Jodi Gerdes, MDAssistant Professor of Clinical Surgery

Louisiana State University Health Science Center

October 11, 2012

Thoracic Outlet Syndrome

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Disclosure Dr. Jodi Gerdes

I do not have any commercial interests.

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Objectives Historical perspectives Types of thoracic outlet syndrome Diagnosis and management

Historical Perspectives

History Galen – 2nd century – first description of

cervical ribs in medical literature Vesalius – 1543 – Belgian anatomist

described cervical ribs Gruber – 1842 – 4 types of cervical ribs

Sir Astley Cooper (1768-1841) “Prince of Surgery” Guy’s Hospital in London President of the Royal College of

Surgeons Suspensory ligaments of Cooper

Sir Astley Cooper (1768-1841) Many contributions to vascular surgery

Pathophysiology of cerebral circulationProximal ligation of carotid and external

iliac aneurysms 1821 – woman with pulseless, cold arm

and gangrenous changes to fingersCompression and thrombosis of subclavian

artery by a cervical rib

History Coote - 1861 – first cervical rib resection Paget – 1875 – subclavian vein

thrombosis

History William Halsted – 1916 - described how

cervical ribs cause subclavian artery post-stenotic dilatation

History Law – 1920 – described congenital

bands and ligaments that compressed the lower brachial plexus

Murphy – 1910 – excised normal first rib Adson and Coffey – 1927 – division of

anterior scalene muscle without cervical rib resection

Ochsner, Gage, DeBakey – 1935 – scalene anticus syndrome (Naffziger’s syndrome) – scalenotomy in the absence of cervical rib

History Peet – 1956 – “thoracic outlet

syndrome” Clagett – 1962 – posterior approach to

first rib resection Roos – 1966 – transaxillary first rib

resection Gol – 1968 – infraclavicular approach

History Arteriography and venography

introduced in the 1960s for diagnostic purposes

Jebsen – 1968 – nerve conduction studies

Urschel applied to TOS patients Princeton football player with nTOS

Types of Thoracic Outlet Syndrome

TOS Combination of anatomic anomalies,

physical activities, and life events Constellation of upper extremity

symptoms Compression of neurovascular bundle at

thoracic outletBrachial plexus (C5-T1)Subclavian veinSubclavian artery

Anatomy Scalene triangle Costoclavicular space Pectoralis minor space

Scalene MusclesWide vs narrow triangleCongenital bands/ligaments

Cervical ribs Incidence 0.74%Female:male ratio 7:3Complete vs incompleteMore common on left

Anomalous 1st ribs Incidence 0.76%Equal occurrence in men and women

Anatomic Variations

Epidemiology 20-50yo

<5% teenagers10% over 50Rarely >65

70% female70% cervical ribs occur in females

Types of TOS nTOS – 95%

Most difficult to diagnose and treat vTOS – 2-3% aTOS - <1%

Neurogenic TOS Etiology

Hyperextension neck injury (whiplash)Repetitive stress injuries (typing, assembly

lines)Falls on slippery floors/ice

Neurogenic TOS Predisposing Factors

Scalene muscle anomaliesNarrow scalene trianglesCongenital ligaments/bandsHigh plexus rootsCervical ribs

Neurogenic TOS Classification of Congenital Bands and Ligaments within the Scalene Triangle 1 - Extends from the anterior tip of an incomplete cervical rib to the middle of the first thoracic

rib; inserts just posterior to the scalene tubercle on the upper rib surface 2 - Arises from an elongated C7 transverse process in the absence of a cervical rib and attaches

to the first rib just behind the scalene tubercle; associated with extension of the transverse process of C7 beyond the transverse process of T1 on anteroposterior spine radiographs

3 - Both originates and inserts on the first rib; starts posteriorly near the neck of the rib and inserts anteriorly just behind the scalene tubercle

4 - Originates from a transverse process along with the middle scalene muscle and runs on the anterior edge of the middle scalene muscle to insert on the first rib; the lower nerve roots of the brachial plexus lie against this band

5 - Scalene minimus muscle arises with the lower fibers of the anterior scalene muscle, runs parallel to this muscle but passes deep to it to cross behind the subclavian artery and in front of or between the nerve roots, and inserts on the first rib; any fibers passing anterior to or between the plexus but posterior to the artery

6 - Scalene minimus muscle inserting onto Sibson's fascia over the cupula of the pleura instead of onto the first rib; labeled separately to distinguish its point of insertion

7 - Fibrous cord running on the anterior surface of the anterior scalene muscle down to the first rib and attaching to the costochondral junction or sternum; lies immediately behind the subclavian vein, where it may be a cause of partial venous obstruction

8 - Arises from the middle scalene muscle and runs under the subclavian artery and vein to attach to the costochondral junction

9 - Web of muscle and fascia filling the inside posterior curve of the first rib and compressing the origin of the T1 nerve root

Adapted from Roos, Am J Surg

Neurogenic TOS Pathophysiology

Neck trauma stretches and tears scalene muscle fibers

Swelling of muscle belly pain, parathesias, numbness, weakness

Scarring/fibrosis of muscle belly occipital headaches, muscle spasms

Neurogenic TOS Machleder et al 1986 (UCLA)

Type 1 slow twitch muscle fibers convert to Type II fast twitch fibers following stretch injury in scalene muscles

Convert back after severing the muscle Sanders et al 1990

>2x more connective tissue cells in anterior scalene after trauma

Neurogenic TOS Symptoms

Pain, parathesias, numbness, weaknessThroughout affected hand/arm

Not necessarily localized to peripheral nerve distribution

Extension to shoulder, neck, upper back not infrequently

“Upper plexus” disorders – radial and musculocutaneous nerve distributions

“Lower plexus” disorders – median and ulnar nerve distributions

Neurogenic TOS Symptoms

Occipital headachesPerceived muscle weakness

Actual weakness and atrophy are rareVasomotor symptoms

Vasospasm, edema, hypersensitivity (CRPS)

Neurogenic TOS Pectoralis minor syndrome

Compression of neurovascular bundle under the pec minor

Pain over anterior chest and axillaFewer head/neck symptomsConsider pec minor tenotomy with thoracic

outlet decompression

Venous TOS Etiology

Developmental anomalies of costoclavicular space

Repetitive arm activities – throwing, swimming, overhead activities

Venous TOS Predisposing Factors

Relationship of vein to subclavius tendon and costoclavicular ligament

Dimensions of costoclavicular space Repetitive trauma to vein causing

fibrosis, stenosis, thrombosis

Paget-Schroetter syndrome Effort thrombosis of axillary-subclavian

vein Associated with TOS in some cases

Acute occlusionPainTightnessDiscomfort during exerciseEdemaCyanosis Increased venous patternTenderness over the axillary veinGangrene (1/23 patients)

Physical activitiesLifting or pulling heavy objects, basketball,

baseball, painting, tennis, raquetball, football, golf, wrestling, weightlifting, scrubbing, shoveling snow, swinging rifle

Up to 40% had residual symptoms after treatment

Arterial TOS Etiology

Cervical or anomalous first ribAnomalous anterior scalene insertion

Arterial TOS Pathophysiology

Arterial compression resulting in post-stenotic dilatation or aneurysm

Distal embolization of thrombus

Arterial TOS Symptoms

Digital or hand ischemiaCutaneous ulcerationsForearm pain with usePulsatile supraclavicular mass/bruit

Diagnosis and Treatment

Diagnosis “the most accurate diagnosis of TOS…

must rely on a careful history and thorough, appropriate physical examination”

David B Roos, MD

No single diagnostic test has sufficient specificity to prove or exclude the diagnosis

Neck trauma preceding onset of symptoms

Repetitive stress injury Occipital headaches Pain over trapezius, neck, shoulder,

chest Specific disabilities regarding work and

daily activities Exertional arm pain Other specialists seen and

tests/procedures performed

History

Differential Diagnosis nTOS Carpal tunnel syndrome Ulnar nerve compression Rotator cuff tendinitis Cervical spine strain/sprain Fibromyositis Cervical disk disease Cervical arthritis Brachial plexus injury

Differential Diagnosis aTOS Other sources of emboli

Cardiac, aortic arch, hypothenar hammer syndrome, coagulopathies

Vasculitis Radiation-induced arteritis Connective tissue disorders Arterial dissection Atherosclerotic disease Traumatic

Pulse exam Listen for bruits Edema/cyanosis/collateral veins Tenderness over scalene muscles

(trigger points) or pectoralis minor Reduced sensation to very light touch in

fingers Provocative maneuvers

Physical Exam

With the patient seated, arms at the sides, the radial pulse is palpated and the examiner listens for bruits above the clavicle

Elevate arm and turn the chin both toward and away from the involved side

A positive test results in diminished radial pulse, bruit, and numbness and tingling

Up to 50% of healthy volunteers have a positive test – unreliable for diagnosis of TOS

Adson Test

Elevated arm stress test Most accurate clinical test (Roos) Hold “surrender” position for 3 minutes

while opening/closing hands

EAST

EAST nTOS

Heaviness, progressive weakness, numbness

Tingling in fingers, progressing up arm vTOS

Cyanotic arm with distended forearm veins aTOS

Ischemic, cramping pain

Positive response indicates compression of cervical roots or brachial plexus

Negative response is usually adequate to rule out nTOS

Upper Limb Tension Test

Imaging Xrays

Cervical ribElongated C7 transverse processHypoplastic 1st ribCallous formation from clavicle or 1st rib

fracturePseudoarthrosis of 1st rib

Unable to image soft tissue anomalies and fibromuscular bands – seen only at time of surgery

CT/MRI usually negative but can rule out other pathologies

MR neurography – newer technology to detect localized nerve function abnormality

Imaging

Imaging aTOS

Segmental arterial pressuresAngiography

vTOSDuplex U/SVenography

Use positional maneuvers during the studies

Consider bilateral studies

EMG/NCS Reduction in NCV to <85m/s Positive results

Aid in evaluation of other conditionsPoor prognostic factor if truly nTOS –

indicate advanced neural damage Negative results

Exclude other conditionsMay still be nTOS

Electrophysiology Testing Medial antebrachial cutaneous nerve

(MAC) Lowest branch of inferior trunk of brachial

plexusMore sensitive to compression than other

branches Higher sensitivity and specificity than

EMG/NCS

Most useful when diagnosis is unclear Correlation between relief of symptoms

after block and successful outcome after surgical decompression

Scalene muscle block

Physical therapy Physical therapy Physical therapy

Therapist must have experience in evaluation and treatment of nTOS

20-30% of patients respond, do not require surgical treatment

Treatment nTOS

Treatment nTOS Neck stretching Posture correction Avoid neck traction, weights, resistance

exercises, strengthening exercises

Treatment nTOS If no improvement after several months

Live with symptomsSurgical decompression

Treatment vTOS Catheter-directed thrombolysis Anticoagulation Surgical decompression with

intraoperative venography and subclavian vein PTA

Transaxillary approachAdvantages

Limited field of operative dissection Cosmetically placed incision Sufficient exposure (for 1 person) Achieve 1st rib resection and anterior

scalenectomy Removal of anomalous ligaments and fibrous

bandsDisadvantages

Incomplete exposure of entire scalene triangle Difficulty achieving brachial plexus neurolysis Limited if vascular reconstruction is needed

Surgical Treatment

Supraclavicular approachAdvantages

Wide exposure of all anatomic structures Permits complete resection of anterior and

middle scalenes as well as brachial plexus neurolysis

Allows resection of cervical ribs and anomalous 1st ribs

Vascular reconstruction is possible

Surgical Treatment

Adjunctive proceduresPectoralis minor tenotomyCervical sympathectomy

Surgical Treatment

Complications Injury to

Subclavian artery/veinBrachial plexusPhrenic nerveLong thoracic nerveThoracic ductSympathetic chain Intercostal brachial cutaneous nerve

(axillary) Pneumothorax Lymph leakage

Transaxillary 1st rib resectionGood – 80%Fair – 6%Poor – 15%

Supraclavicular approachGood – 77%Fair – 15%Poor – 8%

Outcomes

No difference in long term results between the 2 approaches

No difference in outcome based onPresence of any particular provocative test

resultsExperience of operating surgeon

Predictors of ongoing disabilityAmount of work disability preopLonger intervals between injury and

diagnosisOlder age at time of surgery

Outcomes

Associations between preexisting psychological factors and socioeconomic characteristics have been examined

Independent risk factors associated with persistent disabilityMajor depressionSingleLess than a high school education

Outcomes

Results vary by etiology of symptomsFailure in 42% with symptoms after a work-

related injury or repetitive stressFailure in 26% with symptoms after auto

accidentFailure in 18% with nonspecific etiology

Outcomes

Postoperative scarring most common cause

Seprafilm – no change in recurrence rates but made plexus easier to find at reoperationWrap nerve roots prior to wound closure

Surgiwrap – only 8 recurrences in 175 patients in early studies

Recurrent nTOS

JVS Oct 2012 Retrospective review of 161 patients

with nTOS following first rib resection and scalenectomy (FRRS)

Unresolved, recurrent, and/or contralateral symptoms

JVS Oct 2012 161 patients, 182 FRRS

21 had bilateral procedures 121 females, 40 males Mean age 38.8yrs Mean f/u 12.8 +/- 12 months 128 patients (142 FRRS) reported

resolved symptoms – 78%

JVS Oct 2012 23 patients (24 FRRS) reported

unresolved symptomsOlderActive smokersLonger length of symptoms at initial

presentationHigher incidence of comorbid conditions

Chronic pain syndromes Neck/shoulder disease Etiology – trauma Opioid use and Botox injections more common

JVS Oct 2012 Unresolved symptoms

Physical therapyAnesthetic or steroid injectionsCT-guided Botox injectionsShoulder arthroplastyNeuroplasty of brachial plexus

6/23 patients - freedom from opioids

JVS Oct 2012 16 patients (16 FRRS) reported

recurrent symptoms at 12.1 +/- 9.7 monthsChronic pain syndromesNeck/shoulder diseaseReinjury – 31.3%

JVS Oct 2012 Recurrent symptoms

Physical therapyCT-guided Botox injectionsAnesthetic/steroid injectionsBiceps tendonesis, acromioplasty,

discectomy 13/16 patients - freedom from opioids

JVS Oct 2012 Patient demographics and clinical

variables play a role in successful vs failed surgical outcomesOlderLonger duration of symptomsChronic pain syndromes (fibromyalgia)Neck/shoulder disease (DJD, rotator cuff

tear)Opioid usePrevious surgeryActive smokers

JVS Oct 2012 Improper diagnosis vs complicated

recovery due to comorbid conditions Other studies discuss reoperation for

residual rib or incomplete scalenectomy

Case Presentation

45 yo female with 10yr history of L arm pain and hand numbness

Exacerbated by external rotation and abduction of shoulder

2 L shoulder surgeries, carpel tunnel release

Extensive PT

History

Past Medical/Surgical HistoryGERDHypothyroidismRaynaud’s phenomenon2 L shoulder surgeries (2005, 2008)L wrist carpel tunnel release (Sept 2010)

History

Social HistoryNo tobaccoOccasional alcohol

History

Physical ExamP 80, R 16, BP 116/72, equal BPs in UEsNeck: no carotid bruits, no

supra/infraclavicular bruitsExt: absent L radial pulse with LUE

externally rotated and abducted and head turned away, develops harsh bruit over L clavicle with this maneuver as well

Neuro: CNs intact, motor/sensory intact

History

NCV and EMG – June 2010Mild thoracic outlet on LMild denervation L tricepsPossible mild L C7 radiculopathy

Non-invasive Studies

Positional PVRsRUE

Occlusive with arm at 180 degrees and head turned away

LUE Occlusive with arm in military position and at

180 degrees with head turned away

Non-invasive Studies

MRI neck – no cervical rib

MRI L shoulder – tear glenoid labrum and glenohumeral ligament

Imaging

L transaxillary first rib resection Follow-up

L hand numbness resolved Post-op pain in neck/shoulder slowly

improving

Treatment

Conclusions nTOS most common nTOS most difficult to diagnose Treatment

Physical therapyAnterior scalene block Informed consent prior to surgery

Conclusion “A surgeon recognizing nTOS should not

be dissuaded by the impression that these problems are frequently associated with psychiatric overtones, dependency on pain medications, and ongoing litigation”

Rutherford’s Vascular Surgery 7th Edition

Thank you.

Baylor University Medical Center Proceedings 2007