Thoracic Outlet Syndrome

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Thoracic Outlet Syndrome
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• It refers compression of subclavian vessels and
  brachial plexus at the superior aperture of the
  thorax.
• The symptoms can be neurologic or( and )
  vascular.
• The pain may be atypical and predominant in the
  chest wall and parascapular area, simulating
  angina pectoris.

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• 4. Diagnosis of nerve compression can be
  determining the ulnar nerve conduction velocity(
  UNCV ).
• 5. Physiotherapy to improve posture, strengthen
  shoulder girdle, and stretch neck muscle is used
  initially.
• 6. Surgery includes extirpation the first rib,
  usually through transaxillary approach.

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A. ANATOMIC CONSIDERATIONS

• A-0
• The subclavian vessels and brachial plexus
  transverse the cervicoaxillary canal into the
  arm.
• The outer border of the first rib divides the
  canal into a proximal and a distal division.
• The proximal division is composed of the scalene
  triangle and the space bounded by the clavicle
  and the first rib( costoclavicular space ).

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A. ANATOMIC CONSIDERATIONS

• 4. The proximal division is the most critical for
  neurovascular compression. It is bounded
  superiorly by the clavicle and the subclavius
  muscle inferiorly by the first rib
  anteromedially by the sternum, clavipectal fascia
  and the costocoracoid ligament and
  posterolaterally the scalenus media muscle and
  the long thoracic nerve.

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A. ANATOMIC CONSIDERATIONS

• The axilla, which is the outer division of
• the cervicoaxillary canal is bounded with
  pectoralis minor muscle, the coracoid process,
  and the head of humerus.

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A-1 Compression Factors

• Many factors can induce thoracic outlet
• syndrome, including congenital, trauma and
  atherosclerotic factors.
• 2. Bony abnormalities are present in 30 of
  patients, such as cervical rib, bifid first rib,
  fusion of first and second ribs or previous
  thoracoplasty.

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A-2 Adson or Scalene Test

• 1. The patient is asked to (1) take and hold a
• deep breath (2) extend the neck fully (3)
  turn the face into one side.
• 2. It will tighten the anterior and middle
  scalene muscles.
• 3. Diminution or loss of the radial pulse
  suggests compression.

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A-3 Costoclavicular Test( Military Position )

1. The back is downward and backward.
2. The costoclavicular space will be narrowed by
   approximating the first rib and the clavicle.
3. Diminution or loss of the radial pulse suggests
   compression.

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A-4 Hyperabduction Test

• 1. The arm is hyperabducted to 180 degrees.
• 2. Diminution or loss of the radial pulse
  suggests compression.

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A-5 Arm Claudication Test

1. The shoulder is drawn backward and upward. The
   arm is raised horizontally with the elbow flexed
   90 degrees.
2. With excise of hands, pain and numbness indicates
   compression.

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B. SYMPTOMS AND SIGNS

1. Symptoms of never compression is present most
   frequently.
2. Pain and paresthesia are present in 95 of
   patients.
3. Motor weakness is present in 10 of patients.
4. Pain is insidious in onset and involves the
   neck, shoulder, arm or hand.
5. Atypical pain involving anterior chest wall and
   parascapular area is called pseudoangina.

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B. SYMPTOMS AND SIGNS

• 5. Symptoms of vascular compression is less
  common than neurologic compression.
• 6. Symptoms of vascular compression includes
  coldness, weakness, fatigability of the hand and
  arm. Pain is more diffuse in distribution.
• 7. Raynauds phenomenon is occasionally seen.

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B. SYMPTOMS AND SIGNS

• 8. Venous compression is recognized by venous
  distension, edema and discoloration of the hand
  and arm.
• 9. Thrombosis of the subclavian vein( effort
  thrombosis or Paget-Schroetter syndrome ) is
  infrequently.

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B. SYMPTOMS AND SIGNS

• 10. However, objective physical findings are
• more in patients with vascular
  compression.
• 11. Objective physical findings of vascular
• compression are diminution or loss of the
• radial pulse in tests , Raynauds
• phenomenon, venous distension or edema
• 12. Objective physical findings of neural
• compression are hypoesthesia, anesthesia
  and
• muscle weakness and atrophy.

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C. DIAGNOSIS

1. PE, history, radiographs of chest and cervical
   spine, neuroloical consultation, EMG and UNCV.
2. Pulmonary, esophageal and chest wall causes must
   be ruled out.

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C-1 Nerve Conduction Velocity

1. The normal average UNCV is 72m/sec across the
   thoracic outlet.
2. In patients of thoracic outlet syndrome, the
   average UNCV is 53m/sec( 32-65 m/sec ) across the
   thoracic outlet.

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C-2 Angiography

1. Bruits in the supra- or infraclavicular spaces
   suggests stenosis, and absence of pulse denotes
   total occlusion.
2. Retro- or antegrade arteriograms of the
   subclavian and brachial arterial systems are
   indicated.
3. Phlebograph is indicated in patients of venous
   stenosis or obstruction.

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C-3 Differentiated Diagnosis

• Table 42-3

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D. THERAPY

1. Physiotherapy is performed before surgery.
2. Physiotherapy includes heat massage, active neck
   exercise, scalenus anticus muscle stretching,
   strengthening of the upper trapezius muscle, and
   posture instrusion.
3. Most patients with a UNCV above 60 m/sec improve
   with phsiotherapy.
4. Most patients with a UNCV below 60 m/sec must
   undergo surgery with resection of the first rib
   and correction of other bony deformities.

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D. THERAPY

• 5. Roos et al. suggested resection of the first
  rib, and a cervical rib when present, is best
  performed through the transaxillary approach,
  with decompression of 7th and 8th cervical and
  1st thoracic root.
• 6. The anterior supraclavicular, infraclavicular
  and posterior approach were ever reported.
• 7. Posterior approach is especially important
  because 80 of patients are females.

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D-1 Technique of Transaxillary Resection of First
Rib

1. The patient was placed lateral position with
   involved arm abducted to 90 degrees.
2. A transaxillary incision was made between
   pectoralis major m. and latissimus dorsi m.
3. The insertion of the scalenus anticus m. on the
   first rib was dissected and muscle is divided.
4. The first rib is divided at middle portion.
5. The scalenus media m. can not be cut from the
   rib. The long thoracic nerve must be preserved.

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D-1 Technique of Transaxillary Resection of First
Rib

• 6. It is preferable to remove the entire first
  rib.
• 7. The periosteum should be fragmented and
  destoyed to avoid callus formation and
  regeneration of the rib.
• 8. Removal of incompletedly resected or
  regenerated rib and lysis of the brachial plexus
  can be done through posterior approach.
• 9. The anterior supraclavicular approach is used
  for arterial bypass and reconstruction.

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D-2 Results

• The results of first rib resection is good in
  85, fair in 10 and poor in 5.
• Uniform improvement of symptoms is usually in
  patients of primarily vascular compression.
• There are 2 groups of patients, who have neural
  compression.

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D-2 Results

• The 1st group includes patients with ulnar
  neuralgia and diminution of radial pulse. 95 of
  this group are improved after first rib
  resection.
• The 2nd group includes patients with atypical
  pain distribution with or without pulse change in
  compression tests. Although many patients can
  improve after first rib resection, the fair and
  poor results may mostly occur in the group.

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D-2 Results

• 6. No hospital mortality is related directly to
  
• the procedure.
• 7. Morbidity includes pneumothorax, hematoma and
  infection.

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E. PAGET-SCHROETTER SYNDROME

1. It refers effort thrombosis of the
   axillary-subclavian vein inducing by excessive or
   unusual use of the arm in addition to one or more
   compressive elements.
2. It is usually seen in professional athletes,
   Linotype operators, painters and beauticians.
3. Anticoagulants and conservative exercise can be
   used to treat it.

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E. PAGET-SCHROETTER SYNDROME

• 4. First rib resection is indicated for patients
  with recurrent disease when returning to work.
• 5. Bypass with veins and other conduits has
  limited application.

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F. RECURRENT THORACIC OUTLET SYNDROME

1. 10 of surgically treated patients have shoulder,
   arm or hands pain and pareathesia. Most patients
   can be relieved with physiotherapy and muscle
   relaxant.
2. In 1.6 of patients, symptoms exacerbate and
   persist.
3. Most recurrences occur in 3 months
   postoperatively.

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F. RECURRENT THORACIC OUTLET SYNDROME

• 4. Pseudorecurrence
• (1) A 2nd rib was mistakenly resected for
• a 1st rib
• (2) A 1st rib was resected but a cerical
• rib was left.
• (3) A cervical rib was resected but
• an abnormal 1st rib was left.
• (4) A 2nd rib was resected but a rudimentary
  1st
• rib was left.

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F. RECURRENT THORACIC OUTLET SYNDROME
F. REC

• 5. True recurrence
• The 1st rib was not resected completely.
• 6. All patients with recurrence after 1st rib
• resection should undergo physiotherapy. If
• symptoms persist and UNCV is still low
• then re-operation is indicated.
• 7. Re-operation is always done through the
  posterior thoracoplasty approach.

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F. RECURRENT THORACIC OUTLET SYNDROME

• 8. The anterior or supraclavicular approach is
• not adequate for re-operation.
• 9. The basic elements for re-operation are
• (1) resection of recurrent or persistent bony
  
• remnants
• (2) neurolysis of the brachial plexus or
• nerve roots
• (3) dorsal sympathectomy of T1, T2, T3
• ganglia

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F. RECURRENT THORACIC OUTLET SYNDROME

• 10. The technique includes a high thora-
• coplasty incision, extending 3 cm
• above the angle of the scapula, halfway
• between the angle of the scapula and
• spinous processes, and caudate 5 cm from
• the angle of scapula.
• 11. The trapezius and rhomboid muscles are
  divided..

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F. RECURRENT THORACIC OUTLET SYNDROME

• 12. The scapula is retracted by incision of the
• LD muscle over the 4th rib.
• The posterior superior serratus muscle
• was divided and sacrospinalis muscle is
  retracted medially.
• 14. The 1st and cervical rib must be resected, if
  present subperiosteally.
• 15. The regenerated periosteum is extirpated.

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F. RECURRENT THORACIC OUTLET SYNDROME

• 16. If excessive scar is present the it is
• necessary to perform sympathectomy
• initially. This involves resection of a 1-
• inch segment of 2nd rib posteriorly to
• locate the sympathetic ganglia.
• 17. Neurolysis is performed using a nerve
• stimulator but not into the sheath.

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F. RECURRENT THORACIC OUTLET SYNDROME

• 18. A J-P drain is left in the area of brachial
• plexus. Depo-Medral, 80 mg, is left in the
• area of brachial plexus.
• 19. The arm is kept in sling to be used
• gently for 3 months.
• 20. When the problem is vascular, involving
• false or mycotic aneurysms, bypass graft is
  
• interposed. The saphenous vein is usually
  used.

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F. RECURRENT THORACIC OUTLET SYNDROME

• 21. 7 of patients underwent 2nd re-operation
• for rescarring. No death occurred. Only
• one patient had infection and needed
• drainage.