Thoracic Outlet Compression Syndrome Research Articles

New Paradigms for Thoracic Outlet Compression and Thoracic Outlet Syndrome, with or without Complications or Sequelae: A Trans-Continental and Trans-Disciplinary Opinion Paper

The anatomy of the human shoulder predisposes the neurovascular bundle to compression at different levels of the thoracic outlet during abduction of the arm. There are four possible levels of compression at the thoracic outlet pathway: at the costo-clavicular angle, the inter-scalenic angle, under the pectoralis minor muscle or at the level of the humeral head. The positional thoracic outlet compression (TOC) often remains completely asymptomatic. When symptomatic, compressions are collectively referred to as thoracic outlet syndrome (TOS) and may require surgery if physical therapy fails to improve symptoms. The “thoracic outlet compression with complications or sequelae” (the acronym of which is “TOC-CS”, which can be simplified as “TOX”) will almost invariably lead to surgery to release the compression, and other possible treatment targeting the complications as required. There is a continuum between TOC, TOS and TOX, which are simply different clinical stages of the same mechanical issue, just like the Rutherford grades represent different stages of lower extremity arterial disease. We believe that discriminating between TOC, TOS and TOX clarifies clinical definitions and their respective treatment options. TOC is to be considered as a physiological positional phenomenon, TOS requires medical or surgical treatment and surgery should be considered as a primary option in TOX.

Extensive supraclavicular rib resection and scalenectomy in neurogenic type of thoracic outlet compression syndrome

Background The majority of patients with thoracic outlet compression syndrome present with vague upper limb pain and paresthesia and lack clear evidence of compression on investigations and are known as the 'disputed Neurogenic type'. Patients and methods We retrospectively reviewed 39 patients (eight bilateral) who underwent 47 operations to evaluate the prognosis, outcome, and complications of surgical treatment of the disputed neurogenic type of thoracic outlet syndrome by extensive anterior supraclavicular decompression with complete excision of the first rib, the cervical rib and/or an elongated transverse process of C7 as well as scalenectomy and excision of any anomalous fibromuscular bands. Results Results were graded on the basis of symptomatic improvement. Excellent results were reported in 24 (51%) operations, good results in 18 (38%), and fair results in five (11%) operations. None of our patients considered their operation as a failure. There were no major complications; however, recurrence of symptoms occurred in three (6.5%) patients after an average of 19 months. Conclusion This procedure was found to be successful, with a low rate of complications and recurrence.

A Hand Surgeon's Advanced Experience with Thoracic Outlet Compression Syndrome

Although hand surgeons may often see patients with arm and hand pain, numbness and tingling in their practice, the possibility of the presence of thoracic outlet compression syndrome (TOCS) is not often considered. In our practice almost half of newly referred patients have the complaint of upper extremity pain, numbness and tingling. In approximately 50% of these patients detailed history and physical examination are suggestive of TOCS. For this reason it is quite important to recognize the possibility of the existence of this condition. Very often in the past, and occasionally today, this condition has been considered a controversial subject by numerous physicians because of the absence of objective findings in many patients. For several years it has been very well known that the objective findings are present in about 10% of patients and the remaining 90% of patients have subjective complaints. For this reason it has been one of the most commonly underrated, overlooked, and misdiagnosed conditions. During the last 22 years our experience with combined surgical approach for this condition (transaxillary first rib resection with immediate transcervical anterior and middle scalenectomy) has been quite satisfactory. During these years over 850 of these procedures were performed. Between 1989 and 2002 (13 years) 532 patients from a wide geographic area had this combined approach procedure. We were able to locate 358 of these patients for follow-up and of those only 102 responded to our questionnaire. Of the 102 who responded, 95 reported improvement of their symptoms. From 2003 to the middle of 2012, 350 patients from a wide region had this combined procedure. We sent a questionnaire to these patients and had only 57 to respond. Of those who responded, there were 19 bilateral interventions performed a few months apart, with a total of 76 procedures performed. Results based on these 76 procedures revealed 95% improvement of their symptoms. This combined approach for TOCS is the most complete intervention with high rate of improvement and low rate of recurrences.

A Hand Surgeon's Further Experience With Thoracic Outlet Compression Syndrome

Because hand surgeons frequently see patients with arm and hand pain, numbness, and tingling, it is important for them to recognize the possibility of the presence of thoracic outlet compression syndrome (TOCS). Approximately 40% to 50% of patients with this condition have associated peripheral nerve compression symptoms. Only about 10% of patients with suspected TOCS might show some objective evidence during physical examination and other examination modalities. For this reason, TOCS is one of the most overlooked, misdiagnosed, and underrated conditions. During the past 20 years (1989-2009) our surgical experience with combined-approach surgery for TOCS, involving transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy, has been gratifying. During this period, more than 750 patients had this combined procedure. Between the end of 1989 and 2002 (13 years), 532 patients (many of whom were from out of state) had this kind of intervention. At the end of 2002, we surveyed our patients for the outcome of their surgery. Unfortunately, we were able to locate only 358 patients, and only 102 patients returned a mailed questionnaire. About 95 patients reported improvement of their symptoms. Since the beginning of 2003, more than 230 patients have had the same procedure. It is our impression that the outcome of the surgery in this last group of patients is at least as good as (if not better than) the earlier reported outcome in the first group of patients. The combined surgical approach to TOCS with transaxillary first rib resection and transcervical scalenectomy is the most complete procedure for total decompression of the thoracic outlet, with a much better rate of improvement of symptoms and a lower rate of recurrences. The surgical techniques of these two procedures are described.

Thoracic Outlet Syndrome: A Primer on Objective Methods of Diagnosis

Thoracic outlet syndrome (tos) is a disabling symptomatic condition that arises from injury to nerves of the brachial plexus and the subclavian vessels as these structures pass from the neck and thorax into the upper limb. 1 Sanders R. Thoracic outlet syndrome: a common sequela of neck injuries. JB Lippincott, Philadelphia1991 Google Scholar , 2 Atasoy E. Thoracic outlet compression syndrome. Orthop Clin N Am. 1996; 27: 265-303 PubMed Google Scholar , 3 Luoma A. Nelems B. Thoracic outlet syndrome: thoracic surgery perspective. Neurosurg Clin North Am. 1991; 2: 187-225 PubMed Google Scholar , 4 Heughan C. Thoracic outlet compression. Can J Surg. 1984; 24: 35-36 Google Scholar The condition usually presents with pain, fatigue, and deep muscle aching suggesting a nonspecific nocicentric type of injury signal. Neuropathic reports suggesting direct nerve injury may localize symptoms to the medial cord of the plexus or ulnar innervated area of the upper limb. Arterial insufficiency may produce overlapping chronic or acute symptoms such as ischemic pain in the limb, coldness, or blanching in the hand during exercise. A subclavian artery aneurysm may produce emboli and distal digital ischemia. 1 Sanders R. Thoracic outlet syndrome: a common sequela of neck injuries. JB Lippincott, Philadelphia1991 Google Scholar Venous obstruction may be associated with chronic swelling in the limb. Acute venous thrombosis may be experienced after vigorous exercise in patients with costoclavicular compression. 1 Sanders R. Thoracic outlet syndrome: a common sequela of neck injuries. JB Lippincott, Philadelphia1991 Google Scholar , 5 Machleder H.I. Evaluation of a new treatment strategy for treatment of Paget-Schroeder syndrome: spontaneous thrombosis of the subclavian vein. J Vasc Surg. 1993; 17: 305-317 Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar •Discuss the different signs and symptoms between neurologic, arterial, and venous thoracic outlet syndrome. •Describe the Wright's and Adson’s tests. •Discuss the role of plain x-rays in the diagnosis of thoracic outlet syndrome. •Compare and contrast the various vascular imaging studies for thoracic outlet syndrome. •State the role of Botox in thoracic outlet syndrome. •Discuss the test of selective symptom provocation associated with oxygen saturation in the diagnostic algorithm of thoracic outlet syndrome. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month's test, visit http://www.assh.org/professionals/jhs. •Discuss the different signs and symptoms between neurologic, arterial, and venous thoracic outlet syndrome. •Describe the Wright's and Adson’s tests. •Discuss the role of plain x-rays in the diagnosis of thoracic outlet syndrome. •Compare and contrast the various vascular imaging studies for thoracic outlet syndrome. •State the role of Botox in thoracic outlet syndrome. •Discuss the test of selective symptom provocation associated with oxygen saturation in the diagnostic algorithm of thoracic outlet syndrome. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month's test, visit http://www.assh.org/professionals/jhs. Journal CME QuestionsJournal of Hand SurgeryVol. 35Issue 9Preview Full-Text PDF

Diagnosis of thoracic outlet syndrome. Relative value of electrophysiological studies.

The diagnostic utility of various electrophysiological techniques was evaluated in patients with thoracic outlet compression syndrome (TOCS). Our results suggest that in true neurogenic TOCS, there is no standard electrophysiological picture, but that this evolves with the severity of the syndrome. The first changes observed are electromyographic, followed by changes in F-wave and SEPs, followed finally by changes in nerve conduction parameters. EMG study was certainly more informative, showing neurogenic damage not only in limbs with neurological signs but also in about 1/4 of limbs with only subjective symptoms. The study of F-wave and SEPs does not seem to be particularly helpful, however, in view of the peculiar changes found in these patients, SEPs may be a useful complement to EMG. Nerve conduction studies were of little utility since changes in these parameters are only found in patients with long-standing anomalies and severe atrophy.

Simultaneous Surgical Release of Ipsilateral Pronator Teres and Carpal Tunnel Syndromes

Because of overlapping symptoms, carpal tunnel syndrome is sometimes diagnosed and a more proximal site of compression may be missed. Incomplete relief following carpal tunnel surgery may be caused by the failure to identify the second site of compression. A retrospective review was performed on 61 patients who were diagnosed as having both carpal tunnel syndrome and pronator teres syndrome of the ipsilateral median nerve. Besides precise medical history and physical evaluation, nerve conduction velocity studies and electromyography were performed. All patients but two had ipsilateral endoscopic carpal tunnel release and pronator teres release. Results after surgery were clinically assessed and evaluated as follows: complete relief, partial relief, or no relief. Postoperative evaluation resulted in 39 of 61 patients (64 percent) experiencing complete relief. Thirteen patients (21 percent) had partial relief. Eight of these patients were secondarily diagnosed with more proximal compression. Five of them had thoracic outlet compression syndrome, and three of them had cervical radiculopathy. For five patients, no specific reason was found for experiencing only partial relief. Nine patients (15 percent) had no significant relief. Among those patients, four were diagnosed with thoracic outlet compression syndrome and two with cervical radiculopathy; for three patients, the authors found no specific reason for failure. The main benefit of using this protocol in this selected group of patients is to shorten total morbidity time and to avoid exposure of the patient to two operations instead of one.

Das asymptomatische Thoracic-outlet-Kompressionssyndrom

The thoracic outlet compression syndrome has a great number of clinical variations. Arterial and venous perfusion impairment is an associated symptom, nerve irritation can occur with or without vascular problems. The degree of nerve damage ranges from transient irritation to permanent motoric and sensory defects. The lack of space in the supracostoclavicular compartment is the cause for nerve compression. The degree of neural damage depends on the degree and duration of the compression. Anatomic variations between the clavicle and first rib are frequent causes for the TOS: accessory ribs and muscles, and fibrous bands have been described. A preexisting chronic compression may lead to a subclinical TOS, in this case an inadequate trauma of minor degree may be sufficient to manifest a plexus palsy. Intraoperative findings in children with incomplete and complete brachial plexus palsy and the corresponding findings in adults prompted us to present this communication.

Combined Surgical Treatment of Thoracic Outlet Syndrome: Transaxillary First Rib Resection and Transcervical Scalenectomy

Many different procedures have been developed to treat thoracic outlet compression syndrome (TOCS), a condition in which neurovascular structures in the thoracic outlet region are compressed. Currently, transaxillary first rib resection and transcervical anterior and middle scalenectomy are the most popular and standard procedures. In the early 1980s, some surgeons started to perform both procedures, starting with the scalenectomy and following with a transaxillary first rib resection. We have found that performing these procedures in the reverse order, starting with the first rib resection and following immediately with a transcervical anterior and middle scalenectomy accomplishes total decompression of the thoracic outlet area with much better improvement of symptoms and much lower recurrence rate.

Surgical management of the thoracic outlet compression syndrome

There is some disagreement about whether the first rib should be excised in the presence of a cervical rib for the relief of the thoracic outlet compression syndrome (TOCS). Over a 14-year period (1975-1988) 58 patients have undergone surgery for TOCS. Forty-four patients (76 per cent) had vascular symptoms, 28 (48 per cent) with a neurological component; 11 (19 per cent) had only neurological symptoms. Thirty-six patients (62 per cent) had the first rib excised; 19 (33 per cent) had a cervical rib excised; two (3 per cent) had a division of fibrous bands; and one patient had a large transverse process resected. Follow-up details were available on 53 patients (91 per cent). Overall 38 (72 per cent) were cured of their symptoms, 11 (21 per cent) had a significant improvement, and four (8 per cent) showed no improvement. There was no significant difference between the results following excision of a cervical rib or of a first rib in terms of relief of symptoms. In patients with TOCS who have a cervical rib, excision of the cervical rib alone without excision of the first rib would appear to be an appropriate treatment.

Thoracic Outlet Compression Syndrome: A Rare Cause of Upper Extremity Symptoms in Children

Children frequently complain of upper extremity pain often secondary to trauma, yet rarely do they suffer from thoracic outlet compression syndrome (TOCS). Through 1997 the literature contains only 6 reported cases: 4 in the United States, 1 in Turkey, and 1 in Italy.1-3 Although family physicians need to focus on the common causes of symptoms, we must consider the unexpected possibilities. Fortunately, we can use our knowledge of adult medicine to recognize unusual pediatric presentations.

Diagnosis of Thoracic Outlet Syndrome Using Electrophysiologically Guided Anterior Scalene Blocks

There is no "gold standard" for diagnosing thoracic outlet compression syndrome (TOS), however, anesthetic blocks of the anterior scalene muscle (ASM) have been used as a means of predicting which patients may benefit from surgical decompression. The standard technique of using surface landmarks often results in inadvertent somatic block and sympathetic block because there is no reliable verification of needle tip localization. The present study was undertaken to determine if needle tip localization can be improved by using electrophysiological guidance. ASM blocks were performed for patients with a diagnosis of possible TOS. An insulated hypodermic needle was inserted into the ASM which was identified during electromyogram (EMG) activation maneuvers. Stimulation was performed to make sure that the needle tip was not in the brachial plexus. Local anesthetic was instilled and the intensity of pain induced by TOS stress maneuvers was compared to pain ratings obtained after control injections. The ASM could be identified electromyographically in all 122 cases. There were no instances of inadvertent somatic block nor sympathetic block. Of 38 patients who underwent surgical decompression of the thoracic outlet, 30 of 32 (94%) with a positive block had a good outcome compared with 3 of 6 (50%) who underwent surgery in spite of a negative block. Electrophysiological guidance facilitates accurate needle tip placement in the performance of ASM blocks; the results of these blocks appear to correlate with surgical outcomes.

Síndrome de la compresión neurógena en la salida torácica

The nerve conduction studies, F-waves and dermatosomal and lor somatosensory evoked potential have a low level of sensitivity for Thoracic Outlet Compression Syndrome (TOCS) diagnosis. A standard negative electrodiagnostic study does not exclude the presence of TOCS. The purpose of this neurophysiological note is that the Wright's hyperabduction, costoclavicular compression and Adson's scalenus tests important in making a clinical diagnosis of TOCS can be used as neurophysiological provocative maneuvers to determine the effect of braquial position on electrodiagnostic parameters. Nine selected TOCS patients were evaluated previous and following provocative maneuvers for 3 and 6 minutes. The results showed a positive electrodiagnostic study in 7/9 patients. It is suggested that patients with presumptive TOCS and negative electrodiagnostic findings be reevaluated immediately after 6 minutes of Wright's, Adson's or costoclavicular compression provocative tests.

Presidential address: Venous disorders—Reflections of the past three decades

Presidential address: Venous disorders—Reflections of the past three decades

Thoracic outlet compression syndrome caused by a schwannoma of the C7 nerve root

This is the first report of a schwannoma originating from the C7 nerve root causing thoracic outlet compression syndrome. The patient was a 30-year-old woman with a 3-year history of numbness on the radial side of the left hand, left arm tiredness, nocturnal pain in the left forearm and pain in the left elbow, shoulder and neck. Conservative treatment and previous operations, including carpal tunnel release and first rib resection, provided no relief. A left scalenectomy was performed. During the removal of the anterior scalene muscle, a mass approximately 3 cm long and 1.5 cm in diameter was noted under the anterior scalene muscle involving the C7 nerve root. The tumour was encapsulated and covered with attenuated and stretched nerve fascicles. It was completely excised without disturbing the nerve fascicles. The clinical impression was schwannoma, which was confirmed on pathological examination.

Surgical Treatment of Thoracic Outlet Compression Syndromes. II. Supraclavicular Exploration and Vascular Reconstruction

Supraclavicular exploration has become a widely utilized, versatile, and effective approach in the treatment of thoracic outlet compression syndromes. It is applicable to neurogenic, arterial, and venous form of TOS. Although certain aspects of the surgical anatomy are quite familiar to most vascular surgeons, considerable attention must be given to the details of this procedure to avoid inadequate decompression, serious injury, or predictable causes of recurrent compression. Supraclavicular exploration and its variations provide an excellent approach to the entire spectrum of problems encountered in patients with TOS, and in many centers it has superceded the transaxillary approach previously popularized for these disorders. Because supraclavicular exploration for TOS involves a number of unique technical considerations and because it is typically applied to a difficult clinical problem outside the routine experience of most vascular surgeons, it should be undertaken only with appropriate training and interest in the comprehensive management of patients with TOS.

Surgical Treatment of Thoracic Outlet Compression Syndromes: Diagnostic Considerations and Transaxillary First Rib Resection

The thoracic outlet encompasses a unique anatomic region dominated by the first rib, the anterior and middle scalene muscles, and their associated structures. Within this relatively confined space, the subclavian artery, the subclavian vein, and the five nerve roots of the brachial plexus are all potentially subject to extrinsic compression (Fig. 1). Vascular lesions associated with thoracic outlet compression typically give rise to easily recognized syndromes, such as effort thrombosis of the subclavian vein or poststenotic aneurysms of the subclavian artery complicated by thromboembolism. In contrast, the diagnosis of neurogenic thoracic outlet compression syndrome (TOS) often remains difficult, confusing, and elusive. An increasing body of experience demonstrates that excellent results can be achieved by a comprehensive, multidisciplinary approach to neurogenic TOS, including a prominent role for surgical treatment in well-selected patients.’ Nonetheless, uncertainty in diagnosis and disappointing results of teatment have led some to question the very existence of neurogenic TOS, adding to the many controversies surrounding this condition.* The purpose of this two-part series is to outline the current management strategies and surgical

Thoracic Outlet Compression Syndrome

This article is concerned with thoracic outlet compression syndrome (TOCS), one of the most controversial subjects in medicine. It may also be the most underrated, overlooked, misdiagnosed, and probably the most important and difficult to manage peripheral nerve compression in the upper extremity. Contents of the chapter include the historical aspect, anatomy, etiology and incidence, pathophysiology, symptomatology, diagnosis, conservative and surgical treatment, other conditions associated with TOCS, and results of TOCS surgical treatment.

Breast pain and the thoracic outlet compression syndrome

Mastalgia is a common symptom presenting both to general practitioners and surgeons. The breast pain which may radiate down the arms can vary from mild intensity to occasionally severe pain affecting the patient's lifestyle and sexual relationships. Non-cyclical mastalgia can be difficult to treat. Neurovascular compression at the thoracic outlet has not been recognised as a cause of this condition. We present five cases where severe mastalgia was relieved by surgical treatment of thoracic outlet compression syndrome (TOCS).

Surgical management of the thoracic outlet compression syndrome: Davies AH, Walton J, Stuart E, Morris PJ. Br J Surg 1991;78:1193–1195

Surgical management of the thoracic outlet compression syndrome: Davies AH, Walton J, Stuart E, Morris PJ. Br J Surg 1991;78:1193–1195