Thoracic Outlet Syndrome

Author: Daniel Hatch

Topic updated on 01/25/13 7:07pm

Introduction

A neurovascular compressive neuropathy with either a neurogenic or vascular etiology
- neurogenic
  - caused by compression of neurovascular bundle as it passes over the first rib or through the scalene muscle
  - causes include
    - scalene muscle abnormalities
    - scapular ptosis
    - clavicle and first rib malunion
    - cervical rib
    - vertebral transverse process
    - in athletes
      - fibromuscular bands
      - abnormal pectoralis minor
      - repetitive shoulder use
      - extreme arm positions
      - weightlifting, rowing, swimming
- vascular
  - caused by compressed subclavian vessel or aneurysm
  - may lead to emboli in the hands
Epidemiology
- occurs in females > males
Associated conditions
- Paget-Schroetter syndrome
  - thoracic outlet syndrome with compression of subclavian vein in the developed athlete due to scalene muscle hypertrophy

Presentation

Symptoms
- vascular
  - arterial ischemia
  - Raynaud's phenomenon
  - venous congestion
  - cold intolerance
- neurologic
  - pain and swelling of upper extremities
  - ulnar nerve paresthesias
    - differentiated from more distal compression neuropathies due to sensory differences in medial brachial and antebrachial cutaneous nerves
Physical exam
- provocative tests (variable reliability)
  - Wright
    - abduction and external rotation with the neck rotated away leads to loss of pulse and reproduction of symptoms
  - Adson
    - extension of the arm with the neck extended and turned towards the affected side may result in loss of radial pulse or reproduction of symptoms with inhaling
  - Roos
    - hands repeatedly opened and closed while holding them overhead for 1 minute can reproduce symptoms

Imaging and Studies

Radiographs
- recommended views
  - c-spine x-ray to rule out cervical rib
  - chest x-ray to rule out Pancoast tumor
Angiography
- if etiology is vascular will show subclavian vessel disease or aneurysm
EMG and NCV
- studies usually equivocal

Treatment

Nonoperative
- physical therapy and activity modifications
  - indications
    - first line of treatment
  - technique
    - shoulder girdle strengthening, proper posture, and relaxation techniques
Operative
- neurologic decompression
  - indications
    - neurogenic etiology
    - nonoperative modalities have failed
    - progressive and severe neurologic deficits and pain
  - technique
    - address site of compression
      - repair clavicle malunion
      - transaxillary first rib resection (90% good to excellent results)
      - scalene takedown
      - pectoralis minor tenotomy
      - release of fibromuscular anomalous bands
- vascular reconstruction (open or interventionally)
  - indications
    - subclavian aneurysm present
    - persistent insufficient vascularity
  - emboli to the hands
    - treat with acute heparinization, embolectomy (or TPA if vessels too small), 7-10 days of heparin, followed by three months of warfarin

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Qbank (1 Questions)

TAG

(OBQ06.247) A 35-year-old businessman complains of tingling and numbness in his fingers of both hands, mostly in the ring and small fingers, made worse with overhead activity. Neurologic exam and electromyography-nerve conduction study is normal. His cervical spine x-ray is shown in figure A. What is the most likely diagnosis? Topic

Review Topic

FIGURES: A

1. C5-6 cervical disk herniation
2. C6-7 cervical disk herniation
3. bilateral cubital tunnel syndrome
4. bilateral radial tunnel syndrome
5. thoracic outlet syndrome

PREFERRED RESPONSE ▶

DISCUSSION: The thoracic outlet space is created by the clavicle, first rib, subclavius muscle, costoclavicular ligament, and anterior scalene muscle. It most often affects subclavian artery, vein, and the lower trunk (C8 & T1) of the brachial plexus. The neurological exam may reveal sensory changes in the ring and little finger and intrinsic weakness. Radiographs here show cervical ribs, but could also show a Pancoast tumor or even be normal. Leffert reviewed thoracic outlet syndrome and cautioned that surgery be reserved for intolerable symptoms as surgical complications can be significant.

REFERENCES:

1. Leffert, R. Thoracic outlet syndromes. Hand Clinic 1992; 8: 285 - 297 PMID:1613036 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Eric Shirley MD,

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Groups

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Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Leffert, R. Thoracic outlet syndromes. Hand Clinic 1992; 8: 285 - 297 PMID:1613036 (Link to Abstract)

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