Thoracic Outlet Compression Syndrome TOCS

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Thoracic Outlet Compression Syndrome (TOCS)

• Philip Fisher DO, PhD
• Huntington, West Virginia

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History of TOCS

• First Described by Thorburn in 1905
• Overdiagnosed Trashcan Dx for 35 Years, Then
  Debunked by Roos Wilburn
• Roos et al determined that there were at least 5
  different syndromes that were being lumped into
  one diagnosis.
• Lumpers vs Splitters remains the source of the
  controversy of TOC Syndrome(s)

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Various Forms of TOCS

• Vascular Compression
• a) Subclavian Artery _at_ a Cervical Rib
• b) Subclavian Vein/Artery _at_ Ant-Scalene Muscle
• c) Neurovascular Bundle between Clavicle/1st Rib
• Neurological Compression
• C8 T1 Lower Trunk
• Confusion with RSD (CRPS) Radiculopathy

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Anatomy of The Thoracic Outlet

• 1st Rib
• Scalene Anterior
• Scalene Medius
• Clavicle
• 3 Trunks (UML)
• Subclavian AV

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Anatomical Structures

• C56 Upper Trunk
• C7 Middle Trunk
• C8 T1 Lower Trunk
• Scalene Ant Med
• Elongated C7 Transverse Process?
• Costovertebral Joint Laxity?

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Diagnostic Testing

• Electrodiagnostic
• Erbs Point Prolonged Latency Across Brachial
  Plexus
• Prolonged F-Wave
• Maneuvers
• Adson Ant Scalene Test Stretch to obliterate
  Radial Pulse
• Roos Test -Similar, but add a cough to make
  fingers tingle
• X-Ray Palpation
• Cervical Rib or C-V Joint Injury

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Treatment Options

• 1st Rib Retention Brace. Crossing-Guard Style
• OMT to restore C-V Joint Configuration/Integrity
• P.T./HEP Scalene Stretching, Theracane
• Orthopedic Cementing of the CV Joint
• Surgical Resection of Cervical Rib or 1st Rib