascular compression. Progression of neurological symptoms. Nerve conduction velocity < 60m/s

Trans cervical or trans axillary(Roos) resection of 1st rib often with release of scalene muscles.

Extraperiosteal excision of Cervical rib(to prevent its regeneration) .Often a cervical sympathectomy is also needed.

Roos approach

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F. RECURRENT THORACIC OUTLET SYNDROME

1. 10% of surgically treated patients have shoulder, arm or hands pain and pareathesia. Most patients can be relieved with physiotherapy and muscle relaxant.

2. In 1.6% of patients, symptoms exacerbate and persist.

3. Most recurrences occur in 3 months postoperatively.

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F. RECURRENT THORACIC OUTLET SYNDROME

4. Pseudorecurrence (1) A 2nd rib was mistakenly resected for a 1st rib (2) A 1st rib was resected but a cerical rib was left. (3) A cervical rib was resected but an abnormal 1st rib was left. (4) A 2nd rib was resected but a rudimentary 1st rib was left.

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F. RECURRENT THORACIC OUTLET SYNDROME

5. True recurrence The 1st rib was not resected completely.6. All patients with recurrence after 1st rib resection should undergo physiotherapy. If symptoms persist and UNCV is still low then re-operation is indicated. 7. Re-operation is always done through the

posterior thoracoplasty approach.

F. REC

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F. RECURRENT THORACIC OUTLET SYNDROME

8. The anterior or supraclavicular approach is not adequate for re-operation. 9. The basic elements for re-operation are (1) resection of recurrent or persistent bony remnants (2) neurolysis of the brachial plexus or nerve roots (3) dorsal sympathectomy of T1, T2, T3 ganglia

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F. RECURRENT THORACIC OUTLET SYNDROME

10. The technique includes a high thora- coplasty incision, extending 3 cm above the angle of the scapula, halfway between the angle of the scapula and spinous processes, and caudate 5 cm from the angle of scapula. 11. The trapezius and rhomboid muscles are

divided..

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F. RECURRENT THORACIC OUTLET SYNDROME

12. The scapula is retracted by incision of the LD muscle over the 4th rib.13. The posterior superior serratus muscle was divided and sacrospinalis muscle is retracted

medially. 14. The 1st and cervical rib must be resected, if present

subperiosteally.15. The regenerated periosteum is extirpated.

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F. RECURRENT THORACIC OUTLET SYNDROME

16. If excessive scar is present the it is necessary to perform sympathectomy initially. This involves resection of a 1- inch segment of 2nd rib posteriorly to locate the sympathetic ganglia.17. Neurolysis is performed using a nerve stimulator but not into the sheath.

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F. RECURRENT THORACIC OUTLET SYNDROME

18. A J-P drain is left in the area of brachial plexus. Depo-Medral, 80 mg, is left in the area of brachial plexus. 19. The arm is kept in sling to be used gently for 3 months.20. When the problem is vascular, involving false or mycotic aneurysms, bypass graft is interposed. The saphenous vein is usually used.

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F. RECURRENT THORACIC OUTLET SYNDROME

21. 7% of patients underwent 2nd re-operation for rescarring. No death occurred. Only one patient had infection and needed drainage.

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