Excision Of Cervical Rib Research Articles

A Case of Arterial Thoracic Outlet Syndrome Thrombus Extending to Juxtavertebral Artery

Arterial thoracic outlet syndrome (TOS) constitutes less than 1%, involving the second part of the subclavian artery (SCA). It can present as an acute upper limb ischemia or aneurysm formation. Here is a case of a 29-year-old male presented with complaints of rest pain over the left hand for the past 2 weeks. Upon evalution, found to have bilateral cervical rib with left subclavian artery occlusion. Treated by cervical rib excision decompression of scalene triangle, subclavian endarterectomy and left brachial embolectomy. Arterial TOS secondary to the cervical rib is rare; pathology involving this external compression results in repeated trauma in the intima of the SCA, resulting in subclavian stenosis, poststenotic dilatation, thrombosis, and aneurysm formation with mural thrombus and distal embolization. Symptomatic cases need decompression +/- arterial repair.

Arterial Thoracic Outlet Syndrome - Clinical Presentation, Surgical Management, and Outcome

Objective: The main objective of this study was to review the clinical presentations, surgical management, and outcome of surgical procedures for arterial thoracic outlet syndrome (TOS). Methodology: This is a retrospective analysis of arterial TOS patients admitted in our department (Institute of Vascular Surgery, Madras Medical College, Chennai) from August 2012 to July 2022. Results: This study enrolled 81 patients, with mean age of 41.13 (12-65 years) and 50.61% male (41) and 49.39% female (40), associated with distal arterial lesions - 63 (77.77%), among which 50.61% - occlusion in the brachial artery (33), 24.69% in forearm arteries (15), and 24.69% in the axillary artery (15). About 95.06% of patients had cervical rib (77), 2.46% - first rib abnormality (2), 2.46% - soft-tissue compression (2), 59.25% was SCHER Stage III (48), 33.33% SCHER stage I (27), and 7.40% SCHER stage II (6). All patients had undergone a supraclavicular approach. The most common arterial lesions were subclavian artery (SCA) thrombus in 53.08% (43), occlusion in 17.28% (14), and dilatation in 29.62% (24) cases. The cervical rib excision with anterior scalenectomy in 95.06% (77), and 1st rib excision with anterior scalenectomy 2.46% (2) and soft tissue resection with anterior scalenectomy 2.46% (2) of patients. SCA intervention/reconstruction was done in 88.88% (72) of cases. Two patients had underwent above elbow amputation (2.46%) and no mortality and SCA patency was 100%. Conclusion: Cervical rib excision with anterior scalenectomy with or without thrombectomy is an effective procedure for arterial TOS cases.

Feasibility of Opioid-Free Anesthesia for Cervical Rib Excision: A Case Series and Review of Literature

AbstractBackground Perioperative pain management following cervical rib excision can be compounded in the background of chronic pain disorder caused by the neurovascular compression. The former mandates an enhanced analgesic requirement wherein the perioperative opioid use, in particular, can be associated with a peculiar adverse-effect profile and abuse potential. Appropriate to the context, an opioid-free anesthesia (OFA) protocol can be instrumental in minimizing the incidence of the aforementioned.Case Series While two patients necessitated OFA owing to opioid contraindication, the formulated protocol was evaluated in another six consecutive patients posted for elective cervical rib excision. A combined paravertebral block and superficial cervical plexus block was employed alongside general anesthesia. Intravenous dexmedetomidine and lignocaine assisted the conduct of OFA, and paracetamol dosing was continued into the postoperative period. Intraoperative rescue analgesia was ensured by a ketofol bolus (1:1 mixture of ketamine and propofol) whereas intravenous diclofenac was used for postoperative rescue analgesia.Results OFA could be successfully contemplated in all eight patients. A single bolus rescue dose of ketofol had to be administered in two patients intraoperatively and diclofenac had to be administered as postoperative rescue analgesic in two patients. There was no incidence of postoperative nausea/vomiting or any block-related complications. The postoperative stay was uneventful with an acceptable patient satisfaction.Conclusion The index experience reiterates the fact that a prudent combination of nonopioid multimodal analgesics with case-based locoregional techniques can feature as a successful OFA protocol, albeit mandating future prospective studies in this novel area of clinical interest.

Surgical Decompression for Thoracic Outlet Syndrome in Adolescent Patients

Objectives: Thoracic outlet syndrome represents a complex combination of symptoms in the upper extremity that occurs due to compression of the neurovascular structures of the thoracic outlet or subcoracoid space. It can be seen in overhead athletes and is commonly misdiagnosed as other shoulder pathology. This study seeks to highlight patient characteristics, intraoperative findings, and both short term and long term outcomes of thoracic outlet decompression in the adolescent population as well as a comparison of outcomes by mechanism of injury including athletes. Methods: A retrospective chart review was performed of patients between the ages of 13 and 21 with a clinical diagnosis of TOS that were treated surgically by a single surgeon between 2000 and 2015. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient reported outcome scores including quickDASH, CBSQ, VAS, and SANE were obtained for a cohort of patients with long-term follow up ranging from 2 to 15 years. Results: The study population consisted of 54 adolescents (61 extremities) aged 13-21 at the time of presentation. There was a 3:1 female to male ratio. Patients saw an average of 2.08 other healthcare providers before referral to our institution. The most common surgical procedures included neurolysis of the brachial plexus (60; 98.4%), anterior scalenectomy (59; 96.7%), middle scalenectomy (54; 88.5%), excision of the first rib (28; 45.9%), excision of cervical rib (5; 8.2%), and subclavian artery manipulation (50, 81.9%). A second incision in the subcoracoid space was utilized in 28 (45.9%) extremities for exploration of the infraclavicular brachial plexus with release of the coracocostal ligament in 26 of these 28 patients (92.9%). Long-term follow-up data, including patient reported outcomes, was collected for 24/54 patients (44%). In this patient subset, the average follow-up was 69.5 months and ranged from 24 months to 180 months. The average preoperative VAS was recorded at 8.2 with an average postoperative VAS of 2.0, showing an improvement of 6.2 points. The average preoperative SANE score was 28.9 and the average postoperative SANE score was 85.4 with an improvement in 56.5. The average postoperative quickDASH score was 11.4. The average postoperative CBSQ score was 27.4 . The average postoperative NTOS Index score was 17.2. Subgroup analysis was performed analyzing patients having a first rib excision versus patients where their first rib was left intact. There was no difference regarding clinical outcome measures in these groups including CBSQ, VAS, SANE score, quick DASH and NTOS index. An additional subgroup analysis was performed comparing mechanism of injury including overuse from sports, trauma, and idiopathic causes. There was also no difference regarding clinical outcome measures in these groups including CBSQ, VAS, SANE score, quick DASH and NTOS index. Conclusion: We found no difference in clinical outcome scores in patients treated with rib resection versus patients with the first rib left intact. We also found no difference in outcomes with respect to mechanism of injury including overhead sports athletes. Overall, patients did well long-term after decompression of the thoracic outlet. Thoracic outlet syndrome should be considered in the differential diagnosis of athletes with upper extremity pain especially if they have neurologic findings.

IF13. Arterial Thoracic Outlet Syndrome: Outcomes of Direct Repair of Subclavian Artery Aneurysms

Arterial complications of thoracic outlet syndrome (TOS) are rare (<1%). Surgery involves decompression of thoracic outlet, repair of subclavian aneurysm, and often embolectomy. Most published series have reported interposition graft for repair of subclavian aneurysm. The objective of this study was to evaluate the long-term results of decompression and direct repair of subclavian artery aneurysm in arterial TOS. This was a retrospective review of a prospectively maintained database. All patients who underwent surgery for arterial TOS from January 2001 to April 2017 were included. Patients’ demographics, presentation, treatment, and outcomes were reviewed. Direct repair of subclavian artery aneurysm included longitudinal arteriotomy, intimectomy, and tailoring. There were 62 operations performed on 53 patients for arterial TOS. Mean age at presentation was 35.62 years (range, 13-65 years). The female to male ratio was 1.65:1.0. There were 12 patients with bilateral arterial TOS, although all presented with unilateral symptoms. Three patients presented with acute limb ischemia. The remaining patients had delayed presentation (range, 30 days-2 years), including neck pain and swelling (7), upper limb claudication (33), rest pain and digital cyanosis (5), and stroke (1). The cause of arterial TOS was complete cervical rib in 50 (94%) patients (12 bilateral), incomplete first rib in 2 (4%) patients, and compression with scalenus anticus in 1 (2%) patient. All 12 asymptomatic TOS patients showed arterial compression, and 3 patients refused surgery for the asymptomatic limb. Surgery included thoracic outlet decompression by anterior scalenotomy (62), excision of cervical rib (59), and excision of first rib (3). Of the 62 operations (89%), 55 included direct repair of subclavian aneurysm: longitudinal arteriotomy, intimectomy, and aneurysmorrhaphy; 2, resection and end-to-end anastomosis; and 2, interposition grafts. Trans-subclavian embolectomy was done in 47 and transbrachial in 27 patients. Early complications included hemothorax requiring chest drain (one), lymph leak (one), phrenic nerve paresis (one), and brachial neurapraxia (two). Mean follow-up was 2 years (range, 6 months-5 years); 13 patients were lost to follow-up after 6 months. Follow-up is at regular intervals clinically and with duplex ultrasound scan. Residual ischemia (asymptomatic) is present in 12 of 53 patients (23%). One patient has persistent neuralgia. Asymptomatic dilation of directly repaired subclavian artery was identified in one patient at 18 months of follow-up, and he is under surveillance. Direct repair of subclavian artery aneurysm in arterial TOS patients can be performed safely. Recurrent dilation is rare and can be managed conservatively.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs

ObjectiveThe transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. MethodsWe reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. ResultsBetween 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). ConclusionsThis series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.

Excision of Cervical Rib through Supraclavicular Approach

Thoracic Outlet Syndrome (TOS) is a clinical condition due to compression of the neurovascular structures, such as brachial plexus and subclavian vessels, during their course between the neck and axilla. Different etiological factors including cervical rib are involved in this diverse group of disorder. Depending on these factors, patients presents with either neurological or vascular compromise. Multiple disciplinary team effort and appropriate surgical technique such as the supraclavicular approach to eliminate the definitive element defines cure in terms of long term functional capacity. We report a case of a 27 year old female who presented with complain of progressive left upper limb pain and paresthesias. We planned an excision of cervical rib with thrombectomy and stenting of the subclavian artery though a supraclavicular approach.

Management of Acute Upper Extremity Ischemia: Treatment Strategies and Outcome

The aim of the study was to evaluate etiology, type of procedure, limb salvages attempted, and outcomes in acute upper limb ischemia (AULI). Patients from January 2013 to December 2014 with AULI (excluding trauma, iatrogenic) admitted at our hospital (Jain Institute of Vascular Sciences, Bengaluru, India) were included in the study. The analysis included 43 patients (53% males), mean age of 51 ± 12 years. Three patients presented ≤6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. AULI constitutes ∼12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.

Multicenter Randomized Clinical Trial of Four Different Devices for Endovascular Aneurysm Repair: Design of the LEOPARD Trial

Results: The analysis included 43 patients (53% males), mean age of 51 6 12 years. Three patients presented #6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. Conclusions: AULI constitutes w12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.

Surgical Management of Vascular Thoracic Outlet Syndrome: A Teaching Hospital Experience

Thoracic outlet syndrome (TOS) consists of a group of distinct disorders that are caused by compression of the brachial plexus and/or subclavian artery and vein. The aim of this study was to highlight the different modalities of diagnosing and treating vascular TOS and evaluate outcomes. We conducted a retrospective cohort study between 1999 and 2011 using the medical records database from a teaching hospital. During the study period, 54 cases with vascular TOS were identified in 38 patients. Bilateral TOS was in 16 patients. The median age of the patients was 33 years (range 12-49), and the majority (79%) were female. Arterial TOS represented forty-nine cases (90.7%). Preoperative information derived from plain x-ray, duplex scanning and in selected cases computed tomography (CT) and/or angiography. Decompression of the TOS was performed through a supraclavicular approach in all cases with scalenectomy coupled with either cervical rib excision (70%), 1st rib excision alone (15%) and excision of both cervical and 1st ribs (15%). Adjunctive vascular reconstructive procedures were done in 11 cases (20.3%); 9 arterial cases and 2 venous cases. There was no mortality; however, postoperative complications occurred in 7 cases (13%). The use of advanced radiological imaging and careful surgical planning for Vascular TOS in a high volume center resulted in good outcomes.

Supraclavicular Scalenectomy for Thoracic Outlet Syndrome—Functional Outcomes Assessed Using the DASH Scoring System

To evaluate supraclavicular scalenectomy ± cervical rib excision for thoracic outlet syndrome (TOS), employing Disability of Arm, Shoulder, and Hand (DASH) scoring for functional assessment post-decompression. A QuickDASH score was calculated for each patient using the algorithm: ([sum of responses/n] - 1) × 25, where n = number of completed responses. Nonparametric analysis was employed, with significance defined as P ≤ .05. Twenty-one patients were treated for TOS by the same surgeon; with 5 bilateral procedures (total = 26 procedures). Median DASH scores pre- and postoperatively were 68.5 and 36.0, respectively (P = .002). Just one reported worsening of symptoms postoperatively. Antecedent trauma and smoking were inversely associated with DASH score postoperatively (P = .005 and P = .005). Postoperative scores were less for patients with vascular symptoms (P = .011); scores did not change significantly for those with neurologic (P = .066) or mixed symptoms (P = .345). This study reconfirmed the value of supraclavicular approach for TOS, with the vast majority reporting subjective improvement.

“Double cervical rib with uncommon presentation”

Double or Bilateral cervical ribs. Pseudo arthrosis of cervical rib with first rib causing neurovascular complication is a rare congenital anomaly. We report a case of young man who presented with intermittent claudication in the right hand and involvement of peripheral nerves. He had bilateral cervical ribs. Left side cervical rib was small. Right side cervical rib had pseudo arthrosis with first rib. There was total occlusion of subclavian artery beyond first part. Abnormal sensation in the inner aspect of hand and fingers. He was managed with subclavian to axillary artery bypass with 6 mm Goretex graft and excision of cervical rib on right side and division of all sclaenus muscles i.e. scelnus anterior, medium minimus with fibrous bands to free subclavian artery and nerves.

Arterial Complications of Thoracic Outlet Syndrome

Arterial complications of thoracic outlet compression have serious potential implications; however, these complications rarely appear. Between 1990 and 2006, prospectively collected data on 27 patients with arterial complications of thoracic outlet syndrome were analyzed. The causes of arterial compression were cervical rib (20 [74.1%]), abnormalities of the first thoracic rib (three [11.1%]), soft tissue anomalies (two [7.4%]), and hypertrophic callus after clavicle fracture (two [7.4%]). In all cases, a combined supraclavicular and infraclavicular approach was used. Decompression was achieved by cervical rib excision in 13 (48.1%) patients, combined cervical and first rib excision in seven (26%), and first rib excision in six (22.2%). Associated vascular procedures included resection and replacement of the subclavian artery (26 [97.3%]), one subclavian-axillary and one axillary-brachial bypass as well as 17 (63%) brachial embolectomies. The mean follow-up period was 7 years 4 months (range, 1-16 years). Two pleural entries, two transient brachial plexus injuries, and one subclavian artery rethrombosis were found. Complete resolution of symptoms with a return to full activity was noted in all cases. In surgical treatment, a combined anterior supraclavicular and infraclavicular approach is recommended as well as transbrachial embolectomy in all cases with symptoms of distal embolization.

Left Cervical Chyloma After Cervical Rib Excision

Post-traumatic and post-surgical chylothorax is a common entity. Surgical excision of a cervical rib can be done either by transcervical or transaxillary approach, though transaxillary is recommended one. Injury to thoracic duct is quite rare in surgeries involving excision of a cervical rib. We report a case of a 40-year-old female who presented with a swelling in the left cervical region which had developed after left cervical rib excision done 3 months ago. Excision of the cyst revealed a chyloma. A chyloma after cervical rib excision has never been reported before.

Right supra- Clavicular approach for simultaneous treatment of dysphagia lusoria and cervical rib with scalene node biopsy: A case report

Anomalous origin of aberrant right subclavian artery (ARSA) is a congenital anomaly where symptomatic patients require surgical intervention. It can be associated with other congenital anomalies. A 38-year-old, woman with a 4-year history of progressive dysphagia had bilateral cervical rib and a scalene node. She underwent surgical repair by right supraclavicular approach. She tolerated the procedure well, and was discharged home, symptom free, on postoperative day 4. This approach provides good exposure for simultaneous management of dysphagia lusoria and excision of cervical rib.

Cervical Rib Syndrome - 2 Cases Report -

Cerivical rib syndrome, one of four common causes of thoracic outlet syndromes, have similar symptoms which accidentally discovered in simple x-ray and needs to be distinguished with other syndromes. Thoracic outlet syndromes are classified according to anatomical structures that causes symptoms; cervical rib syndrome, scalenus anticus syndrome, costoclavicular syndrome and hyperabduction syndrome. Various treatments for thoracic outlet syndromes have been introduced, such as; conservative care, excision of cervical rib and first rib and release of anterior scalenus muscle by supraclavicular approach and excision of cervical rib and first rib by axillary approach. We would like to report a case on a 16 years old girl and a 21 years old man who had cervical rib syndrome and treated successfully without excision of the first rib but excised cervical rib and released anterior scalenus muscle by supraclavicular approach.

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

Experience of Supraclavicular Exploration and Decompression for Treatment of Thoracic Outlet Syndrome

The purpose of this study was to assess the symptomatic outcome of patients with thoracic outlet syndrome who underwent decompression of the thoracic outlet. In our unit we prefer the supraclavicular approach, performing anterior scalenectomy with excision of fibrous bands or cervical ribs if present. Operative details were gained by theater logbook and case note review. Over a 6-year period, 31 patients (37 limbs) underwent thoracic outlet decompression. Of the 37 affected limbs, the indications for surgery were a combination of both neurological and vascular symptoms in 24 patients (65%), neurological symptoms in 24 (65%), and 4 patients (11%) had vascular symptoms alone. All patients were assessed for postoperative outcome either at out-patient clinics or by personal contact. From the results of this study we concluded that supraclavicular scalenectomy and cervical rib excision with selective first rib excision is a safe and effective procedure for most patients with thoracic outlet syndrome.

The thoracic outlet syndrome in athletes.

The array of symptoms that characterize thoracic outlet syndrome (TOS) often lead to a failure or delay in diagnosing this condition in persons who are physically active. Using the key words and phrases "thoracic outlet syndrome," "sport," "exercise," and "athlete," the MEDLINE files from 1991 to April 1996 were searched. Articles dating before 1991 were accessed by cross-referencing the more recent articles. TOS results from compression of the neural or vascular structures of the upper extremity at the thoracic outlet. Clinical manifestations can include upper extremity pain, paresthesias, numbness, weakness, fatigability, swelling, discoloration, and Raynaud phenomenon. Four symptom patterns have been described: upper plexus, lower plexus, vascular, and mixed. The lower brachial plexus pattern is the most common. Specific causes of outlet compression include injury to the scalene or scapular suspensory muscles, anomalous fibromuscular bands, cervical ribs, clavicular deformity, and pectoralis minor tendon hypertrophy. The diagnosis of TOS is established on the results of the history and physical examination. Ancillary studies are most helpful to rule out other conditions rather than confirm the diagnosis of TOS. In most cases the initial treatment is nonoperative with an emphasis on rehabilitative exercises for the neck and shoulder girdle. Surgery is indicated for acute vascular insufficiency, progressive neurologic dysfunction, and refractory pain that fails conservative treatment. The surgical technique involves the release or removal of the structures that cause compression and can involve scalene muscle release, first rib resection, cervical rib excision, and resection of fibromuscular bands.

Arterial complications of the thoracic outlet syndrome

Arterial complications due to compression of the thoracic outlet are uncommon. The objective of this study was to review our fairly extensive experience with this problem with particular reference to its management. Patients entered into the Vascular Clinic database were reviewed over an 11 year period. Twenty six records were found. In 24 patients the vasculopathy was caused by a cervical rib (complete in 15) and in two by an anomaly of the first rib. In all patients the basic arteriopathy was a fibrous structure with a post-stenotic aneurysm in 13. Seventeen presented with a fixed pulse deficit; 13 had a palpable aneurysm and 12 had distal embolisation. Two patients refused operation. In 22 with cervical rib, the rib was removed via a supraclavicular incision, an anterior scalenectomy was performed and the arterial pathology repaired on its merit, usually by vein graft replacement or bypass. In two with first rib anomalies these were resected by the transaxillary route. Twenty three patients have been followed for between 3 months and 10 years; 20 are cured and three have residual claudication. Our results show that simple excision of the cervical rib via the supraclavicular route together with vascular reconstruction is adequate. This is in disagreement with the view of those who advocate routine excision of the first rib in addition to cervical rib excision.