thoracic outlet syndrome
DESCRIPTION
an update of my original presentationTRANSCRIPT
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THORACIC OUTLET SYNDROME
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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.
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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.
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Subcoracoid tunnel
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contents
Brachial plexus Subclavian artery Subclavian vein
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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
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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
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Types :
1) Completely bony
2) Completely fibrous
3) Combined
4) Bony swelling
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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.
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Cervical rib
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Cervical rib
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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
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Interscalene triangle
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Costoclavicular space
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Hyperabduction syndrome
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Arterial compromise
Fatigue Weakness Coldness Upper limb claudication Thrombosis Paraesthesia Gangrene Raynaud's phenomenon due to thrombosis with
distal embolisation
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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.
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Neural compromise
Paraesthesia Pain in shoulder, arm, forearm and fingers Occipital headache – referred from tight
scalene muscles Weakness of forearm, hand.
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Clinical tests
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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.
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Elevated arms stress test
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Adson's (Scalene) Test
Radial pulse diminishes and disappears on turning chin to same side.
Decreases space between scaleneus anterior and medius .
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Adsons test
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Halsted's costoclavicular compression test
45° abduction and extension of arm with downward pressure on shoulders –neck turned to opposite side- reproduce symptoms
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Exaggerated military position
Patient shrugs shoulders with deep inhalation while drawing the shoulders backward in an exaggerated military position – radial pulse diminishes.
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Military position
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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.
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Wright's hyperabdution test
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Tinel sign – in supra and infraclavicular region Phalens sign – in carpel tunnel syndrome (CTS)
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Differential diagnoses
Carpel tunnel syndrome Spinal canal tumors Shoulder myositis Angina pectoris Raynaud's disease Ulnar nerve compression - epicondylitis
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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
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Double crush syndrome – TOS with other peripheral sites of nerve compression(CTS)
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Treatment
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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 .
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Surgical treatment
Indications: Symptoms persists with non operative
treatment. Associated vascular compression. Progression of neurological symptoms. Nerve conduction velocity < 60m/s
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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.
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Roos approach
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Thank you....