Thoracic outlet syndrome

A Brief description on types,causes,symptoms and treatment

1. THORACIC OUTLET SYNDROME Anything that narrows Costoclavicular space

2. DEFINITION Thoracic outlet syndrome (TOS)- a collection of symptoms brought about by abnormal compression of the neurovascular bundle by bony, ligamentous or muscular structures in the narrow space between clavicle and 1st rib – the thoracic outlet.

3. Thoracic outlet is bounded Anteriorly: Manubrium Sterni Posteriorly: Spine Laterally: First Rib

4. ANATOMY The thoracic outlet is composed of five successive spaces the vascular and nervous elements go through : The inter costo scalenic defile The prescalenic defile The costoclavicular space The sub-pectoral tunnel The humeral space

5. The intercosto-scalenic defile

6. Prescalenic defile

7. Cervico axillary canal divided into PROXIMAL COSTOCLAVICULAR SPACE DISTAL AXILLA.

8. Costoclavicular space is bounded by Superiorly: Clavicle Inferiorly: First Rib Antero medially: Costo clavicular Ligament Postero laterally: Scalenus medius muscle

9. Scalenus Anticus muscle divides costoclavicular space into 2 compartments Anteriorly: Subclavian vein Posteriorly: Subclavian Artery and Brachial Plexus Posterior compartment is called Scalene triangle bounded Anteriorly: Scalenus Anticus Posteriorly: Scalenus Medius Inferiorly: 1 st Rib

10. Interscalene triangle

11. Subcoracoid area

12. Pectoralis minor muscle and coracoid process

13. First clinical description given by A.Cooper 1821 W H Willshire described about cervical rib H Coote first resection of cervical rib. In 1956 Peet introduced the term thoracic outlet syndrome .

14. c ontents viscera thymus trachea oesophagus lung apices • vessels, nerves and lymphatics common carotid arteries confluences of internal jugular and subclavian veins phrenic nerves vagus nerves recurrent laryngeal nerves thoracic duct prevertebral fascia muscles st e r no c l e i do m a sto i d muscle anterior and middle scalene muscles sternohyoid muscle sternothyroid muscle

15. Principal Causes of TOS

16. Race No racial predilection exists. Sex Thoracic outlet syndrome is traditionally more common in women than in men, with a female-to-male ratio as high as 3:1. Age Thoracic outlet syndrome is most common in people aged 10-50 years

17. Classification

18. Subgroup 1 - ( neurologic) – 95% of cases This type is secondary to compression of the brachial plexus caused by various soft tissue and bony abnormalities at the point where the nerves pass between the anterior and middle scalene muscles

19. Subgroup 2 - (venous type) 3-4 % of cases. Venous thrombosis may be categorized into primary and secondary thrombosis based on the etiology . Primary venous thoracic outlet syndrome, or primary venous thrombosis, is also called Paget- Schrötter syndrome named after the 2 individuals who first described this entity: Paget, who described it in 1875, and von Schrötter , in 1884.

20. Subgroup 3 (arterial type): 1-2 % of cases. This type is associated with the most serious complications, including limb ischemia (which may result in the loss of the affected upper extremity).

21. Neurogenic TOS Etiology Hyperextension neck injury (whiplash) Repetitive stress injuries

22. Predisposing Factors Scalene muscle anomalies Narrow scalene triangles Congenital ligaments/bands Cervical ribs

23. Pathophysiology Neck trauma stretches and tears scalene muscle fibers Swelling of muscle belly pain , parathesias , numbness, weakness Scarring/fibrosis of muscle belly occipital headaches.

24. Symptoms Pain, parathesias , numbness, weakness throughout affected hand/arm Not necessarily localized to peripheral nerve distribution Extension to shoulder, neck, upper back Upper plexus” disorders “Lower plexus” disorders Occipital headaches Perceived muscle weakness Actual weakness and atrophy are rare Vasomotor symptoms Vasospasm, edema , hypersensitivity (CRPS)

25. Neurologic compression Pain and/or parasthesia of the neck, shoulder region, arm or hand, depending on the root involved Often bilateral Difficulty with fine motor tasks of the hand Examination reveals :sensitive disorders muscle weakness muscle atrophy (long fingers flexors) Palpation of subclavicular area may cause pain

26. Pectoralis minor syndrome Compression of neurovascular bundle under the pectoralis minor Pain over anterior chest and axilla Fewer head/neck symptoms

27. Venous TOS Etiology Developmental anomalies of costoclavicular space Repetitive arm activities – throwing, swimming, overhead activities.

28. Predisposing Factors Relationship of vein to subclavius tendon and costoclavicular ligament Decrease in dimensions of costoclavicular space Repetitive trauma to vein causing stenosis, thrombosis

29. 1 . Acute occlusion Pain Tightness Discomfort during exercise Edema Cyanosis 2. Increased venous pattern Swelling Feeling of heaviness Easily fatigued arm and hand Superficial vein distension Thrombophlebitis of the upper limb Tenderness over the axillary vein ,Gangrene rarely Venous compression

30. Interscalene triangle Artery , Nerves V e i n Costoclavicular space Subcoracoid area Artery, Vein , Nerves

31. Arterial TOS Etiology Cervical or anomalous first rib Anomalous anterior scalene insertion

32. Symptoms Digital or hand ischemia Cutaneous ulcerations Forearm pain with use Pulsatile supraclavicular mass/bruit Arterial compression : Easily fatigued arms and hands Rest pain of hand and fingers Paleness – coldness of the hand Raynaud’s phenomenon Ischemic signs, distal gangrene due to repeated embolization, or to subclavian artery thrombosis

33. DIAGNOSIS Clinical maneuvers Radiography Ultrasonography Magnetic resonance (MR) angiography Computed tomographic (CT) angiography Angiography and venography

34. Adson maneuver Patient is instructed to take and hold a deep breath and extend his neck fully and then asked to turn his head towards the side being examined. Obliteration or diminuation in the radial pulse suggest compression.

35. The Roos test The patient repeatedly clenches and unclenches the fists while keeping the arms abducted and externally rotated (palms forward and upward). The elbows are braced slightly behind the frontal plane for 3mins The test is positive when symptoms are reproduced with this maneuver A positive test is very suggestive of the thoracic outlet syndrome.

36. Hyperabduction maneuver Evaluates compression of the neurovascular bundle between the coracoid process and the pectoralis minor muscle. The patient externally rotates the shoulders and extends the arms out from the chest and then above the head.

37. Wright's hyperabdution test

38. Halsted's Costoclavicular maneuver Evaluates compression of the neurovascular bundle between the clavicle and the first rib. The patient assumes an exaggerated military position with shoulders pushed backward and pressed downward.

39. Diagnosis and Treatment

40. Diagnosis • “the most accurate diagnosis of TOS…must rely on a careful history and thorough, appropriate physical examination ” • No single diagnostic test has sufficient specificity to prove or exclude the diagnosis

41. DD nTOS Carpal tunnel syndrome Ulnar nerve compression or neuritis Rotator cuff tendinitis Cervical spine strain/sprain Fibromyositis Cervical disk disease Cervical arthritis Brachial plexus injury

42. DD aTOS Other sources of emboli: Cardiac and aortic arch arch causes Coagulopathies Vasculitis Radiation induced arteritis Connective tissue Disorders Arterial dissection Atherosclerotic disease Traumatic

43. IMAGING X-rays Cervical rib Elongated C7 transverse process Hypoplastic 1st rib Callous formation from clavicle or 1st rib fracture Pseudoarthrosis of 1st rib Unable to image soft tissue anomalies and fibromuscular bands – seen only at time of surgery

44. CT/MRI can rule out other pathologies Magnetic resonance (MR) angiography computed tomographic (CT) angiography of the thoracic inlet, especially with recently devised techniques and protocols, are noninvasive modalities that provide image quality comparable to that of angiography and venography

45. Angiography and venography remain the criterion standards for the radiologic diagnosis of these conditions, and they have the added benefit of enabling potential endovascular treatment. MR neurography – newer technology to detect localized nerve function abnormality

46. aTOS Segmental arterial pressures Angiography vTOS Duplex U/S Venography Consider bilateral studies •

47. EMG Reduction in NCV and low amplitude motor responses Positive results Confirms the clinical diagnosis Poor prognosis if true neural damage present Negative results Does not exclude TOS Both EMG/NCV have lo sensistivity for TOS

48. Electrophysiology Testing Medial antebrachial cutaneous nerve (MAC) Lowest branch of inferior trunk of brachial plexus More sensitive to compression than other branches Higher sensitivity and specificity with EMG/NCS

49. Scalene muscle block Most useful when diagnosis is unclear Patient in supine position with neck hyperextended and turned to opposite side. Lateral border of sternocledomastoid is palpated andabout 1.5 inches above the clavicle anterior scalene muscle is palpated 5- 7ml of plane bupivacaine and 1ml of betamethasone is injected. Relief of symptoms ranging from few days to weeks. Good relief of symptoms confirms the diagnosis. 2-3 injections can be given.

50. Treatment Conservative management aims to increase the space in the thoracic outlet area and to relieve compression on the neurovascular structures. Step 1 proper postural changes and correct faulty postures. Step 2 manipulate and mobilize and relax 1st rib and clavicular , scapular, pectoral muscles. Step 3 strengthen the shoulder girdle muscles and stretch scalene muscles

51. Pain control Muscle relaxants NSAIDS Ultrasonography with ionatophorosis Transcutaneous electric nerve stimulation. (TENS) Local anesthetic injections.

52. Edema control gloves Compressive garments Elevation of limb Active range of motion exercises Retrograde massages Phonophoresis controls pain and edema

53. Ergonomics Work posture related changes Relative adjustment of chair height so that forearm restscomfortably and without shoulders being elevated or depressed. Avoid carrying heavy weights on effected side Avoid hyperextension of neck and hyperabducting postures

54. PHYSICAL THERAPY Is the key of T.O.S. treatment Its purpose : open the costo-clavicular space fight against physiological shoulders falling attitude Has to be progressive, painless, bilateral Average duration : 3 to 6 months If properly executed : 70 to 90% of good results

55. Exercises Involves relaxing shoulder girdle and stretching the scalene and pectoral muscles. Neck : neck side bending exercises neck rotation neck flexion exercises Shoulder : shrugging of shoulders pendulum exercises

56. TREATMENT OF T.O.S. PHYSICAL THERAPY (2) Muscular relaxation

57. TREATMENT OF T.O.S. PHYSICAL THERAPY (3) Correct shoulder falling attitude

58. TREATMENT OF T.O.S. PHYSICAL THERAPY (4) Reinforce muscles that ‘‘open’’ the costo- clavicular space

59. TREATMENT OF T.O.S. PHYSICAL THERAPY (5) Respiratory reeducation

60. Treatment nTOS • Neck stretching • Posture correction • Avoid neck traction, weights, resistance exercises, strengthening exercises

61. SURGICAL TREATMENT OF T.O.S. Surgical treatment is indicated: after failure of physiotherapy in T.O.S. with venous or arterial complications (thrombosis, aneurysms…) in case of nervous compression in case of symptomatic cervical rib

62. Surgical decompression  S y m p t o m s pe rsists b e yond 2 m on t h s of conservative management.  Associated vascular compression with poststenotic dialatation.  Co m p l e t e occ l us io n of a l a rg e vesse l.  P r og r ession of n e u r o lo g i cal sy m p t o m s.  Ne r ve conduction ve lo c it y < 60 m /s

63. 1 st rib resection and scalenectomy are standard procedures for TOS 1 st rib resection is recommended for lower type TOS Scalenectomy is recommended for upper type TOS Best results and less chance of recurrence with combined 1 st rib resection and scalenectomy.

64. Scalenectomy Incision :8cms incision, 1.5cm above middle third of clavicle. 80-90% of scalenus anterior muscle and 40-50% of scalenus medius muscle removed. Protect long thoracic nerve and phrenic nerve. Complications : neck hematoma, chylus drainge, dyspnea due to phrenic nerve irritation.

65. 1 st rib resection Transaxillary approach Supraclavicular approach Infraclavicular approach Posterior approach.

66. Transaxillary approach ( Roos approach) Transverse Incision at the level of third rib just below the axillary hair line. Advantages Limited field of operative dissection Cosmetically placed incision Achieve 1 st rib resection and anterior scalenectomy Removal of anomalous ligaments and fibrous bands. Less blood loss, no muscles are divided.

67. Incomplete exposure of entire scalene triangle Difficulty achieving brachial plexus neurolysis Limited if vascular reconstruction is needed Disadvantages

68. Supraclavicular approach Advantages Wide exposure of all anatomic structures Permits complete resection of anterior and middle scalenes as well as brachial plexus neurolysis. • Allows resection of cervical ribs and anomalous 1 st ribs • Vascular reconstruction is possible

69. Infraclavicular approach ADVANTAGES Ideal for venous and arterial obstruction. Venous embolectomy. Arterial reconstruction. DISADVANTAGES Poor view of thoracic outlet. Poor excision of posterior part of the rib.

70. Posterior approach Advantages cervical rib can be easily resected. Sympathetectomy can be done Disadvantages Vascular reconstruction can not be performed.

71. Thoracoscopic First Rib Resesction Three 10mm portal are made - 1 s t anterior 3 rd ICS -2 nd lateral 5 th ICS - 3 rd lateral wall of 6 th ICS Endoscopic drill is used to dissesct the rib

72. Adjunctive procedures Pectoralis minor tenotomy . Sympathectomy :

73. Treatment vTOS • Anticoagulation therapy with heparin and oral anticoagulants. • Fibrinolytics • Catheter-directed thrombolysis. • Thrombosis is < 3days old : Thrombectomy • Chronic thrombosis : Venous Bypass

74. Complications Nerve injury bracial plexus injury Long thoracic nerve of bell Phrenic nerve Intercostobrachial nerve. Vagus and Reccurent laryngeal nerve Vascular injury Subclavian vein and artery

75. Thoracic duct injury Lymphatic fistula Lymphocele C hylothorax Pleural complication pleural damage Pneumotharax Pleural effusion

76. Recurrent nTOS • Postoperative scarring most common cause. • Recurrence usually is seen within 3months. • To minimize scar tissue formation patient is instructed to perform active range of motion exercises beginning the day after surgery. Performed every 3-4 hrs for atleast 6 months.