review ofthoracic outlet syndrome (tos)

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Hashim et al. World Journal of Pharmacy and Pharmaceutical Sciences

REVIEW OFTHORACIC OUTLET SYNDROME (TOS)

Dr. Safaa Hussein Hashim ALALi*

M. B. CH. B, Hdcariothoracic Surgery.

ABSTRACT

Thoracic outletsyndrome is an umbrella term that describes the

potential compression of the brachial plexus, subclavian vein or

subclavian artery by different clinical disorders. This review covers the

classification, clinical findings, physical examination findings and

management of this challenging syndrome under the light of recent

scientific research. Various medical specialties can encounter TOS

within their field of expertise. TOS should not be viewed as a single

clinical entity that simply manifests variations from one patient to

another. TOS is composed of three very discrete subgroups, and

treatment should be individualized after diagnosis is definite.

INTRODUCTIONT

horacic outlet syndrome (TOS) constitutes agroup of diverse disorders that result in

compression of the neurovascular bundle exitingthe thoracic outlet. The thoracic outletis

ananatomical are a in the lower neck definedas a group of three spaces between the

clavicleandthe first rib through which several important neurovascular structures pass; more

detailed anatomical descriptions will correspond with discussions of the relevant pathology.

These structures include the brachial plexus, subclavianartery, and subclavian vein.

Compression of this area causes a constellation of distinct symptoms, which can include

upper extremity pallor, paresthesia, weakness, muscleatrophy, and pain.

TOS classifications are based on the pathophysiology of symptoms with subgroups consisting

of neurogenic (nTOS), venous (vTOS), andarterial (aTOS) etiologies. Furthermore, each one

of these subgroups can be related to either congenital, traumatic, or functionally acquired

causes. Examples of congenital etiologies include the presence of a cervical rib or an

anomalous first rib. Traumatic causes most commonly include whip-lash injuries and falls.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 10, Issue 2, 322-338 Review Article ISSN 2278 – 4357

*Corresponding Author

Dr. Safaa Hussein Hashim

ALALi

M. B. CH. B,

Hdcariothoracic Surgery.

Article Received on

16 Dec. 2020,

Revised on 06 Jan. 2021,

Accepted on 26 Jan. 2021

DOI: 10.20959/wjpps20212-18291


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Functional acquired causes can be related to vigorous, repetitive activity associated with

sports or work. Diagnosis of TOS is generally dependent on clinician familiarity of TOS

coupled with an evaluation of symptoms and patient-specific risk factors. Clinical suspicion

can then be confirmed with provocative physical exam maneuvers, radiographic, and

orvascularstudies.

Because of the wide range of etiologies and lack of expert consensus for diagnostic testing,

the true incidence of TOS is difficult todiscern.

Several articles report an incidence of 3–80/1000. Neurogenic TOS accounts for over 90% of

the cases, followed by venous and arterial etiologies. Historically, TOS presents with

Symptom onset between the ages of 20–50 yearsold and is more prevalent in women.

With the wide range of multifactorialetiologies, it also makes sense that best-

practicetreatments for TOS involve a comprehensiveand multi-disciplinary approach.

Managementoptions can include surgery, lifestylemodification, pain management,

anticoagulation, physicaltherapy, and rehabilitation. This article there fore intends to review

the mostrelevant, noteworthy, and up-to-date literature, and toprovide clinicians with a

concise summary ofboth diagnosis and management for TOS. Acomprehensive electronic

literature search (1970–2018) process was conducted that included PubMed, EMBASE, and

MEDLINE databases, and Google Scholar. Previous materials publishedin peer-reviewed

journals and grey literaturewere reviewed in a systematic manner.

References cited in relevant articles were alsoreviewed. Search terms used included

‘‘thoracicoutlet syndrome’’ AND ‘‘imaging’’ OR ‘‘angiography’’OR ‘‘diagnosis’’ OR

‘‘neurogenic’’ OR‘‘venous’’ OR ‘‘arterial’’ OR ‘‘NSAIDs’’ OR ‘‘physicaltherapy’’ OR

‘‘surgery’’ OR ‘‘antidepressants’’OR‘‘Raynaud’s’’ OR ‘‘neuropathy.

Clinical presentation

For simplification, we used theanatomical classification of TOS:neurogenic TOS, arterial

TOS, andvenous TOS.

Neurogenic TOS accounts for over 90% of all TOS cases. It isseen predominantly in women

aged18-50 years. The most commonetiologicalfactor is a hyper-extension neck injury mostly

whiplashduring motorvehicle accidents. The second most common cause isoveruse

injurysuch as incorrect keyboard us for a long time orhyperabduction of arms during work.


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Anatomical etiologicalfactors includeanomalous first rib, cervical rib, congenital

fibromuscular bands, scalene muscle hypertrophy, congenital narrow interscalene interval.

The symptoms ofneurological TOS are a result of compression ofthe brachialplexus at the

thoracic outlet. Involvement of lower brachialplexus fibers (C8, T1) is more prevalent and

results in pain atsupraclavicularand infraclavicular fossa, neck, scapula, and chest

wall.Patientsexperience radiation of shoulder and neck pain to medial armtypically.

Anoccipital headache and transient facial paresthesias mayalso be present.

The involvementof upper brachial plexus fibers (C5, C6, C7) resultsin pain atanterior neck,

upper jaw, ear, and chest wall. Neck pain mayradiatelaterally on arm. Subjective motor

symptoms like fatigueand weaknessmay accompany pain and paresthesias. Patients

mainlysuffer fromweakness and incompetence in fine motor activities of thehand. However,

in patients with prolonged symptom durationweakness and atrophy primarilyinvolving fourth

and fifth flexordigitorum profundus, hypothenarmuscles innervated by the ulnarnerve is

detected. Weakness andatrophy involving flexor and extensorcarpi ulnaris muscles may also

beseen .

Venous TOS accounts for 5% of allTOS cases. Venous TOS refers tocompression and

thrombosis of thesubclavian vein and is frequentlyreferred to as effort thrombosis or Paget-

Schroetter Syndrome. VenousTOS presents with a sudden onsetpainful, blue and swollen

upperextremity. History of prolongedupper extremity use is often present. The thrombosis of

the subclavianvein will end up with dilatedsuperficial veins that represent acollateral flow to

bypass obstructedsegment. Dilated veins may also bedetected at the shoulder andsuperior

chest wall. Patients mayexperience paresthesiase condary to compression of sensorynerves.

In patients withintermittent obstruction, symptomsmay be transient in nature.

Arterial TOS is the rarest form of TOS comprising 1% of all cases. Arterial TOS refers to

compressionof a subclavian artery usuallyprecipitated by the presence ofanomalous first rib,

cervical rib, hypertrophic scalenus muscles andcongenital fibromuscular band. Compression

of the subclavianartery may lead to post-stenoticarterial dilatation, aneurysmformation,

arterial thrombosis andeventually distal embolization. Patients may stay asymptomatic

untildistal embolization develops. Painis less common in arterial TOS thanvenous and

neurogenic forms. Whenpresent, pain is in the form of adeep, severe, ischemic pain. Patients


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report coldness and pallor afterupper extremity use. Digitalgangrene may be the presenting

symptomin chronic cases.


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Thoracic outlet and relevant anatomy

Findings

The physical examination, as well ashistory, is an important clue fordiagnosis and cl.

Physical examination

Assification of TOS. Despite presenting with similarsymptoms, physical examinationfindings

of three anatomical subtypesdiffer from each other.

A thorough upper extremityneurological examination is necessary when any form of TOS is

suspected ina patient. The neurologicexamination may reveal global handweakness especially

inhypothenar and lateral thenarmuscles. A patchy sensory loss mostlyinvolving lower

brachial plexusfibers is common. Palpation may revealtenderness at scalene muscles,

trapezius and anterior chest wall inneurogenic TOS. Several provocativetests are conducted

toreproduce symptoms.

Brachial tinel’s sign

Tinel's sign is a way to detectirritated nerves. Brachial Tinel’s sign isperformed by light

percussion overthe brachial plexus at supraspinousfossa. The test is positive if atingling in the

distribution of affectednerves is elicited. It is one of themost reliable provocative tests in

thediagnosis of TOS.


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Adson’stest

The test was defined in 1927 byAdson and Coffey to assess theevidence of circulatory

symptomscaused by the presence of a cervicalrib. Several modifications weresuggested after

its description.

Adson’s test is currently describedin the following manner. The radialpulse is palpated by the

examiner onthe wrist. The affected arm islaterally rotated and extended bythe examiner while

the patients take adeep breath, holds it and rotatesthe face to tested shoulder. The

disappearance of the radial pulse withfinal active neck extension isindicative of a positive

test. Thetest lacks sensitivity andspecificity. Moreover, there are nointer-examiner reliability

andvalidity reports of Adson’s test inthe literature.

Roos test

The test was first described in 1976for the diagnosis of TOS. It isalso named as abduction,

externalrotation test or stress abduction test.

The patient is seated both arms inthe 90° abduction, external rotationposition and elbows in

90° flexion. The head is laterally rotated to theopposite side. This positionsnarrows the inter

scalene andcostoclavicular area and reproducessymptoms. If no symptoms occur,patients are

instructed to open andclose fingers making a fist slowlyfor 120-180 seconds. A

gradualincrease in pain at neck and shoulder, paraesthesia in forearm and fingers,inability to

complete the test, dropping arms in lap in markeddistress are indicative of positive testresults.

Mild fatigue during thetest should not be interpreted aspositive. Çalıs et al. investigatedthe

diagnostic value of provocativemaneuvers in TOS and reported that Roos test was themost

sensitivetest.

Costoclavicular compression test

The test is also named as Eden test or exaggerated soldier posturetest. The test is applied in

the sitting position. The radial pulse ispalpated. The patient is asked to position his shoulders

backward anddownwards while protruding the chest, similar to soldier posture.

Thedisappearance of radial pulse or presence of paresthesia, pain, andweakness radiating to

arms are indicative of a positive test.


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Halstead’stest

The test can be applied in the sitting or standing position. The radialpulse is palpated. The

patient is instructed to turn the head to theopposite side and extend the neck. The examiner

pulls on the armapplying traction. The disappearance of radial pulse or presence

ofparesthesia, pain, and weakness radiating to the arm are indicative of apositive test.

Hyperabductiontest

This test wasdefined in 1945 for diagnosis of TOS by Wright. Thetest is appliedin sitting

position. The radial pulse is palpated, and thepatient is instructed to abduct arms in

externalrotation position. Thisposition causes traction of neurovascular bundle around the

coracoidsprocess. The disappearance of radial pulse or presenceof paresthesia, pain, and

weakness radiating to the arm are indicativeof a positive test. Calıs et al. investigated the

diagnostic values of testsfor TOS. Theydemonstrated that Roos test, Halstead‘s test, Brachial

Tinel’s sign, andcostoclavicular test were most sensitive tests. Nordet al. conducted another

study to investigate the false-positiverate andspecificity in normal subjects and carpal

tunnelsyndrome patients ofprovocative maneuvers used to diagnose the thoracicoutlet

syndrome.

They concluded that current provocative maneuvers usedto diagnoseTOS resulted in a high

false-positive rate in normalsubjects and carpaltunnel syndrome patients. Therefore, the

results ofthe provocativetests should be interpreted with caution and should becombined

withdiagnostic clues in the patient history.

Diagnosis of venous TOS is fairly certain in mostpatients after aninitial history and careful

physical examination. Asudden swollen, cyanotic, painful upper extremity in an active

youngmale is thehallmark of the presentation. In older patients, alternative causes forvenous

thrombus should be considered. Physicalexamination findingssuggestive of Pancoast tumor

or malignancy should beinvestigated inelderly patients.

Physical examination findings in arterial TOS arethose of arterialocclusion. Absent or

diminished distal upper extremitypulses, delayedcapillary filling, pallor, sensory deficit

secondaryto ischemia, ischemiaor gangrene at finger tips may be present. Theclinician should

palpatethe supraclavicular area when arterial TOS issuspected. Palpation mayreveal

congenital palpable fibromuscular bands, bonyprominence orpulsation of the supraclavicular

artery.


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Diagnosis and Management

Relevant physical examination

When suspecting TOS, a general physicalexamshould focus on a thorough examination

ofnotonly the shoulder and upper extremity butthecervical spine as well, with

particularattentionto head and neck posture. A carefulcomparisonbetween the affected and

contralateralextremitycan reveal obvious signs of wasting andweakness, while more subtle

differences inskincolor, temperature, and hair distributionmayalso be evident. Depending on

theunderlyingetiology, patients may present with variedyetcharacteristic physical exam

findings oftheunderlying cause of obstruction. Vascular TOScan cause large differences in

bloodpressurereadings between arms ([20 mmHg); the shoulder and chest may appear

edematous invTOS, while the upper extremity may appearpale or cyanotic with a TOS.

Notsurprisingly, nTOS yields more obvious signs of muscularatrophy such as the Gilliatt–

Sumner hand, which is a constellation of atrophicabductorpollicis brevis, hypothenar, and

interossei muscles. Other notable physical examfindings may include supraclavicular fullness

oraneurismal pulsations.


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While the use of individual provocative maneuvers for the diagnosis of TOS has ledto ahigh

number of false positives, studies indicatethat reliance on multiple tests inconjunction may

increase the specificity of TOS identification. below describes commonly used maneuvers in

the physical exam. Astudy by Gillard et al. demonstrated that combiningthe Adson and Roos

test increased thespecificity from 76 to 30% when used aloneto 82% when both are positive.

Diagnostic modalities

Further diagnostic testing is directed predominantlyby clinical symptoms and the type

ofsuspected TOS. While testing is oftenequivocalor negative in nTOS, making it a diagnosis

of exclusion, testing for vTOS focuses on the demonstration of stenosis or occlusion

ofsubclavianvessels. Below are tests commonly usedin diagnosis and surgical planning

forappropriate candidates.

Electrodiagnostic testing

Although a majority of patients will havenormalor negative results, electrophysiological

evaluation via nerve conduction and EMG isindicated for those suspected of nTOS. However,

when positive nTOS presents with acharacteristicpattern of nerve conductionabnormalities.

Sensory response may benormalin the median distribution but diminishedorabsent in medial

antebrachial cutaneousandulnar sensory responses. Additionally, diminishedor absent median

and ulnar motorresponse may be seen, typically with amoreprofound decrease in the median

response. These findings are highly suggestive ofnerveconduction abnormalities involving

the C8 and T1 fibers (T1 usually more affected than C8) andserve to rule out cervical

radiculopathyandmyelopathy.

Injection of local anesthetic into theanteriorscalene muscle has been used

tosuccessfullydiagnose n TOS. Temporary relief of symptoms.


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following medication injection decreasesmusculartension on the neural bundle and

maypredict response to surgicaldecompression. Inthose with a positive response to theblock,


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94% were shown to have a positive outcomefollowingsurgical correction as compared to only

50% of patients who underwentdecompressionfollowing a failed block.

Imaging

Imaging can also be helpful in confirmingsuspectedcases of TOS. Anatomical

abnormalitiesor defects, such as prominent cervicalribs, fracture calluses, or compressive

tumorsarecommonly demonstrated on chest, shoulder, orspine radiographs. Convention

alarteriography and venography, while they may demonstrateextrinsic compression, do not

permit acleardepiction of the impinging anatomicstructure, and they tend to be replaced by

lessinvasiveprocedures (CT, MR imaging, sonography) asdescribed below. In addition

toelectrodiagnostictesting, MR neurogram can providefurther detail to identify

anatomicalrelationshipsor particular sites of compression.

For suspected vascular TOS, ultrasoundmaintains high sensitivity andspecificity,

isnoninvasive and inexpensive, and should bethe initial imaging test of choice. CT

orMRangiography can differentiate equivocalcases orprovide additional anatomic

detailrequired forsurgical planning.

Conservative management strategies

Management strategies depend on theunderlyingetiology of TOS. Initial treatment of

nTOSconsists of conservative measures, whereasvTOS or nTOS with refractory symptoms

mayundergo surgical management. Treatment isreserved only for symptomatic patients,

asthepresence of a cervical rib exists in 0.5%of thepopulation but only a small

fractiondevelopsymptoms.

A consensus on the appropriate conservativeregimen for nTOS remains controversial.

However,a multimodal treatment approach includingpatient education, TOS-

specificrehabilitation, and pharmacologictherapieshave shown positive results. Rehab

isrecommendedas the initial nonsurgical managementfor nTOS and should include

patienteducation (postural mechanics, weight control, relaxationtechniques), activity

modification, and TOS-focusedphysical therapy (active stretching, targetedmuscle

strengthening, etc.) Onestudy demonstrated symptomatic relief in 25 of 42 patients with

nTOS following 6 months of physical therapy.


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Pharmacologic interventions often providesymptomatic relief, and primarily

includeanalgesics (NSAIDs and/or opioids) forneuropathicpain, as well as muscle relaxants,

anticonvulsants, and/or antidepressants asadjuvants. Additionally, injection oflocalanesthetic,

steroids, or botulinum toxintype Ainto the anterior scalene and/orpectoralismuscle have

demonstrated varying levels ofsuccess in observational studies, althoughthe use of BTX-A

failed to demonstratesignificantbenefit in a randomized trial .

Surgical managementstrategy in failedconservative managementand treatment

outcomes

Surgery for TOS is reserved for patientswhohave failed conservative management.

Thethreshold for decompression varies widelyformild to moderate symptoms, but

certainsymptoms require surgery.

As previously discussed, physical therapyand conservative management of nTOS

shouldpersist for at least 4–6 months prior toconsiderationof surgical intervention. However,

for patients with arterial or venous TOS, theinitial intervention is most oftensurgical. A trialof


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anticoagulation via catheter-directedthrombolysisand systemic heparin therapy may befirst

attempted for patients with arterialor vascular TOS In cases of mild upper extremityischemia,

catheter-directed thrombolysismayrestore perfusion. Symptoms refractory tothesemeasures

require surgery.

Surgical candidates should have failedconservativemanagement Most surgical

candidatesexhibit nTOS with uncontrolled pain orprogressively worsening upper

extremityweakness.The surgery of choice is a first ribresectionaimed at brachial plexus

decompression,typicallyperformed by vascular surgeons. Theoperation can also be performed

bythoracicsurgeons, neurosurgeons, orthopedicsurgeons,and plastic surgeons. In nTOS, the

firstribis removed in addition to a scalenectomyorscalenotomy.

The three approaches to brachial plexusdecompression by first rib removal

includetransaxillary, supraclavicular, and infraclaviculartechniques. Each approach has

achievedgood outcomes, with no definitivelysuperiortechnique . While the transaxillary

andsupraclavicular approaches are utilizedmorefrequently, technique is often chosenbased

onthe individual patient and uniqueanatomical considerations. The

supraclavicularapproachrequires a scalenectomy of the middle andanterior scalene muscles to

expose a smallportionof the first rib. The compression istherebyeasily exposed, allowing for

access to thebrachialplexus if neurolysis is indicated. Thetransaxillary approach is performed

byaccessingthe first rib between the pectoralis majorand latissimus dorsi in the axilla. With

the patient in the lateral position, carefuldissectionof the axillary vasculature and nerves

mayexpose the first rib. In this approach, exposure is limited and potential brachial

plexopathymayoccur through over-manipulation andretraction. Less common, the

infraclavicularapproach allows for vascularreconstruction inpatients with venous or arterial

TOS andshouldbe pursued if central venous exposure isrequired.

Brachial plexus injury after first ribresectiondoes occur, but reporting varies widely .In

amulti-institution database study, brachialplexus injuries were reported in 0.6% patientswith

nTOS following transaxillary firstribresection. However, another study oftransaxillary first

rib resections inpatients withnTOS reported a brachial plexus injuryincidenceof 9%, with an

incidence of 4% aftersupraclavicular first rib resection. More recently, the introduction

ofminimallyinvasive techniques has achieved superioroutcomes in first rib removal, as

bothroboticand thoracoscopically assisted approachesminimize brachial plexus manipulation

Additional training, equipment, andexpertise isrequired but may limit the overall surgicalrisk.


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Overall outcomes from surgicaldecompressionare very positive. Following

surgicalintervention, 95% of patients with nTOS reportedexcellent’’ results. In a 5-

yearfollow-upstudy of patients with vTOS, patency rateswerebetter than 95%. Impediments

tosuccessfuloutcomes include major depression orcomorbidconditions that skew the initial

diagnosis.

Recent developments

Asmore patients receive diagnosis andtreatmentfor TOS, the referral pattern has changed.

Insteadof evaluation and treatment by multipledisciplinesbefore consideration of TOS,

patients arenow referred sooner despite a shorterduration ofsymptoms, which improves the

predictedresponse to surgical treatment. Additionally, a rise in the number of adolescent

caseshas beendescribed, owing to repetitive or vigorousactivitysuch as musical instrument or

athleticendeavors. More common in adolescents thanadults, first rib resection has

beensuccessfullyand safely performed for vTOS and aTOSwithgood outcomes and fast

recovery.

Since TOS is a rare and complex group ofdisorders with potentially severe

anddisablingsymptoms, care can be challenging forhealthcare providers. Therefore, a

systematic, organizedapproach to the diagnosis and treatmentof TOS provides an opportunity

forspecialists todeliver patient-centered care and achieveoptimalresults. This specialized type

of care isbestdelivered through the efforts of amulti-disciplinaryteam that consists of various

specialists, including vascular surgery, thoracic surgery, neurology/neurosurgery,

orthopedics, radiology, anesthesiology, pain management, physicaltherapy, and occupational

therapy. Forthis reason, centers of excellence for TOShavebeen established around the

country withdemonstrable improvements in outcomes.

Venous and arterial TOS are diagnosed by acombination of clinical presentation andimaging.

Ongoing developments in thediagnosisof TOS include dynamic CT angiography, MR

neurography, and Diffusion TensorImaging (DTI). These imaging modalities can beused

toidentify brachial plexus branchingvariants inwhich susceptibility to compression by

thescalene muscle is increased. Neurogenic TOS isgenerally more difficult to diagnose as

nerveand tissue inflammation lack consistentradiographicevidence. However, as imaging

studiesevolve, newer modalities with higherqualityallow for improved diagnostic objectivity.


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MRI can evaluate the anatomy of thethoracicoutlet, the soft tissue structures

causingcompression, and allow direct visualization of brachialplexus compression.

Magneticresonance neurography (MRN) is an imagingmodality that allows non-

invasivevisualizationof nerve morphology and signal. In thistechnique, signals from

surrounding soft tissue suchas adipose are suppressed, and pulsationartifactfrom pulsating

blood is removed. Continuedimprovements in high-resolution MRN may, therefore, augment

current diagnosticmodalitiesby facilitating prompt identification ofbrachial plexus

compression across thethoracicoutlet in patients with nTOS.

While MRN denotes a class of techniquesintended for assessment of peripheralnerves,

diffusion tension imaging (DTI) ortractographyis reserved for the CNS. Short

tauinversionrecovery (STIR) sequences and the spectraladiabaticinversion recovery (SPAIR)

preparatorymodule are variations of MRN and deliver amore complete anatomical description

ofthenerves comprising the brachial plexus. DTIsequences to visualize nerve fascicles

areemployed in the modeling technique oftractography, allowing for a more

comprehensiveassessment of peripheral nerve injury. Onestudy regarding MRN demonstrated

a 100% positive predictive value in all 30 patientsinvolved; however, ultrasound

alsoidentifiedcompression all patients with nerve lesionsvisualized on MRN.

Current mainstays of diagnosis includeduplex ultrasound, arteriography, hemodynamictesting

(finger plethysmography) at restand with symptom-producing maneuvers, aswell as CT and

MR angiography. Invasivearteriography and angiography are usefulin thedetection of

complications from aTOS such asthrombosis, embolization, and aneurysm. Theinvasive

nature of these techniques limitstheiruse to surgical planning rather than purediagnostics.

Other non-invasive tests such as MR and CT angiography are more readily employed for

their diagnostic utility outside ofsurgicalplanning. Dynamic testing allows theclinicianto

evaluate arterial compression withprovocativemaneuvers, while imaging helps to definethe

anatomic source of compression and confirmthe diagnosis of arterial, venous, or nTOS.

Surgical advancements

As noted above, first rib resection withscalenectomyremains the operation of choice

fordecompression, but as surgicaladvancementscontinue to emphasize minimally

invasiveapproaches, some institutionsnowemployVATSin order to achieve a

clearervisualization of theoperative field and potentially minimizeinjuryto the neurovascular


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bundle. Twoadditionalstrategies, the robotic-assisted andendoscopicassistedtrans-axillary

approaches, are noveltechniques with potential benefit, the latteraiming to decrease risk of

pneumothorax

CONCLUSION

TOS is a groupdesignation for several different disorders that affectaxillary arteryor vein or

components of the brachial plexus. Therefore,TOS is almostunique in that it is used to

describe disorders that affectboth bloodvessels and nerve fibers. Various medical specialties

canencounter TOSwithin their field of expertise. TOS should not beviewed as asingle clinical

entity that simply manifests variations fromone patient toanother. TOS is composed of three

very discretesubgroups, andtreatment should be individualized after diagnosis.

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