Symptoms Of Thoracic Outlet Syndrome Research Articles

Compression and stretching of the brachial plexus in thoracic outlet syndrome: correlation between neuroradiographic findings and symptoms and signs produced by provocation manoeuvres

In order to investigate the mechanism of nerve irritation in thoracic outlet syndrome (TOS), we studied 150 patients who presented with symptoms of neurologic TOS between 1985 and 1999. They first performed various provocative physical manoeuvres and then underwent injection of contrast medium into the supraclavicular part of the brachial plexus. Several of the provocative manoeuvres were then repeated and radiographs were again obtained. Based on the neuroradiographs, we identified three subsets of patients; those with only compression (type 1 TOS, n=27, 18%), those with combined compression and stretching (type 2 TOS, n=111, 74%), and those with only stretching (type 3 TOS, n=12, 8%). We were able to correlate the neuroradiological subsets with symptoms elicited by pre-radiographic provocative manoeuvres; in 92 patients (61%) these were elicited by traction manoeuvres. We conclude that stretching is an important factor of nerve irritation in TOS.

胸郭出口症候群のＸ線診断に関する検討

Most patients with thoracic outlet syndrome (TOS) have sloping shoulders or military posture. TOS patients with both postural characteristics demonstrate severe chronic symptoms. In our clinical experiences over the past 10 years, we have diagnosed TOS by identifying the lateral margin of the clavicula radiologically, because the position of the clavicula in the TOS lesion is related to the pathogensis. All patients underwent radiological evaluation of the cervical spine by identifying the metal marker on the anterior margin of the lateral site of the bilateral claviculas, after obtaining the correct lateral view of C7 at sitting. Seventeen normal subjects showed the anterior shift of the marker from the C7-T1 disc level. In 37 patients with unilateral TOS symptoms, the symptomatic side revealed posterior shift from the C7-T1 vertebra, while the asymptomatic side showed anterior shift in normal vertebrae. On 50 patients with bilateral TOS symptoms, most demonstrated posterior shift from the C7-T1 vertebra, and the results were compatible with the symptomatic side with unilateral TOS. The postural characteristics of TOS could be confirmed in our radiological evaluation.

Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome

Objective: Cervical and anomalous first ribs are rare conditions, occurring in less than 1% of the population. This manuscript reviews our management of neurogenic thoracic outlet syndrome (TOS) associated with these congenital anomalies. Methods: During the past 26 years, 65 operations were performed for abnormal ribs that produced symptoms of TOS. Of these, 54 operations were for neurogenic TOS and are covered in this paper. Indications for surgery were disabling pain and paresthesia and failure to respond to conservative treatment. Surgical technique for neurogenic TOS was supraclavicular cervical rib resection and scalenectomy without first rib resection in 22 cases, supraclavicular cervical and first rib resection in 17 cases, supraclavicular excision of anomalous first ribs in five cases, and transaxillary anomalous first rib resections in two cases (total, 46 cases). Eight reoperations were performed for recurrent TOS in patients who previously had undergone cervical and first rib resections. Results: Neck trauma was the cause of neurogenic symptoms in 80% of patients with cervical or anomalous first ribs. The surgical failure rate was 28% for 46 primary operations. A significant variable in results was the etiology of the symptoms. The failure rate for patients in whom symptoms developed after work-related injuries or repetitive stress at work was 42%, and the failure rates for patients whose symptoms followed an auto accident or developed spontaneously were 26% and 18%, respectively. The failure rate in each etiology group also was affected by the operation performed. The failure rate for cervical rib resection without first rib resection in the work-related group was 75% compared with a failure rate of 38% in the non-work-related group. In contrast, when both cervical and first ribs were resected, the failure rate in the work-related group fell to 25% and in the non-work-related group to 20%. These failure rates for the work-related and non-work-related groups are similar to our failure rates in patients without cervical ribs. Conclusion: Surgery for neurogenic TOS in patients with cervical ribs should include both cervical and first rib resection. The presence of cervical or anomalous first ribs in patients with neurogenic TOS does not improve the success rate from surgery compared with patients without abnormal ribs. Neck trauma is the most common cause for neurogenic TOS in patients with abnormal ribs. Cervical and anomalous first ribs are the predisposing factors rather than the cause. (J Vasc Surg 2002;36:51-6.)

Brachial Plexus

AbstractMRI is the primary imaging modality used to diagnose the cause of brachial plexopathy. This unit presents protocols to diagnose the cause of brachial plexus. The provides the core component of this procedure and an alternate protocol is presented for the case of avulsion injury from trauma. A second alternate protocol is presented for the case where neoplastic involvement of the brachial plexus is suspected or any abnormalities are seen. A third alternate protocol is presented for the cases when the patient has symptoms of thoracic outlet syndrome and vascular compression is suspected.

An unusual case of thoracic outlet syndrome associated with long distance running.

An amateur marathon runner presented with symptoms of thoracic outlet syndrome after long distance running. He complained of numbness on the C8 and T1 dermatome bilaterally. There were also symptoms...

Neurovascular compression in the thoracic outlet: changing management over 50 years.

During the past five decades, significant improvements have been made in the diagnosis and treatment of thoracic outlet syndrome (TOS) secondary to sports activities, breast implants, or median sternotomy. Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular decompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurysm or occlusion was treated successfully in 240 patients. Dorsal sympathectomy was performed concomitantly in 71 patients for occlusion or embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained pain syndrome and causalgia that did not improve with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal sympathectomy. The use of hyaluronic acid significantly reduced recurrent scarring.

Thoracic outlet syndrome: A functional dysfunction of the upper thoracic aperture?

To determine possible malfunction of the upper thoracic aperture (an upward displacement of the first rib at the costotransverse joint) as the cause of thoracic outlet syndrome (TOS) symptoms among consecutive TOS patients admitted for conservative treatment. Fifteen consecutive TOS patients, with a positive TOS index, admitted for conservative treatment were investigated with a three-dimensional CT scan of the upper thoracic aperture. A rehabilitation program was administered at a rehabilitation ward. The CT scans were evaluated for a possible upward displacement of the first rib at the costotransverse joint. The outcome of conservative therapy was classified as good if the patient was symptom free and poor if loading of the upper limbs still produced symptoms. Outcome follow-up time was 1 year. An asymmetry of the first rib was shown on the symptomatic side, indicating an upward displacement of the first rib at the costotransverse joint, in 12 of the patients. Only three patients did not respond to therapy. Eleven patients were engaged in sedentary work. Malfunction of the upper thoracic aperture, especially among patients doing sedentary work, seems to cause TOS symptoms. A carefully planned conservative therapy program based on the functional findings of the individual patient is recommended.

Conservative treatment of thoracic outlet syndrome: A 2-year follow-up

Objective: To evaluate a conservative therapy program that aims to restore normal function to the upper thoracic aperture in patients with thoracic outlet syndrome (TOS). Design: A descriptive study of consecutive patients with a positive TOS index seen from 1988 to 1993. After therapy, the patients were followed for a mean period of 24.6 months. Setting: Therapy was initiated primarily in an inpatient rehabilitation ward over an 11.4-day (range 4–24 days) stay. Patients: One hundred nineteen patients (28 men and 91 women) with a positive TOS index participated. At admission, 50% of the patients were employed, 48% were on sick leave or retired, and 2% were unemployed. Interventions: The patients received instructions on how to restore the normal function of their cervical spine and upper thoracic aperture by means of home exercises. Main Outcome Measures: The efficacy of the treatment program was assessed by the frequency of return to work, normalization of the motion of the cervical spine and upper thoracic aperture, and subjective satisfaction with the outcome. Results: At the follow-up examination, 88% of the patients were satisfied with the outcome of their treatment, and the ranges of motion of the cervical spine and upper thoracic aperture had normalized in 8 of 10 patients. Seventy-three percent of the patients returned to work after the therapy, either directly or after retraining, and 88% of the patients carried through the recommendations given at discharge during long-term followup. Normalized grip strength and Tinel's sign predicted patient satisfaction ( p < .001) and return to work ( p < .001). Return to work was more often successful if the work was sedentary rather than heavy ( p < .05). Conclusions: The treatment program provides relief to most patients with symptoms of TOS. If the symptoms are not relieved, the differential diagnosis should be reviewed. Conservative therapy with the aim of restoring the function of the upper thoracic aperture is to be recommended, and long-term follow-up is advisable.

Diagnosis and treatment of thoracic outlet syndrome

Patients who develop symptoms of thoracic outlet syndrome (TOS) have a predisposing anatomic abnormality. In most patients with TOS, the symptoms are caused by entrapment of the brachial plexus and they do not arise from compression of the subclavian artery, as was previously thought. The tests advocated for diagnosing this common syndrome (i.e., evaluating the positional compression of the artery when the arms are raised, the neck is turned, or the shoulders are braced) cannot accurately diagnose this syndrome. There are two reasons for this. The symptoms of TOS are not related to the compression of the artery in the outlet in 98% of patients, and 75% of normal individuals without symptoms show diminished radial pulse on various provocation tests. We employed four timed provocation tests (minute tests) to diagnose TOS: the timed Morley test, timed Wright test; timed Eden test, and elevated arm stress exercise, all of which are very sensitive. In normal individuals without symptoms, 20% experience transitional symptoms such as slight pain and tiredness, on these tests indicating a subclinical state. TOS is treated by keeping the thoracic outlet wide, this being done either conservatively or surgically. In 1993 and 1994, we conservatively treated 418 of 422 patients with TOS by means of active exercise, a brace, and by block therapy. These measures did not reduce the symptoms in 23 of these patients, so surgical treatment was indicated. In the remaining 4 of the 422 patients, conservative treatment was not indicated and surgery was performed directly. All the patients showed significant clinical improvement of varying degree.

Diagnosis of thoracic outlet syndrome in the emergency department.

The use of the emergency department (ED) as a source for primary care has increased the number of patients seen in this setting with even chronic symptoms such as pain, paresthesias, and weakness in the upper extremity. This group may include individuals with thoracic outlet syndrome (TOS). We were concerned that TOS may be underdiagnosed in the ED because of physician unfamiliarity with the signs and symptoms of TOS. Hence, we retrospectively studied cases of TOS seen at the ED of the University hospital during a 29-year period. We believe this is the first report in the English language literature to reflect the assessment and management of TOS in the ED. The study data include clinical presentation, diagnostic tests, and management of TOS. Lack of thorough evaluation resulted in underdiagnosis of TOS in our ED. We recommend that ED personnel pay close attention to patients with symptoms of long duration and that ED physicians be aware of TOS presentation and its management.

Thoracic outlet syndrome in musicians — an approach to treatment

Thoracic outlet syndrome (TOS) can affect the skill of instrumental musicians. This paper details the way in which symptomatic TOS affects the musician and describes two cases of symptomatic TOS in a drummer and a violinist. Evaluation tools and treatment techniques are described.

Long-term outcome of surgery for thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is one of the most controversial symptom complexes in surgery today. Even the existence of TOS is questioned and where it seems to exist, the incidence varies from one country to another. Surgery is often considered the primary treatment; however, the frequency of good results after surgery varies from 24% to 100%, and in recent years the surgical approach has been questioned. In this study 45 patients who had undergone surgery for TOS symptoms over a period of 21 years were examined by an independent clinician an average of 8 years after the operation. Forty-three percent of the performed operations were found to have been successful. Preoperative nocturnal and neck pain were more frequent in the unsuccessful group; no other preoperative characteristics had a predictive value. Preoperative radiographic and neurophysiologic examinations were also not predictive of the outcome. It is recommended that the feasibility of conservative therapeutic approaches should be evaluated before undertaking surgery for TOS symptoms.

Conservative treatment of thoracic outlet syndrome using an orthosis

We describe a strapping device for elevation of the shoulder in patients with thoracic outlet syndrome (TOS). The device was used by 86 patients with TOS whose symptoms had been alleviated by passively raising the shoulder. Symptoms of TOS were classified as proximal, including pain in the shoulder girdle, and distal, in which there were neurological deficits related to the brachial plexus. The device was more effective in patients with distal symptoms: pain disappeared or improved in 67% of patients; numbness in 85%; sensory disturbance in 84%; and motor disturbance in 80%. However, proximal symptoms were relieved in only 65% of the patients. The ability to perform activities of daily living was rated as excellent in 33% of patients, good in 44%, fair in 12%, and poor in 9%. The shoulder orthosis described in this report can counterbalance downward traction on the brachial plexus and reduce the tension on it, thereby relieving symptoms of TOS.

Pre-operative factors and treatment outcome following carpal tunnel release.

The outcome of carpal tunnel release was evaluated retrospectively in 60 hands of 53 patients followed for six to 33 months (median ten months). Outcome was considered good in 27% (pain, weakness, and numbness were essentially resolved); fair in 42% (most of the symptoms improved); and poor in 32% (symptoms persisted or worsened). Patients whose pre-operative work activity was considered physically strenuous were associated with a slightly but significantly poorer outcome (60% good or fair) compared to those in light work or with no employment (89% good or fair). Proportionately fewer patients returned to their original work when they previously engaged in strenuous activity, ranging from 27% for those using air guns to 80% in light work. It appears that the highest chance of a poor outcome from carpal tunnel release occurs in patients who have either associated symptoms of thoracic outlet syndrome or physically strenuous work activities.

Thoracic Outlet Syndrome: A Common Sequela of Neck Injuries

The diagnosis and treatment of thoracic outlet syndrome is still confusing to and controversial among clinicians. Dr Sanders, who has long been interested in this area, has compiled a complete and informative volume addressing this topic based on his 25 years' experience in treating more than 850 patients with symptoms of thoracic outlet syndrome. The book is very organized, with ample subheadings that make it easy to read. The text is supplemented with excellent illustrations and sufficient tables. Particularly important features are the exhaustive summary and the analysis of the existing literature, which are presented clearly and objectively. With additional contributions from physiologists, neurologists, and physiatrists, all aspects of thoracic outlet syndrome are well covered despite some minor repetitions. The text begins by identifying the problem of lack of objective diagnostic criteria for and consensus in treating thoracic outlet syndrome. This is followed by a description of the history and

Recurrent thoracic outlet syndrome after first rib resection.

Seventy-seven patients with 84 operated limbs participated in a follow-up examination on an average of about six years after the resection of the first rib for thoracic outlet syndrome (TOS). Forty-two limbs (50%) were totally asymptomatic one month after the operation and remained so for at least half a year postoperatively. In the follow-up examination, 31 limbs were still asymptomatic, whereas 11 limbs had the same symptoms as before the operation. Of the nine patients with recurrent TOS (two with bilateral resection), seven were women and two were men. These nine patients were on average 38 years old (range = 19 to 51 years) and their jobs consisted of monotonous desk work. Seven of 11 stumps of the first rib were subluxated disclosed by the cervical rotation-lateral-flexion test. The occurrence of a subluxated stump of the first rib in the group of asymptomatic patients was far lower, only 3% (p less than .001). Of the 42 patients with persistent problems, a subluxated stump was encountered in seven (17%). Results of this follow-up examination suggest that monotonous desk work is an important factor causing kinesiologic abnormalities in the thoracic aperture. This abnormal kinesiology contributes to the recurrence of TOS symptoms even after the resection of the first rib.

胸郭出口症候群手術例の検討 熊大式ＴＯＳ臨床症状評価案を用いて

Evaluation of thoracic outlet syndrome (TOS) is very difficult because of its various symptoms. We made an idia of Kumamoto University Thoracic Outlet Syndrome Evaluation Score which includes provisions of Pain, ADL disturbance, autonomic nerve symptom and examination findings. This time we evaluated the pre-and post-operative scores in 31 TOS patients. (41 sides, 18 male, and 23 female) In this study, we found the difference in postoperate score between male and female, Male patients had better results than female patient.In conclusions, our TOS Evaluation Score is usefull, because it can clarify the symptoms of TOS by scoring.

Peripheral nerve disorders in instrumentalists

I evaluated 226 instrumentalists for playing-related symptoms. There were 103 players (46%) of string instruments, 7 keyboard instrumentalists (32%), 44 players (19%) of wind instruments, and 6 percussionists (3%). The mean age was 32 years; 58% were women. Sixty-five patients (29%) had a peripheral nerve disorder; 27 had symptoms of thoracic outlet syndrome; 12 had median neuropathies (carpal tunnel syndrome in 9); 9 had ulnar neuropathies; 6 had cervical radiculopathy; 5 had digital neuropathies; 3 had cranial neuropathies; and 3 had other peripheral nerve disorders. Treatment consisted of modification of playing schedules and technique, plus physical and occupational therapy in 51 and surgical procedures in 9 patients; 5 were not treated. Follow-up at 1 to 8 years showed 74% had a satisfactory result, 14% had slight or minimal improvement, and 12% had no improvement. At the time of writing, all but 4 patients remained in the music profession. It is concluded that playing-related symptoms among instrumentalists are frequently neurological in origin and that the large majority can be helped by conservative or, on occasion, surgical means.

Brachial Artery Entrapment: Compression by the Supracondylar Process

Ischemia occurring during hyperextension of the upper limb in a 25-year-old woman led to the discovery of a supracondylar spur responsible for compression of the brachial artery with anomalous insertion of the pronator teres muscle. Resection of all abnormal structures provided immediate relief of symptoms. When atypical arterial symptoms of thoracic outlet syndrome occur in the upper limb, the brachial artery entrapment syndrome should be considered.

Headache as the leading symptom of the thoracic outlet syndrome.

SYNOPSISIntractable headache is a common presenting symptom of the thoracic outlet syndrome (TOS). We followed thirty patients for at least six months after transaxillary first rib resection. Prior to surgery, twenty‐six reported recurring headache before the appearance of neck and shoulder pain; headache was lateralized in 21 and continual in 14. In 11, intensification of TOS symptoms accompanied headache. After surgery, 11 previously disabled patients returned to work; 13 became head‐ache‐free. Eleven others reported benefit from vaso‐active drugs that had been ineffective pre‐operatively.