Neurogenic Thoracic Outlet Syndrome

Abstract

The thoracic outlet is the area of the body at the base of the neck and upper chest and shoulder region that contains the nerves, artery, and vein as they pass from the upper extremity to the spine and thorax. Each of these three structures can be compressed by abnormal anatomy in one of several areas, which leads to neurogenic, arterial, and venous thoracic outlet syndrome (TOS), respectively. Neurogenic thoracic outlet syndrome (NTOS), although by far the most common form of TOS, is least likely to be associated with defined or even visible pathology. Treatment of NTOS often falls to the vascular surgeon, rather than the thoracic surgeon or the neuro-surgeon, and it is essential that the vascular surgeon is aware of modern terminology, diagnostic criteria, and reporting standards, of which the Society for Vascular Surgery (SVS) has attempted to standardize in recent years. This review examines and discusses the history of NTOS, the anatomy and pathophysiology of the thoracic outlet, evaluation and diagnosis, treatment, special groups, results, and SVS reporting standards. Figures show the anterior view of the right thoracic outlet, the close-up view of the scalene triangle, a view of pectoralis minor space creation and the costoclavicular space, the elevated arm stress test (EAST), the upper limb tension test (ULTT), a useful graphic instrument or classification and treatment recommendations, a radiograph of the anterior cervical spine, chest radiographs illustrating first ribs that may be contributory neurogenic compression, an algorithm for work-up of patients with potential neurogenic thoracic outlet syndrome, two methods of arm elevation for transaxillary first rib resection, steps for transaxillary excision, steps for supraclavicular excision, steps for paraclavicular incision, steps for pectoralis minor release/resection, and graphs comparing postsurgical quality of life for NTOS and VTOS patients. This review contains 15 highly rendered figures and 44 references.