Thoracic Outlet Syndrome

• • 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)

Epidemiology

• • Prolonged hyperabduction in hairdressers, painters, truck drivers

Symptoms and Signs

• • 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)

Imaging Findings

• • Cervical x-ray may identify cervical rib

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

Rule Out

• • Carpal tunnel syndrome

  • Cervical disk disease

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

  • Arterial syndrome: Angiography

  • Venous syndrome: Venography

• • 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)

Surgery

Indications

• • Arterial disease

  • Venous disease

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

References