Definition:
Cluster of Neurogenic or vascular symptoms caused by the compression of the neurovascular bundle at the thoracic outlet (1)
Nomenclature:
Cervical rib syndrome, Scalene Anticus syndrome, Costoclavicular syndrome, Hyperabduction syndrome
Anatomy:
Boundaries of Thoracic Outlet – Spinal Column, First Rib, Sternum
Neurovascular Compression in 3 possible spaces
Etiology and Pathogenesis:
Combination of genetic predisposition and trauma – acute or chronic/repetitive
Anatomic predisposition separated into Soft tissue (70%) and Osseous Abnormalities (30%) (2)
Soft Tissue Abnormalities
Osseous Abnormalities
Demographics:
None available – likely secondary to differing definitions sited
Classic patient, young thin female, forward posture with neck flexion and anteriorly located glenohumeral joint (1)
Clinical Features:
90% Neurogenic, 3% Venous, <1% Arterial
Neurogenic TOS
Vascular TOS
Aterial TOS
Differential Diagnoses:
Examination:
Figure 2 – Allen test/Wright Test :Arm abducted and in posterior scaption, with head turned in contralateral direction to tested side. +ve test is loss of pulse.
Figure 3 – Roos Test: Patient is asked to hold flexed pose, inability to hold pose on affected side represents a positive test.
Figure 4 – Adson test: Patient’s arm is held in extension and 30 deg of abduction with head turned towards/ispilaterally to affected arm. Loss of pulse results in a positive test.
Investigations:
Management: (Evidence Based)
Non-Operative (7)
Operative (8)
Dr. Daniel Abourbih (October 20, 2015 PR ND)
References:
1) Kuhn JE, Lebus V GF, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015 Apr;23(4):222-32
2) Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg. 1992 Oct;16(4):534-42
3) Gillard J, Pérez-Cousin M, Hachulla E, Remy J, Hurtevent JF, Vinckier L, Thévenon A, Duquesnoy B. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001 Oct;68(5):416-24.
4) Braun RM, Rechnic M, Shah KN. Pulse oximetry measurements in the evaluation of patients with possible thoracic outlet syndrome. J Hand Surg Am. 2012 Dec;37(12):2564-9
5) Cho YJ, Lee HJ, Gong HS, Rhee SH, Park SJ, Baek GH. The radiologic relationship of the shoulder girdle to the thorax as an aid in diagnosing neurogenic thoracic outlet syndrome. J Hand Surg Am. 2012 Jun;37(6):1187-93
6) Longley DG, Yedlicka JW, Molina EJ, Schwabacher S, Hunter DW, Letourneau JG. Thoracic outlet syndrome: evaluation of the subclavian vessels by color duplex sonography. AJR Am J Roentgenol. 1992 Mar;158(3):623-30
7) Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am. 1995 Jul;20(4):542-8
8) Urschel HC Jr, Razzuk MA. Neurovascular compression in the thoracic outlet: changing management over 50 years. Ann Surg. 1998 Oct;228(4):609-17.