thoracic outlet syndrome thoracic outlet syndrome prof. t. vidyasagaran hod, dept of vascular...

Thoracic

Outlet

Syndrome

Thoracic

Outlet

SyndromeProf . T. VidyasagaranHOD, Dept of Vascular SurgeryVascular Surgeon, Chennai.

Prof . T. VidyasagaranHOD, Dept of Vascular SurgeryVascular Surgeon, Chennai.

DefinitionDefinition

Upper extremity symptoms

due to compression of the

neuro vascular bundle in the

Thoracic Outlet Area

Upper extremity symptoms

due to compression of the

neuro vascular bundle in the

Thoracic Outlet Area

TOSTOS

95 % Neurogenic

1 % Arterial

2 - 4 % Venous

95 % Neurogenic

1 % Arterial

2 - 4 % VenousVasculogenicVasculogenic

TOSTOS

TOSTOS

Three SpacesThree Spaces

Scalene TriangleScalene Triangle

Costoclavicular spaceCostoclavicular space

Pectoralis minor spacePectoralis minor space

TOSTOS

TOSTOS

Predisposing Anatomic FactorsPredisposing Anatomic Factors

Bony

Congenital narrowing - Cervical 4.5 %

Rudimentary rib

Long C7 transverse process

Acquired narrowing - Malunion

Callus

Exostosis or tumors

Bony

Congenital narrowing - Cervical 4.5 %

Rudimentary rib

Long C7 transverse process

Acquired narrowing - Malunion

Callus

Exostosis or tumors

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS

Scalene MuscleScalene Muscle

Neck trauma - Primary cause

Anatomy of muscle - Predisposing factor

for nerve compression

Splitting of SA

Scalene minimus

Interdigitation

Middle scalene 58 %

Neck trauma - Primary cause

Anatomy of muscle - Predisposing factor

for nerve compression

Splitting of SA

Scalene minimus

Interdigitation

Middle scalene 58 %

SASASMSM

BPBP AA

RibRib

SASASMSM

BPBP AA

Rib0.3 - 2 cms

Rib0.3 - 2 cms

VV VV

TOSTOS

Automobile accidents

Hyperextension neck injuries

Repetitive stress injuries

Automobile accidents

Hyperextension neck injuries

Repetitive stress injuries

Neck TraumaNeck Trauma

Keyboard Jobs Arm Neck stretching

Keyboard Jobs Arm Neck stretching

Neurogenic TOSNeurogenic TOS

SymptomsSymptoms

Young 20 - 45 years70 % WomenParesthesia

All nerves CommonestUlnar Lower chord Median Upper chord

PainHeadaches occipitalScapular pain

Trapezius Dorsal scapular nerveRhomboids

WeaknessVascular - sympathetic response

Young 20 - 45 years70 % WomenParesthesia

All nerves CommonestUlnar Lower chord Median Upper chord

PainHeadaches occipitalScapular pain

Trapezius Dorsal scapular nerveRhomboids

WeaknessVascular - sympathetic response

Neurogenic TOSNeurogenic TOS

Clinical DiagnosisClinical Diagnosis

Supraclavicular muscle tenderness Tinel’s signs - specific signs AER - EAST Decreased sensation to light touch Adson’s 50 % normal individuals

30 % of TOS

Supraclavicular muscle tenderness Tinel’s signs - specific signs AER - EAST Decreased sensation to light touch Adson’s 50 % normal individuals

30 % of TOS

Positional Maneuvers

Pulse deficit

Positional Maneuvers

Pulse deficit

Neurogenic TOSNeurogenic TOS

Diagnostic TestsDiagnostic Tests

Scalene muscle block 4 ml 1 % lignocaine

ASM - Tender area cephalad

94 % - with surgical decompression

Scalene muscle block 4 ml 1 % lignocaine

ASM - Tender area cephalad

94 % - with surgical decompression

Neurogenic TOSNeurogenic TOS

2 cms above clavical3 cms lateral to the midline

2 cms above clavical3 cms lateral to the midline

X ray chest (upper thoracic)

X Ray neck - AP - oblique cervical spine

MRI

X ray chest (upper thoracic)

X Ray neck - AP - oblique cervical spine

MRI

Neurogenic TOSNeurogenic TOS

DDDD

Neurological diseases Spinal cord tumor Multiple sclerosis

Shoulder disorders Shoulder tendinitis Myositis

Nerve compression syndrome Carpal tunnel guyen tunnel Cuboid tunnel epicondylitis

Neurological diseases Spinal cord tumor Multiple sclerosis

Shoulder disorders Shoulder tendinitis Myositis

Nerve compression syndrome Carpal tunnel guyen tunnel Cuboid tunnel epicondylitis

Neurogenic TOSNeurogenic TOS

Cervical spine pathology Cervical spine injury Disc herniation Spinal stenosis

Sympathetic diseases Raynaud’s Reflex sympathetic dystrophy

Cervical spine pathology Cervical spine injury Disc herniation Spinal stenosis

Sympathetic diseases Raynaud’s Reflex sympathetic dystrophy

TreatmentTreatment

Non operative modalities Neck stretching Abdominal breathing Posture exercise Shoulder shrugs Lifting light weight Neck traction

Non operative modalities Neck stretching Abdominal breathing Posture exercise Shoulder shrugs Lifting light weight Neck traction Strengthening

Exercise WorsensStrengthening

Exercise Worsens

IneffectiveIneffective

Neurogenic TOSNeurogenic TOS

SurgerySurgery

Failure of Conservative Disabling symptoms Work

RecreationDaily living

Symptoms more than a year

Failure of Conservative Disabling symptoms Work

RecreationDaily living

Symptoms more than a year

Neurogenic TOSNeurogenic TOS

Decompression of brachial plexusDecompression of brachial plexus

Rib excision

Scalenectomy

Rib excision

Scalenectomy

PrinciplesPrinciplesNeurogenic TOSNeurogenic TOS

ComplicationsComplications

Less than 1 %Less than 1 %

Nerve Injuries

Bleeding

Lymph leakage

Nerve Injuries

Bleeding

Lymph leakage

Neurogenic TOSNeurogenic TOS

Post stenotic dilatation

Aneurysmal dilatation

Thromboembolic complications

Post stenotic dilatation

Aneurysmal dilatation

Thromboembolic complications

Arterial TOSArterial TOS

Pathophysiology Pathophysiology

Significant

Permanent

Long standing

Congenital or acquired bony abnormality

10 years older than neurogenic TOS

Significant

Permanent

Long standing

Congenital or acquired bony abnormality

10 years older than neurogenic TOS

Arterial TOSArterial TOS

DiagnosticDiagnostic

History

Examination - Pulsatile SC mass - bruit

Radiological - Cervical spine - Upper thoracic

Duplex

Arteriography DSADynamic views

Helical CT MRA

Surgical exploration

History

Examination - Pulsatile SC mass - bruit

Radiological - Cervical spine - Upper thoracic

Duplex

Arteriography DSADynamic views

Helical CT MRA

Surgical exploration

Arterial TOSArterial TOS

Management PrinciplesManagement Principles

Surgery

Compression

Subclavian axillary artery lesions

Distal tree status

Surgery

Compression

Subclavian axillary artery lesions

Distal tree status

Arterial TOSArterial TOS

ReconstructionReconstruction

PSD with no intramural thrombosis - No intervention

Tailoring subclavian artery

Intimectomy with tailoring subclavian artery

Vein patch closure

Resection Primary repairGraft interposition

PSD with no intramural thrombosis - No intervention

Tailoring subclavian artery

Intimectomy with tailoring subclavian artery

Vein patch closure

Resection Primary repairGraft interposition

Arterial TOSArterial TOS

Distal EmbolismDistal Embolism

Multiple & diffuse

Various ages

Recent - Thromboembolectomy

Old - Bypass

Distal tree choked - Dorsal sympathectomy

Multiple & diffuse

Various ages

Recent - Thromboembolectomy

Old - Bypass

Distal tree choked - Dorsal sympathectomy

Arterial TOSArterial TOS

Subclavian Axillary Vein ThrombosisSubclavian Axillary Vein Thrombosis

Paget Schroetter Syndrome

Primary Subclavian Axillary Thrombosis

Paget Schroetter Syndrome

Primary Subclavian Axillary Thrombosis

Venous TOSVenous TOS

IncidenceIncidence

1.4 % of all DVT

25 % of all upper DVT

1.4 % of all DVT

25 % of all upper DVT

Venous TOSVenous TOS

Clinical PresentationClinical Presentation

Young males 2 : 1

Age 30 years

Strenuous exercise - 75 %

Dominant extremity 60 - 80 %

Associated neurogenic 4 - 10 %

Young males 2 : 1

Age 30 years

Strenuous exercise - 75 %

Dominant extremity 60 - 80 %

Associated neurogenic 4 - 10 %

Venous TOSVenous TOS

DiagnosisDiagnosis

Clinical swelling

Venous engorgement

Sudden onset

Duplex

Venography MRV

Radionuclide venography

Clinical swelling

Venous engorgement

Sudden onset

Duplex

Venography MRV

Radionuclide venography

Venous TOSVenous TOS

TreatmentTreatment

Rest & Elevation

Systemic anticoagulation

Rest & Elevation

Systemic anticoagulation

LongTerm Morbidity

LongTerm Morbidity

Venous TOSVenous TOS

Venous TOSVenous TOS

Restore luminal patency

Remove extrinsic compression

Intrinsic stenosis

Restore luminal patency

Remove extrinsic compression

Intrinsic stenosis

Venous TOSVenous TOS

Thrombolytic Thrombolytic

Thrombectomy - with decompressionThrombectomy - with decompression

ThrombolyticThrombolytic

Systemic

Catheter directed - Venographic evaluation possible

- Assess extrinsic compression immediately

- Oral anticoagulation 3 months / 1 month

- Decompression

- Balloon angioplasty & stenting

Systemic

Catheter directed - Venographic evaluation possible

- Assess extrinsic compression immediately

- Oral anticoagulation 3 months / 1 month

- Decompression

- Balloon angioplasty & stenting

Venous TOSVenous TOS

PresentationPresentation

Duplex confirmDuplex confirm

Appropriate candidateAppropriate candidate

VenographyVenography

CD ThrombolysisCD ThrombolysisComplete lysisPositional venography

Complete lysisPositional venography

ECEC

TODTOD

No ECNo EC

AnticoagulationAnticoagulation

Intrinsic stenosisIntrinsic stenosis

TOD + Vein patch angioplastyor balloon angioplasty stent

TOD + Vein patch angioplastyor balloon angioplasty stent

Venous TOSVenous TOS

Incomplete lysisIncomplete lysis

AlgorithmAlgorithm

Incomplete LysisIncomplete Lysis

Short occlusionShort occlusion

Operative thrombectomyorBalloon AP Stent

Operative thrombectomyorBalloon AP Stent

Long occlusionLong occlusion

AnticoagulationAnticoagulation

Persistent symptomsPersistent symptoms

SurgerySurgery

Venous TOSVenous TOS AlgorithmAlgorithm

FailureFailure

Trinity Oration

THANK YOU

Scalene TriangleScalene Triangle

Commonest site of

Nerve compression

Brachial plexus

Subclavian artery

Commonest site of

Nerve compression

Brachial plexus

Subclavian artery

TOSTOS

CostoclavicularCostoclavicular

Artery

Vein

Nerve

Artery

Vein

Nerve

TOSTOS

Seldom involved in TOSSeldom involved in TOS

Pectoralis Minor SpacePectoralis Minor SpaceTOSTOSTOSTOS