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  • • Variety of disorders caused by arterial, venous, or neural compression at base of neck

    • Mechanical causes for compression include:

    • -Cervical rib

      -Anomalous ligaments

      -Anterior scalene hypertrophy

      -Positional changes with relation to first rib

    • Patients may describe history of cervical trauma

    • Symptoms rare prior to adulthood, suggesting alteration of normal structure with age is cause

    • Subclavian artery stenosis: Arterial stenosis and poststenotic dilation

    • Subclavian vein compression: Can lead to effort thrombosis (Paget-Schroetter)

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Epidemiology

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  • • Prolonged hyperabduction in hairdressers, painters, truck drivers

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Symptoms and Signs

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  • • Neurologic symptoms predominate

    • Pain, paresthesias, numbness in brachial plexus trunks (ulnar most common)

    • Hand numbness often wakes patients from sleep

    • Motor deficits indicate long duration

    • Muscular atrophy of hand may be present

    • May be reproducible on exam with various maneuvers of shoulder girdle

    Adson test: Weakened radial pulse with arm abduction and head rotated to opposite side

    Tinel test: Light percussion in supraclavicular fossa produces peripheral sensations

    • Venous compression and arterial compression less common

    Subclavian artery compression: Bruit, distal emboli, or arterial occlusion

    Subclavian vein compression: Thrombosis of vein leading to extremity pain and swelling (effort thrombosis called Paget-Schroetter syndrome)

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Imaging Findings

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  • • Cervical x-ray may identify cervical rib

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  • • No objective study to confirm diagnosis of neurogenic thoracic outlet syndrome

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Rule Out

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  • • Carpal tunnel syndrome

    • Cervical disk disease

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  • • Cervical x-ray and electromyography to rule out other causes of neurologic syndrome

    • Arterial syndrome: Angiography

    • Venous syndrome: Venography

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  • • Postural correction and physical therapy

    • If surgical repair warranted, thoracic outlet decompression

    • 2 approaches possible

    • 1. Supraclavicular

      2. Transaxillary

    • Goals:

    • -Excise anterior scalene and fibrous bands

      -Rib resection

    • Arterial disease: Thoracic decompression and arterial reconstruction

    • Venous disease: First treat with thrombolytics or anticoagulation, then thoracic outlet decompression, may need venous reconstruction (open or endovascular)

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Surgery

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Indications

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  • • Arterial disease

    • Venous disease

    • Neurologic symptoms not attributable to other disease and failure of conservative therapy after 3-6 months

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References

Sharp WJ et al. Long-term follow-up and patient satisfaction after surgery for thoracic outlet syndrome. Ann Vasc Surg. 2001;15:32.  [PubMed: 11221941]
Kreienberg PB et al. Long-term results in patients treated with thrombolysis, thoracic inlet decompression, and subclavian vein stenting for Paget-Schroetter syndrome. J Vasc Surg. 2001;33:5100.
Schneider DB et al: Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intra-operative angioplasty. J Vasc Surg 2004;40:599.  [PubMed: 15472583]

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