7/30/2019 Thoracic Outlet Syndrome - Shoulder & Elbow - Orthobullets

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Updated: 6/3/2019
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Thoracic Outlet Syndrome
American Shoulder and Elbow
Ashley Bassett Ranjan Gupta
Surgeons

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& Elbow
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Review Topic 1 4 7

Introduction

Overview
thoracic outlet syndrome is a neurovascular disorder resulting from compression of the
brachial plexus and/or subclavian vessels in the interval between the neck and axilla
treatment may be nonoperative or include surgical decompression or a vascular
procedure depending on the specific etiology
Epidemiology
incidence
1-2% of the population
demographics
females > males (3:1)
tend to be thin with long necks and drooping shoulders
age 20-60
type
neurogenic is most common (95%)
vascular may be venous (4%) or arterial (< 1%)
more common in athletic males compared to athletic females
Pathophysiology
most cases are thought to stem from anatomic predisposition with superimposed neck
trauma (acute or chronic repetitive stress)
anatomically, can be organized into soft tissue (70%) and osseous (30%)
abnormalities
soft tissue
scalene muscle abnormalities
hypertrophy of anterior scalene
passage of the brachial plexus through the anterior scalene muscle

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 rather than posterior within Cases

the interscalene
Videos triangle
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variable origin and insertion

anterior insertion of the middle scalene muscle on the 1st rib
scalenus minimus
accessory muscle found in 30-50% of patients with TOS
originates from cervical transverse process and inserts onto 1st rib
between the subclavian artery and T1 root
anomalous ligaments or bands
fibromuscular bands
increase stiffness and decrease compliance of the thoracic outlet
 Shoulder & Elbow costoclavicular ligament
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abnormal insertion implicated in Paget-Schroetter syndrome

soft tissue tumors
Pancoast tumor
tumor of the pulmonary apex
1-3% of lung cancer cases
generally lack typical symptoms of lung cancer (cough,
hemopytsis and dyspnea)
neuroblastomas
schwannoma of the brachial plexus
abnormal pectoralis minor
osseous
cervical rib
occur in < 1% of the population
arise from the 7th cervical vertebra
four types
type 1: complete rib that articulates with the first rib or manubrium
type 2: incomplete rib with a free distal bulbous tip
type 3: incomplete rib with distal attachment via fibrous band
type 4: short bar of bone (millimeters) extending beyond the C7
transverse process
prominent C7 transverse process
abnormal clavicle or first rib
acute fracture displacement
hypertrophic fracture callus formation
fracture malunion
acromioclavicular (AC) or sternoclavicular (SC) joint injury or dislocation
osseous tumors
bone metastasis to first rib
breast, prostate, kidney
osteoid osteoma
chronic overuse
repetitive shoulder use
frequent lifting above the level of the shoulder
extreme arm positions, including hyperabduction
athletes at risk
weight lifting
rowing
swimming
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vascular
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repetitive compression over time can result vessel damage
aneursym formation
thrombosis
embolic events
limb-threatening ischemia
Associated conditions
Paget-Schroetter syndrome
type of venous thoracic outlet syndrome seen in well-developed young athletes
intermittent obstruction of the subclavian vein in the costoclavicular space by
 Shoulder & Elbow abnormal costoclavicular ligament
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anterior scalene muscle hypertrophy

results in upper extremity deep vein thrombosis

Anatomy

Thoracic outlet
comprised of three distinct spaces
interscalene triangle
proximal space
borders
anterior: anterior scalene muscle
posterior: middle scalene muscle
inferior: first rib
contents
brachial plexus trunks
subclavian artery
subclavian vein does not pass through interscalene triangle
runs beneath anterior scalene muscle prior to entering the costoclavicular
space
costoclavicular space
middle space
separated from the interscalene triangle by the first rib
borders
anterior: clavicle and subclavius muscle
posterior: first rib and scalene muscles
medial: costoclavicular ligament
lateral: upper scapular border
contents
brachial plexus divisions
subclavian artery and vein
retropectoralis minor space
distal space
also known as the thoraco-coraco-pectoral space or subcoracoid space
borders
superior: coracoid
anterior: pectoralis minor muscle
posterior: ribs 2-4
contents

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 brachial plexus cords Evidence

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axillary artery and vein

Presentation

History
presentation is very variable
ranges from mild pain to sensory changes to severe vascular compromise
can be unilateral or bilateral
neurogenic
 Shoulder & Elbow
pain over the neck, trapezius, chest, shoulder and/or arm


92% of patients endorse trapezius pain

upper extremity weakness, numbness and paresthesias
distribution differs from other compression syndromes
nonradicular nature
cervical nerve root compression presents with radicular pain
wide anatomic distribution (plexus)
isolated peripheral nerve compression (cubital tunnel syndrome,
carpal tunnel syndrome) presents with a clear dermatomal
distribution
involves the lower plexus (C8-T1) or combined (C5-T1) in 90% of
patients
upper extremity paresthesias occur in 98%
upper extremity heaviness
particularly with overhead activities
symptoms can be activity-related and/or occur at night-time
night-time symptoms thought to result from decreased pressure on the
brachial plexus with return of sensation manifesting as pain
vascular
venous
episodic cyanotic discoloration and swelling of the limb
distended veins
diffuse deep pain in the arm and forearm
upper extremity heaviness
worse after activity
arterial
unilateral Raynaud-type symptoms
episodic coolness and pallor of the limb, followed by cyanosis and
ultimately erythema
worsens in cold temperatures
pain and numbness
symptoms tend to predominantly involve the hand (distal circulation)
Physical examination
inspection
note specific postures, can increase loading on the brachial plexus
rounded shoulders
increased thoracic kyphosis
downward rotation or depression of the scapula
skin

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 cyanosis, congestion, pallor

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distal ulcerations, signs of microembolic events (rare)

hair distribution
nail changes
muscle atrophy
Gilliatt-Sumner hand
characteristic finding of neurogenic TOS
atrophy of the abductor pollicus brevis (APB), hypothenar muscles and
interossei
palpation
 Shoulder & Elbow
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over the supraclavicular area

may reveal tenderness and/or masses
skin temperature
provocative tests
high rate of false positives
supraclavicular pressure test
evaluates for compression at the interscalene triangle
technique
patient seated with arm resting at side
apply pressure to upper trapezius and anterior scalene muscle,
squeezing for 30 seconds
positive result
reproduction of pain or paresthesias
Adson test
evaluates for compression at the interscalene triangle
technique
patient seated with shoulder slightly abducted and externally rotated,
elbow extended, forearm supinated
examiner palpates radial pulse
patient maximally extends and laterally rotates the neck towards side
being tested, then inhales and holds breath
positive result
reduction in amplitude or loss of radial pulse
51% of normal population has diminished pulse with this
manuever
reproduction of pain or paresthesias
costoclavicular manuever
evaluates for compression at the costoclavicular space
technique
patient seated with the arm at the side, elbow extended, forearm
supinated
examiner palpates radial pulse
patient retracts and depresses the bilateral shoulders, protruding the
chest anteriorly and superiorly ("at attention" stance)
examiner extends the shoulder ~30° for 1 minute
positive result
reduction in amplitude or loss of radial pulse
reproduction of pain or paresthesias
Wright test
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Techniques compression at the Cases
Evidence retropectoralis
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technique
patient seated with arm at the side, elbow extended, forearm supinated
examiner palpates radial pulse
patient laterally rotates neck away from side being test
examiner externally rotates and maximally abducts the shoulder,
holding the arm above the level of the head for 1 minute
positive result
reduction in amplitude or loss of radial pulse
7% of the normal population has dimished or lost radial pulse with
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this manuever
reproduction of pain or paresthesias
Roos test / elevated arm stress test
evaluates the entire thoracic outlet
technique
in seated position, patient abducts the bilateral shoulders to 90° with
the elbow flexed 90°
patient opens and closes the hands for 3 minutes
positive result
reproduction of pain or paresthesias
will often prevent the patient from completing the test for the full 3
minutes
normal person have discomfort with this manuever, but are able
to complete it
resolution of pain or paresthesias with dropping of the arms
Cyriax release test
evaluates the result of unloading the brachial plexus
technique
examiner stands behind patient and grasps the bilateral forearms with
the elbows in flexion and forearms in pronation
examiner leans against the patient's trunk to passively elevate the
shoulder girdle for 3 minutes
positive result
reproduction of pain or paresthesias

Evaluation

Radiographs
recommended views
chest radiograph and cervical spine radiographs
findings
cervical rib
prominent C7 transverse process
low lying shoulder girdle
Pancoast tumor
CT
indications
identify osseous space-occupying lesions
evaluate malunited fractures of the ribs or clavicle

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MRI
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indications
evaluate for soft tissue anatomic anomalies
Nerve conduction studies
EMG and NCV
historically thought to be equivocal and unhelpful
studies were often normal unless significant permanent nerve damage was
already established
recently discovered that nerve fibers from C8 and T1 may show early changes in
neurogenic TOS
 Shoulder & Elbow
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abnormal nerve conduction velocities in the medial antebrachial cutaneous nerve

and median motor nerve to the abductor pollicis brevis
Vascular studies
doppler ultrasound
helpful for evaluating subclavian vein for obstruction or thrombosis
92% specificity and 95% sensitivity for diagnosis of venous TOS
angiography
CT or MR angiography
arteriography
indicated in cases of embolic disease or suspected arterial aneursym
venography
indicated in work up of suspected subclavian or axillary venous thrombosis

Treatment

Nonoperative
activity modification, pain control, physical therapy and modalities
indications
first line of treatment
technique
activity modification to avoid provocative activities
limiting repetitive overhead motion
changing employment if necessary
pain control
NSAIDs, muscle relaxants
physical therapy
core and back strengthening, shoulder girdle strengthening, improving
posture and relaxation techniques
modalities
transcutaneous electrical nerve stimulation
outcomes
less successful in
obese patients
patients on worker's compensation
patients with double-crush neurologic pathology involving the carpal or
cubital tunnels
anterior scalene blocks
indications
neurogenic TOS related to scalene muscule contracture

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 technique
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ultrasound-guided lidocaine or botulinum toxin injections

outcomes
successful block correlates with 14% higher rate of good surgical outcomes
Operative
thoracic outlet decompression
indications
symptoms that have failed conservative treatment for 6 months
progressive muscle atrophy and/or worsening neurologic deficits
technique
 Shoulder & Elbow decompression includes a combination of the following depending on


etiology
first rib resection, anterior and middle scalenectomy, neurolysis
most common procedure
95% good outcomes
isolated scalenectomy
indications
upper plexus symptoms
absence of abnormal bony architecture
excessively muscular or obese patients
recurrent TOS following prior first rib resection
isolated pectoralis minor tenotomy
indications
neurogenic TOS with symptoms reproducible to the
retropectoralis minor spacw
cervical rib resection
release of fibromuscular bands
costoclavicular ligament resection
ORIF of clavicle malunion
vascular intervention
indications
embolic events
stenosis with persistent pain and vascular insufficiency
subclavian aneursym
thrombosis with critical ischemia
technique indications
heparin IV, +/- embolectomy, +/- local thrombectomy, +/- TPA, systemic
anticoagulation
acute embolic event
small vessel embolism - TPA, systemic anticoagulation
large / proximal vessel embolism - embolectomy, systemic
anticoagulation
endovascular stent placement
mild stenotic disease
vascular resection +/- primary repair, +/- saphenous vein graft, +/- arterial
autograft, +/- synthetic graft
subclavian aneursym
severe stenosis or thrombosis with critical ischemia
vascular bypass
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 chronicQBank
emboli with critical ischemia
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Technique

Thoracic Outlet Decompression

approaches
transaxillary
most commonly used approach
pros
superior exposure for the first rib resection
 Shoulder & Elbow allows resection of cervical ribs, costoclavicular ligament, fibromuscular


bands and scalene muscles

access to lower plexus for neurolysis (C7-T1)
more cosmetic scar
no retraction of neurovascular structures necessary for first rib removal
cons
risks brachial plexus injury
supraclavicular
pros
superior exposure of upper plexus (upper and middle trunks), scalene
muscles, neck of the first rib and vascular structures
best approach for isolated scalenectomy and arterial
reconstruction
allows resection of first rib (but requires significant retraction)
cons
inferior visualization for first rib resection
requries retraction of brachial plexus and vascular structures for
complete first rib exposure
posterior
pros
favored for recurrent TOS and in cases of prior neck surgery
may allow better exposure of proximal elements of the brachial plexus
cons
requires extensive muscle dissection that can lead to postoperative
shoulder disfunction
risks injury to the long thoracic, dorsal scapular and accessory nerves
decompression techniques
first rib resection, anterior and middle scalenectomy, neurolysis
usually performed with combined approach
transaxillary: to access first rib and lower plexus
supraclavicular: to access anterior and middle scalene muscles and
upper plexus
specific complications
pneumothorax is one of the most common complications of first rib
resection

Complications

Pneumothorax

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 is one of the most common complications

Evidence of Cases
first rib resection
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(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?  Review Topic
QID: 258

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

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 Login to View Community Videos 2018 Baseball Sports Medicine: Game-Changing Concepts 12/21/2018

Case Presentations and Panel Discussion with 79 views

Q&A Session I: Shoulder Injuries - Moderator
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