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An Interesting Case of Thoracic Outlet Syndrome

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EB is a 30 year old white female who presents with left upper extremity swelling ... Digital ischemia, claudication, pallor, coldness, paresthesia and pain in the ... – PowerPoint PPT presentation

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Title: An Interesting Case of Thoracic Outlet Syndrome


1
An Interesting Case of Thoracic Outlet Syndrome
  • Laurel Romer, M.D.
  • Primary Care Conference
  • May 14, 2008

2
Financial Disclosure
  • I have received no outside financial support for
    this presentation.

3
Learning Objectives
  • Understand the pathophysiology of TOS
  • Learn the provocative maneuvers to diagnose TOS
  • Understand treatment options for TOS

4
Outline
  • Case Presentation
  • Definition
  • Anatomy
  • Epidemiology
  • Differential Diagnosis
  • Symptoms
  • Physical Exam
  • Diagnostic Testing
  • Treatment
  • Case Presentation

5
Case Presentation
  • EB is a 30 year old white female who presents
    with left upper extremity swelling and pain,
    which began while she was watching a movie in a
    theater. She says that when she left the movie, a
    couple of hours after the symptoms initially
    began, she noted that the swelling of her left
    arm was worse and there was pain in her shoulder
    region. She also could not get her ring off of
    her finger and her left hand was dusky. She did
    not have any shortness of breath or pleuritic
    chest pain. A few days before that the patient
    had been shoveling snow during a heavy snow storm
    and the day after that developed upper
    respiratory symptoms including sore throat, sharp
    chest pain, a sensation of her ears being plugged
    and swollen glands in her neck.

6
Case Presentation
  • The patient had a Doppler evaluation which
    revealed clot in the subclavian and axillary
    veins. A CT scan of the chest revealed no
    evidence of pulmonary embolism. She had a
    hypercoagulable workup which was negative. She
    was treated with heparin and then started on
    Coumadin and consideration was given a couple of
    times to giving thrombolytics but this was not
    done. She was taken off her OCP.

7
Case Presentation
  • Ultrasound of the left upper extremity was
    performed about 15 days after the onset of
    symptoms and revealed interval partial
    recanalization of the left subclavian vein and
    slight increase in flow within the left axillary
    vein in a patient with previous occlusive
    thrombus in these vessels.
  • MRI of the left upper extremity was performed to
    look for a compressive component to her
    vasculature in the left upper extremity as a
    cause for the DVT.

8
TOS - Definition
  • Adson first described his maneuver in 1927
  • Thoracic Outlet Syndrome first coined in 1956
  • Upper extremity symptoms due to compression of
    the neurovascular bundle by various structures in
    the area just above the first rib and behind the
    clavicle
  • Etiologies include congenital bony structures,
    fibromuscular abnormalities, posture, certain
    movements, trauma

9
TOS - Anatomy
Google Images
10
TOS - Epidemiology
  • 3 to 80 cases per 1000
  • Ages 20-40
  • Women gt Men (41)
  • Neurogenic TOS (90) gt Venous TOS gt Arterial TOS
    (lt1)
  • Cervical ribs occur in lt 1 of population
  • 70 women

11
TOS Differential Diagnosis
  • Cervical disc disease
  • Cervical facet disease
  • Malignancies (Pancoast/local tumors, spinal cord
    tumors)
  • Peripheral nerve entrapments (ulnar or median
    nerve)
  • Brachial plexitis
  • Rotator cuff injuries
  • Fibromyalgia, muscle spasm
  • Neurologic disorders (MS)
  • Chest pain, angina
  • Vasculitis
  • Vasospastic disorder (Raynauds)
  • Neuropathic syndromes of upper extremity

Talu, GK Agri 17 (2005), 5-9.
12
TOS - Symptoms
  • Neurogenic TOS
  • Pain, paresthesia, and weakness in the hand, arm
    and shoulder, plus neck pain and occipital
    headaches
  • Raynauds phenomenon, hand coldness and color
    changes are also seen frequently in NTOS

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
13
TOS - Symptoms
  • Venous TOS
  • Swelling of the arm, plus cyanosis is strong
    evidence of subclavian vein obstruction
  • Pain often present, but may be absent
  • Arm swelling distinguishes VTOS from ATOS and NTOS

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
14
TOS - Symptoms
  • Arterial TOS
  • Digital ischemia, claudication, pallor, coldness,
    paresthesia and pain in the hand (but rarely in
    the shoulder/neck)
  • Symptoms are a result of arterial emboli from a
    mural thrombus in a subclavian artery aneurysm or
    from thrombus forming distal to subclavian artery
    stenosis

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
15
TOS Physical Exam
  • VTOS
  • arm swelling
  • cyanosis
  • distended superficial veins over the shoulder and
    chest wall
  • NTOS
  • Tenderness over scalene muscles
  • Positive provocative tests

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
16
TOS Physical Exam
  • Provocative tests
  • Adson test
  • Neck rotation and head tilting (ear to shoulder)
    eliciting pain and paresthesia down the
    contralateral side
  • 90AER - Abducting arms to 90 degrees in external
    rotation, brings on symptoms within 60 seconds
  • Upper Limb Tension Test

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
17
Fig. Upper Limb Tension Test (ULTT). Position 1
Arms abducted to 90 with elbows
extended. Position 2 Dorsiflex wrists. Position
3 Tilt head to side, ear to shoulder. Each
maneuver progressively increases stretch on the
brachial plexus.
                                               
    
18
TOS Diagnostic Testing
  • Neck or chest xray
  • Detects cervical rib or elongated C7 transverse
    process
  • EMG/NCS
  • Normal in large majority of clinically NTOS
  • Most common finding in NTOS is ulnar neuropathy
  • Recent study suggests NCV abnormalities of the
    sensory medial antebrachial cutaneous nerve are
    seen in NTOS
  • MRI/CT
  • Venography/venous duplex
  • VTOS
  • Arteriography
  • Only indicated in ATOS

Seror, O. Clin Neurophysiol 115 (2004),
2316-2322.
19
TOS Treatment
  • Conservative Management
  • Massage, hydrotherapy and PT
  • Behavioral modification/avoidance of provocative
    activities
  • PT to strengthen muscles of the pectoral girdle
    and restore normal posture
  • Improvement 50-90

20
TOS Treatment
  • Definitive management
  • Surgical decompression of the neurovascular
    bundle
  • First rib resection
  • Scalenectomy
  • Subclavian artery reconstruction
  • Cervical sympathectomy

21
Case Presentation
  • A few months later, venous duplex ultrasound
    appears normal. There is no evidence of
    impingement on either side. Both veins are
    patent by duplex but there is bilateral
    impingement in multiple stress positions on both
    the right and left side.

22
Case Presentation
  • EB met with a vascular surgeon who felt that she
    was at high risk for recurrence of BUE DVT (off
    anticoagulants) without definitive treatment
  • A left 1st rib resection was performed
  • A few months later a right 1st rib resection was
    performed
  • She was taken off anticoagulants
  • She was restarted on her OCP along with Aspirin
    81mg qd
  • She was strongly advised to continue longterm
    with a shoulder girdle strengthening exercise
    program

23
References
  • Barkhordarian, S. J Hand Surg 32 (4/2007),
    565-570.
  • Demondion, X, et al. Radiographics 26 (2006),
    1735-1750.
  • Sanders RJ, et al. J Vasc Surg, 46 (2007),
    601-604.
  • Seror, O. Clin Neurophysiol 115 (2004),
    2316-2322.
  • Talu, GK Agri 17 (2005), 5-9.
  • Vanti C, et al. Eura Medicophys 43 (2007), 55-70.
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