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Thoracic outlet syndrome (TOS) encompasses a trio of conditions that result from compression of the neurovascular structures that serve the upper extremity: the brachial plexus (neurogenic thoracic outlet syndrome), the subclavian vein (venous TOS), and the subclavian artery (arterial TOS), and each syndrome is defined by a distinct presentation. The name TOS was previously designated according to the etiology of the compression—that is, scalenus anticus, costoclavicular, hyperabduction, cervical rib, or first rib syndrome. Most compressive factors operate against the first rib and produce a variety of symptoms, depending on which neurovascular structures are compressed. These factors, along with common etiologies and symptoms, are illustrated in Figure 143-1. This chapter will review the anatomy and pathophysiology of thoracic outlet syndrome and the transaxillary approach to first rib resection. Subsequent chapters will detail other surgical approaches to first (and cervical) rib resection including supraclavicular (Chapter 144) and thoracoscopic approaches (Chapter 145) and will address the vascular interventions often additionally required for venous TOS.

Figure 143-1

Compression factors in the thoracic outlet with the signs and symptoms produced.


Peet et al. coined the term thoracic outlet syndrome to designate compression of the neurovascular bundle at the thoracic outlet.1 Until 1927, the cervical rib was commonly thought to be the cause of symptoms of this syndrome.2 Hunauld, who published an article in 1742, is credited by Keen as the first observer to describe the importance of a cervical rib in causing symptoms.3 In 1861, Coote performed the first operation to remove a cervical rib removal.4 A “cervical rib syndrome” was coined by Thomas and Cushing in 1903 when describing brachial plexopathy and the resectional procedure to treat it.5 Unaware of this report, Bramwell recognized symptoms of neurovascular compression caused by a normal first rib in the same year,6 and Murphy is credited with the first resection of the first rib.7 Law in 1920 reported the role of adventitious ligaments in producing cervical rib syndrome,8 and in 1927, Adson and Coffey suggested a role for scalenus anticus muscle in producing cervical rib syndrome.9 This was further developed by Naffziger and Grant and by Ochsner et al. in 1935, who popularized resection of the scalenus anticus muscle.10,11 In 1943, Falconer and Weddell incriminated the costoclavicular membrane in the production of neurovascular compression.12 Wright in 1945 described the hyperabduction syndrome with compression in the costoclavicular area by the tendon of the pectoralis minor.13 Rosati and Lord in 1961 added claviculectomy to anterior exploration, scalenectomy, cervical rib resection when present, and resection of the pectoralis minor and subclavius muscle, as well as the costoclavicular membrane.14

Brickner and Milch in 1925, and later Telford and Stopford, suggested that the first rib was the cause ...

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