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Management of Chronic Thoracic Outlet

SyndromeDavid Rigberg, MD

Professor of SurgeryVascular Surgery DivisionUCLA School of Medicine

� Disclosures: Speaker honorarium for W.L. Gore and Associates, 9/2015.

Outline Outline Outline Outline –––– 7 Minutes7 Minutes7 Minutes7 Minutes

� Diagnosis of neurogenic TOS-vTOS and aTOS non controversial� Anterior approach� Trans-axillary approach

BRACHIAL PLEXUS

SUBCLAVIAN ARTERY

SUBCLAVIAN VEIN

NeuroNeuroNeuroNeuro----Vascular Structures Vascular Structures Vascular Structures Vascular Structures Crossing the Thoracic OutletCrossing the Thoracic OutletCrossing the Thoracic OutletCrossing the Thoracic Outlet

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Subcalvian Artery

AnteriorScalene

Subcalvian Vein

SubcalviusMuscle

Subcalvian Artery

AnteriorScalene

Subcalvian Vein

SubcalviusMuscle

Venous Triangle

Subcalvian Artery

T 1 Nerve Root Middle

Scalene Subcalvian Artery

T 1 Nerve Root Middle

Scalene

Inter-Scalene Triangle

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Clinical Presentations

� Neurogenic 90-95%� Venous 2-8%� Arterial 1-2%

Nomenclature is misleading – combined sx may be present.

No single pathognomonic symptom or finding. Clinical diagnosis.

Diagnosis most often is a process of exclusion and clinically appropriate symptoms / findings.

Diagnosis nTOSDiagnosis nTOSDiagnosis nTOSDiagnosis nTOS

Positional - Stress Testing

Abduction External Abduction External Abduction External Abduction External Rotation (AER)Rotation (AER)Rotation (AER)Rotation (AER)

Upper Extremity Upper Extremity Upper Extremity Upper Extremity Limb Tension Test Limb Tension Test Limb Tension Test Limb Tension Test (UELTT)(UELTT)(UELTT)(UELTT)

Roos Elevated Arm Roos Elevated Arm Roos Elevated Arm Roos Elevated Arm Stress Test (EAST)Stress Test (EAST)Stress Test (EAST)Stress Test (EAST)

Neurogenic TOSPhysical Findings� AER Testing 100%� Upper Limb Tension 98� Scalene tenderness 94� Scalene pressure radiation 92� Neck rotation 90� Head tilt 90

Sanders JVS 2007

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Neurogenic TOS: Diagnostic Testing

ExclusionC-spine MRIEMG / NCV

InclusionC-SPINE X-RAYTOS MR study (MRI/MRA/MRV)SSEP or MAC SNPAnterior Scalene Muscle Block

Neurogenic TOS� Imaging� XR� MRI� MRA� CTA� Angio� U/S

Thoracic Outlet: Assessment with MR Imaging in Thoracic Outlet: Assessment with MR Imaging in Thoracic Outlet: Assessment with MR Imaging in Thoracic Outlet: Assessment with MR Imaging in Asymptomatic and Symptomatic PopulationsAsymptomatic and Symptomatic PopulationsAsymptomatic and Symptomatic PopulationsAsymptomatic and Symptomatic Populations

35 healthy volunteers and 54 patients with clinical symptoms of thoracic outlet syndrome (TOS)

� Patients were included in the study when at least two provocative clinical tests reproduced the

���symptoms

Xavier Demondion, MD, et al . Université de Lille 2, France. Radiology, 2003

MRI Diagnosis of nTOS MRI Diagnosis of nTOSMRI Diagnosis of nTOSMRI Diagnosis of nTOSMRI Diagnosis of nTOS� 54 patients with TOS:� Smaller costoclavicular distance (P < .001), � Thicker subclavius muscle (P < .001), � Wider retropectoralis minor space (P < .001) than

did volunteers. � Vascular or nerve compression in 44 (81%).� Arterial compression in 72% of TOS patients. � Nerve compression in 7% of TOS patients.

� No arterial or nerve compression seen in volunteers. � No standardized criteria

Demondion X et al. Radiology 2003;227:461-468

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS

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ELECTRODIAGNOSTIC TESTINGELECTRODIAGNOSTIC TESTINGELECTRODIAGNOSTIC TESTINGELECTRODIAGNOSTIC TESTING

EMGNCVSSEPMAC

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOSNerve Conduction StudiesNerve Conduction StudiesNerve Conduction StudiesNerve Conduction Studies

(EMG / NCV)(EMG / NCV)(EMG / NCV)(EMG / NCV)� R/O Peripheral N Compression� Carpal Tunnel Syndrome� Cubital Tunnel Syndrome

� Peripheral Neuropathy

� Cervical Radiculopathy

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS

CA WORKERCA WORKERCA WORKERCA WORKER’’’’S COMPS COMPS COMPS COMPGuidelinesGuidelinesGuidelinesGuidelines

� Electro Diagnostic Testing “is reliable” for diagnosis TOS

� Must Have all three:� Median Motor Amplitude reduced 50% vs

contralateral arm� Ulnar Sensory Amplitude reduced 60%� DenervationDenervationDenervationDenervation of lower trunk muscles

Defines “True Neurogenic” TOS – less than 5% of all.

SSEP Improved PostSSEP Improved PostSSEP Improved PostSSEP Improved Post----OpOpOpOpNeurogenic TOS

Of 80 TOS patients 59 (74%) with Abnormal SSEP51 (86%) improved with surgery 8 (14%) showed no improvement

Post-op SSEP correlated with outcome (pos or neg) in 92%

. Somatosensory Evoked Potentials (SSEP) in the Assessment of Thoracic Outlet Compression SyndromeMachleder HI, Moll F, Nuwer M, Jordan S. J Vasc Surg. 1987

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Anterior Scalene Muscle BlockAnterior Scalene Muscle BlockAnterior Scalene Muscle BlockAnterior Scalene Muscle Block� U/S-Guided Injection of Lidocaine into Anterior Scalene

muscle.

� Results in relaxation of anterior scalene muscle. � No anesthesia. � No paralysis. � (Not an inter-scalene block.)

� Positive: Greater than 50%reduction of symptoms.

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOSDiagnosis of Thoracic Outlet Syndrome Using Diagnosis of Thoracic Outlet Syndrome Using Diagnosis of Thoracic Outlet Syndrome Using Diagnosis of Thoracic Outlet Syndrome Using Electrophysiologically Guided Anterior Scalene Electrophysiologically Guided Anterior Scalene Electrophysiologically Guided Anterior Scalene Electrophysiologically Guided Anterior Scalene

BlocksBlocksBlocksBlocks

� 122 Patients evaluated for TOS� 122 underwent ASMB

� 102 patients diagnosed with TOS� 20 patients diagnosed with other condition� 1 had Positive ASMB = 5% false negative

Jordan and Machleder. Annals of Vascular Surgery 1998

� Positive ASMB 32 patients 30 (94%) improved. � Negative ASMB 6 patients 3 (50%) improved.

Jordan and Machleder. Annals of Vascular Surgery 1998

Guided Anterior Scalene BlocksGuided Anterior Scalene BlocksGuided Anterior Scalene BlocksGuided Anterior Scalene BlocksSurgical OutcomesSurgical OutcomesSurgical OutcomesSurgical Outcomes

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS

Observation: This is the only test which directly relates anatomy and symptoms.

ConclusionsConclusionsConclusionsConclusionsExclude other causesClinical findingsCombined testsIndividual patient…

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Thoracic Outlet DecompressionThoracic Outlet DecompressionThoracic Outlet DecompressionThoracic Outlet DecompressionSurgical Approaches

� Scalenectomy (supra-clavicular )� Posterior rib resection� Claviculectomy� Trans-axillary rib and scalene muslce

resection� Supra-clavicular Scalene and rib

resection� Anterior Infra-clavicular

Thoracic Outlet DecompressionThoracic Outlet DecompressionThoracic Outlet DecompressionThoracic Outlet DecompressionSurgical Approaches

� Supra-clavicular Scalene and rib resection

� Trans-axillary rib and scalene muslceresection

Supra-Clavicular Scalene Muscle and 1st Rib Resection Supra-Clavicular Scalene Muscle and Rib

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Supra-Clavicular Scalene Muscle and Rib Supra-Clavicular Scalene Muscle and Rib

Dorsal ScapularNerve

Long ThoracicNerve

Brachial PlexusC5, C6, C7

PhrenicNerve

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Supra-Clavicular Scalene Muscle and Rib Supra-Clavicular Scalene Muscle and Rib

Supra-ClavicularLimitations: The anterior portion of the first rib is not accessible.

This alone may be inadequate for decompression of v TOS.

Supra-ClavicularTraction and manipulation of neural structures is required.

Possibly increased risk of nerve injuries.

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Arterial TOSArterial TOSArterial TOSArterial TOS TransTransTransTrans----Axiallary First Rib ResectionAxiallary First Rib ResectionAxiallary First Rib ResectionAxiallary First Rib Resection

Advantage: working beneath nerves.

Division of Anterior ScaleneDivision of Anterior ScaleneDivision of Anterior ScaleneDivision of Anterior Scalene TransTransTransTrans----Axillary Rib ResectionAxillary Rib ResectionAxillary Rib ResectionAxillary Rib Resection

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Venous Channel

vTOS

nTOS

Surgical Complications686 operations in 491 patients

Trans AxTrans AxTrans AxTrans Ax Scalene SupraScalene SupraScalene SupraScalene Supra111 (16%) 279 (41%) 278 (41%)111 (16%) 279 (41%) 278 (41%)111 (16%) 279 (41%) 278 (41%)111 (16%) 279 (41%) 278 (41%)

� Br Plexus Br Plexus Br Plexus Br Plexus 3 (2%)3 (2%)3 (2%)3 (2%) 0000 7 (2.5%)7 (2.5%)7 (2.5%)7 (2.5%)� Phrenic Phrenic Phrenic Phrenic 1 (1)1 (1)1 (1)1 (1) 19 (7%)19 (7%)19 (7%)19 (7%) 6 (2.1)6 (2.1)6 (2.1)6 (2.1)� ScapulaScapulaScapulaScapula 2 (2)2 (2)2 (2)2 (2) 0000 1 (.04)1 (.04)1 (.04)1 (.04)� ArteryArteryArteryArtery 0000 0000 1 (.04)1 (.04)1 (.04)1 (.04)� VeinVeinVeinVein 2 (2)2 (2)2 (2)2 (2) 1111 3 (1.1)3 (1.1)3 (1.1)3 (1.1)� PleuraPleuraPleuraPleura 44 (40)44 (40)44 (40)44 (40) 5 (2)5 (2)5 (2)5 (2) 46 (17)46 (17)46 (17)46 (17)

Treatment of TOS: comparison of different operations Sanders, JVS, 1989

Neurogenic TOS

Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS� Results

Good Fair Poor

Scalene 56% 13% 31%Supra Rib 83% 13% 4%Trans Ax Rib 83% 5% 12%

Thoracic Outlet Syndrome: A Common Sequela of Neck Injuries Richard J. Sanders and Craig E. Haug 1991

ConclusionsConclusionsConclusionsConclusions� Different approaches for different

situations� Key to all is understanding the anatomy

and pathophysiology.