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Thoracic outlet syndrome (TOS), a term coined by Rob and Standeven,1 refers to symptomatic compression of the structures of the thoracic outlet (subclavian vessels and brachial plexus) at the superior opening of the chest. It was previously designated as scalenus anticus, costoclavicular hyperabduction, cervical rib, and first thoracic rib syndromes per presumed etiologies. The various syndromes are similar, and the compression mechanism is often difficult to identify. Most compressive factors operate against an osseous structure, most commonly the first rib.2,3

It has been suggested that the evolution to an erect posture occurred faster than the adaptation by the thoracic outlet to changes in the thoracic cage, particularly the shoulder girdle.4


At the superior aspect of the thoracic cage, the subclavian vessels and the brachial plexus traverse the cervicoaxillary canal to reach the upper extremity. The cervicoaxillary canal is divided into two sections by the first rib: the proximal division, composed of the scalene triangle and the costoclavicular space, and the distal division, composed of the axilla (Fig. 145-1). The proximal division is important to achieving acceptable neurovascular decompression. It is bounded superiorly by the clavicle, inferiorly by the first rib, anteromedially by the costoclavicular ligament, and posterolaterally by the scalenus medius (middle scalene) muscle and the long thoracic nerve. The scalenus anticus (anterior scalene) muscle, which inserts on the scalene tubercle of the first rib, divides the costoclavicular space into two compartments: The anteromedial compartment contains the subclavian vein, and the posterolateral compartment contains the subclavian artery and the brachial plexus. The latter compartment, which is bounded by the scalenus anticus muscle anteriorly, the scalenus medius muscle posteriorly, and the first rib inferiorly, is called the scalene triangle.

Figure 145-1

The cervicoaxillary canal has a proximal division consisting of the scalene triangle and costoclavicular space and a distal division composed of the axilla. The proximal division is more susceptible to neurovascular compression.


The cervicoaxillary canal, particularly its proximal division, also termed the costoclavicular area, normally has ample space for the passage of the neurovascular bundle without compression. Narrowing of this space occurs during functional motions of the upper extremities. It narrows during abduction of the arm because the clavicle rotates backward toward the first rib and the insertion of the scalenus anticus (anterior scalene) muscle. In hyperabduction, the neurovascular bundle is pulled around the pectoralis minor tendon, the coracoid process, and the head of the humerus. During this manoeuvre, the coracoid process tilts downward and thus exaggerates the tension on the bundle. The sternoclavicular joint, which ordinarily forms an angle of 15 to 20 degrees, forms a smaller angle when the outer end of the clavicle descends (as in drooping of the shoulders in poor posture), and ...

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