Type Of Thoracic Outlet Syndrome Research Articles

Pediatric thoracic outlet syndrome: a systematic review with metadata.

Thoracic outlet syndrome (TOS) typically considered a condition of the adult population; it is often disregarded in children and adolescents due to its limited recognition within the pediatrics. The current study aims to systematically review and provide insights into TOS among pediatric patients. PubMed, Scopus, Web of Science, and Google Scholar databases were thoroughly searched for English language studies published until March 15th, 2024. The study included those articles focusing on pediatric or adolescent individuals diagnosed with TOS. Data collected from studies encompassed date of publication, number of participants or reported cases, age (years), gender of participants, type of TOS, affected side, type of treatment, surgical approach, bony abnormality, duration of symptoms (months), outcome, and follow-up time duration (months). The current study comprised 33 articles, 21 of which were case reports, 10 of which were case series, and the remaining were cohort studies. In this study, 356 patients were included. Females constituted 234 (65.73%) of the patient population. Among TOS types, neurogenic TOS was found among 201 (56.5%) patients. Sporting-related activity or physical activity was present in 193 (54%) patients, followed by a history of trauma in 27 (7%) patients. Pediatric patients exhibited a higher percentage of vascular TOS than their adult counterparts, with the supraclavicular approach emerging as the preferred treatment method. Sports-related activities were identified as the primary risk factor associated with pediatric TOS.

Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis

Background: Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. Purpose/Hypothesis: The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. Results: Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. Conclusion: The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.

Surgical approaches for thoracic outlet decompression in the treatment of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a controversial and uncommon syndrome. Three different diagnoses can be made based on the compressed structure: arterial TOS, venous TOS, and neurogenic TOS. Diagnosing TOS, especially neurogenic TOS, remains difficult since a single diagnostic tool does not exist. Although this resulted in a lot of confusion, standardization of care and outcome improved daily care practice measures in the last decade. Current treatment algorithms consist of both conservative and surgical treatment approaches, which should be chosen depending on the type of TOS and extend of the complaints. Surgical treatment of TOS is performed via thoracic outlet decompression (TOD). TOD surgery includes complete resection of the first rib (cartilage to cartilage), transection of the scalene muscles and complete neurolysis/venolysis or arteriolysis. Four different approaches can be chosen for TOD surgery: the transaxillary (TA), supraclavicular (SC), paraclavicular (PC), and infraclavicular (IC) approach. The TA, SC, and PC approach can be used for every form of TOS. However, the PC approach is mostly used for treating venous TOS. The IC approach has no role in treating neurogenic or arterial TOS and is only used for venous TOS. Every approach has its own benefits and limitations and literature does not agree on what approach is best. Therefore, the used surgical approach for TOD should be based on the surgeon's preference and experience. The aim of this review is to present an overview of the diagnostic pathway and provide an in-depth description of the surgical approach in each form of TOS.

Combined nerve and vascular ultrasound in thoracic outlet syndrome: A sensitive method in identifying the site of neurovascular compression.

We investigated the diagnostic utility of combined nerve and vascular ultrasound in thoracic outlet syndrome (TOS) in a retrospective cohort study on two sites, involving 167 consecutive patients with the clinical symptoms suggestive of neurogenic and/or vascular TOS, and an age- and sex-matched control group. All patients and control subjects underwent nerve ultrasound of the supraclavicular brachial plexus to look for fibromuscular anomalies / compression of the brachial plexus in the scalenic region, and vascular ultrasound of the infraclavicular subclavian artery with the arm in neutral and abducted position, serving as an indicator for costoclavicular compression of the neurovascular bundle. Based on clinical symptoms, neurogenic TOS (81%) was the most frequent type of TOS, followed by combined neurogenic and arterial TOS (8%). The frequency of abnormal nerve and/or vascular ultrasound findings differed significantly from the control group (P<0.00001). The pooled sensitivity was 48% for nerve ultrasound, 85% for vascular ultrasound, and 94% when combined. Among the findings, the fibromuscular ‘wedge-sickle sign’, indicating compression of the lower trunk in the scalenic region by a congenital fibromuscular anomaly (e.g. Roos ligaments), showed the highest specificity (100%). A bony ‘wedge-sickle sign’ was also delineated, where lower trunk compression is caused by the neck of the 1st rib. As implied by the higher sensitivity of vascular ultrasound, the most common site of compression was the costoclavicular space, but multilevel compression was also frequently observed. In summary, combined nerve and vascular ultrasound is a sensitive and reliable method to support the diagnosis of TOS. It can also identify the site(s) of compression, with obvious therapeutic consequences.

A case report on botox for neurogenic thoracic outlet syndrome – An alternative to surgery

Thoracic outlet syndrome (TOS) remains one of the underdiagnosed conditions due to the unavailability of specific tests. The pain of TOS may mimic shoulder pain and or cervical radicular pain. Understanding the pathology and type of TOS is the key to successful management. Although surgery remains the final permanent solution in a conformed case of TOS, conservative therapies do provide great relief from pain. Botox remains one of the modalities in managing TOS pain by relieving the spasm of the scalene group of muscles and thereby alleviating the compression symptoms.

Prevalence of various anomalies of costal element at cervico-thoracic junction in and around lucknow region of uttar pradesh: A radiological study.

Morphological diversities of the costal element at the cervico-thoracic junction adversely affect the positioning of its various neurovascular and soft tissue structures which form the etiological basis of symptoms in many cases of a non-traumatic type of Thoracic Outlet Syndrome (TOS). These rib variants represent disturbances of early organogenesis and are associated with stillbirths, childhood cancers, and several other congenital malformations. The present study aims to document the current prevalence, gender preferences, and laterality associations of various costal anomalies at the thoracic outlet in the reference population. A retrospective cross-sectional analytical study was conducted on 1474 PA skiagrams of the cervico-thoracic region, which comprised 919 males and 555 females of zero days to 73-year age. In 13.02% population, costal element exhibited anomalous development. Anomalies of the costal process of C7 vertebra showed higher(12.20%) prevalence compared to the thoracic first(0.81%). Elongation of the cervical 7 transverse process was most common(10.71%) followed by cervical rib(1.49%), rudimentary first rib (0.54%), and fusion of first and second ribs(0.27%). Cervical 7 costal anomalies showed a significant inclination towards females. No significant association with laterality and sidedness was observed for any of the anomalies. The study highlights a higher prevalence of an elongated transverse process of C7 compared to cervical rib and first rib anomalies in the reference population.

Sindrom Outlet Dada

Background: Thoracic Outlet Syndrome is one of the rarest diseases in the world with not a lot of information behind it. It is a collection of symptoms caused by compression in the neurovascular bundle exiting the Thoracic Outlet. The Thoracic Outlet is a structure under the neck between the first costae and the clavicle. Objective: To know more about Thoracic Outlet Syndrome comprehensively. Methods: Using literature studies from national and international journals by summarizing the topic of discussion and comparing the results presented in the article. Results: Thoracic Outlet Syndrome is a disease with various etiologies. The. The diagnosis of the disease is determined by the symptoms exhibited. Thoracic Outlet Syndrome can be divided into 3 types, which are Arterial Thoracic Outlet Syndrome, Venous Thoracic Outlet Syndrome, and Neurogenic Thoracic Outlet Syndrome. Physical rehabilitation and change in lifestyle remain the first-line treatment for this disease, with complications, surgery is recommended. Conclusion: There are many things still unknown to Thoracic Outlet Syndrome, early diagnosis is essential to diagnose the type of Thoracic Outlet Syndrome to determine the correct treatment for the type.

Safety of robotic first rib resection for thoracic outlet syndrome

ObjectivesRobotic first rib resection (R-FRR) is an emerging approach in the field of thoracic outlet syndrome (TOS) that has technical advantages over traditional open approaches, including superior exposure of the first rib and freedom from retracting neurovascular structures. We set out to define the safety of R-FRR and compare it with that of the conventional supraclavicular approach (SC-FRR). MethodsWe queried a prospectively maintained, single-surgeon, single-institution database for all FRR operations performed for neurogenic TOS and venous TOS. Preoperative, intraoperative, and complications were compared between approaches. ResultsSeventy-two R-FRRs and 51 SC-FRRs were performed in 66 and 50 patients, respectively. These groups were not significantly different in age, body mass index, sex, type of TOS, or preoperative use of opioids. Length of procedure and hospital stay were not different between groups. Postoperative inpatient self-reported pain (visual analog scale score 4.7 vs 5.2; P = .049) and administered morphine milligram equivalents (37.5 vs 81.1 MME, P < .001) were significantly lower in R-FRR than SC-FRR. Brachial plexus palsy was less frequent after R-FRR than SC-FRR (1% vs 18%, P = .002) and resolved by 4 months in call cases. All cases were sensory palsies with the exception of 2 motor palsies, which were both in the SC-FRR group. In multivariable analyses, R-FRR was independently associated with less frequent total complications than SC-FRR (P = .002; odds ratio, 0.08; 95% confidence interval, 0.02-0.39). ConclusionsR-FRR provides outstanding exposure of the first rib and eliminates retraction of the brachial plexus and its consequences.

Traditional medicine treatment for thoracic outlet syndrome: A protocol for systematic review of randomized controlled trials.

Background:Diagnosis of thoracic outlet syndrome (TOS) is challenging; however, proper evaluation and treatment ensure relief from symptoms in most patients. A comprehensive approach to treatment is important, considering the multifactorial etiology of TOS. The objective of this systematic review is to describe the methods for evaluating the effectiveness and safety of acupuncture-based traditional medicine treatments for TOS.Methods:A total of 13 databases will be searched, from their inception to the present date, for studies that have investigated the treatment of TOS. Databases that will be included are MEDLINE, Embase, AMED, Cochrane Library, CINAHL, and 4 Korean, 2 Chinese, and 2 Japanese databases.We will include randomized controlled trials (RCTs) assessing acupuncture-based traditional medicine for the treatment of any type of TOS. All RCTs on traditional medicine with any form of acupuncture will be eligible for inclusion. The methodologic quality of the RCTs will be analyzed using the Cochrane Collaboration tool to assess the risk of bias, and the confidence in the cumulative evidence will be assessed using the grading of recommendations assessment, development, and evaluation instrument.Ethics and dissemination:The results of this systematic review will be published in a peer-reviewed journal and disseminated both electronically and in print. The review will be updated to inform and guide health care practices.Trial registration number:PROSPERO 2020 CRD42020164869

Throwing can Increase the Stiffness of the Scalene Muscle

Objectives:Thoracic outlet syndrome (TOS) has been reported as a set of symptoms due to the compression of the brachial plexus and subclavian vessels in the region of the thoracic outlet1. As a type of TOS, scalenus anticus syndrome involves the compression of the brachial nerves as they pass through the interval surrounded by the anterior and middle scalene muscles, and the first rib bone or cervical rib2. Recently, exercise-induced TOS is becoming more common in athletes, especially for those who perform repetitive overhead and hyperabduction maneuvers with upper limbs, such as baseball players. However, the effect of throwing on the stiffness of the scalene muscles is unknown. Thus, the purpose of this study was to quantitatively measure the stiffness of the scalene muscles using real-time shear wave elastography (SWE). The stiffness of scalene muscles was hypothesized to increase for the throwing side of baseball players.Methods:Thirty college baseball players (age range 19 to 21 years) were included for this study. Ultrasonic SWE with a 2-10 MHz linear array probe transducer (Aixplorer; SuperSonic Imagine, Aix-en-Provence, France) was used to assess the stiffness of the anterior and middle scalene muscles. Each participant was sited. The measurements were performed in two arm positions; 1) adducted and neutral rotation of the shoulder 2)90 degree of abduction and external rotation of shoulder with elbow flexed to simulate a clinical examination known as Roos test3. In both of the arm positions, the transducer was positioned just superior to the clavicular bone, parallel to its axis. Transducer was moved superiorly and tilted to visualize the superior surfaces of the anterior and middle scalene muscles parallel to the surface of the fifth cervical nerve simultaneously (Figure 1A). In this position, shear wave elastography was performed to measure the elasticity of each scalene muscle as its stiffness. Each muscle was divided into superior and deep areas. In both areas of each muscle, three 3mm-diameter circles were set to measure the elasticities of the scalene muscles and its averaged data in each area was defined as each stiffness (Figure 1B). A repeated-measures analysis of variance (ANOVA) was used to compare the elasticity of superior and deep areas in anterior and middle scalene muscles in throwing and non-throwing side. Values of p<0.05 were considered statistically significant.Results:For the throwing side, higher stiffness was found in the deep part of the middle scalene muscle compared to the superior and deep parts of the anterior scalene muscle with an adducted and neutrally rotated shoulder (p=0.0433). Moreover, the muscle stiffness was significantly higher in the superior and deep part of the middle scalene muscle than in the superior and deep parts of anterior scalene muscle in an abducted and externally rotated position of shoulder (p =0.00187). Meanwhile, no significant difference was found in the anterior and middle scalene muscles for the non-throwing side in both arm positions.Conclusion:In professional athletes with TOS who experienced surgical treatment, moderate to severe hypertrophy of the anterior scalenus muscles has been reported to be found4. Meanwhile, although the stiffness of the scalene muscles can be also related to the compression on the brachial plexus and on subclavian vessels in the region of the thoracic outlet, its quantitative measurements in the scalene muscles has not been reported. In this study, at throwing side, the muscle stiffness significantly increased in the superior area of middle scalene muscle in throwing side. While no contribution was identified in the scalene muscles at non-throwing side. As a result, repeat throwing motion can increase the stiffness of the middle scalene muscle. As a result, the brachial plexus and/or the subclavian artery could be compressed at the interscalene triangle. Throwing athletes with TOS should be treated, considering the stiffness of the middle scalene muscle, even conservative or surgical treatment. Our study was the first study to evaluate the effects of throwing on the stiffness of the scalene muscles in throwing athletes. Repetitive throwing motion can affect the stiffness of middle scalene muscle. Reduction of the middle scalene muscle should be considered to treat throwing athlete who has TOS.Figure 1.

A case of symmetric retrograde thromboembolic cerebral infarction in an 8-year-old child due to arterial thoracic outlet syndrome

Arterial type of thoracic outlet syndrome belongs to the most unusual mechanisms of stroke in children in the first decade of life. We present a case diagnosed for bilateral and symmetric changes due to retrograde thromboembolic phenomenon. Regarding the age of the patient, the appropriate diagnostics and management are still a matter of debate in pediatric and neurological literature.

Cervical Rib Prevalence and its Association with Thoracic Outlet Syndrome: A Meta-Analysis of 141 Studies with Surgical Considerations

Cervical ribs (CR) are supernumerary ribs that arise from the seventh cervical vertebra. In the presence of CR, the boundaries of the interscalene triangle can be further constricted and result in neurovascular compression and thoracic outlet syndrome (TOS). The aim of our study was to provide a comprehensive evidence-based assessment of CR prevalence and their association with TOS as well as surgical approach to excision of CR and surgical patients' characteristics. A thorough search of major electronic databases was conducted to identify any relevant studies. Data on the prevalence, laterality, and side of CR were extracted from the eligible studies for both healthy individuals and patients with TOS. Data on the type of TOS and surgical approach to excision of CR were extracted as well. A total of 141 studies (n= 77,924 participants) were included into the meta-analysis. CR was significantly more prevalent in patients with TOS than in healthy individuals, with pooled prevalence estimates of 29.5% and 1.1%, respectively. More than half of the patients had unilateral CR in both the healthy and the TOS group. The analysis showed that 51.3% of the symptomatic patients with CR had vascular TOS, and 48.7% had neurogenic TOS. Most CR were surgically excised in women using a supraclavicular approach. CR ribs are frequent findings in patients with TOS. We recommended counseling asymptomatic patients with incidentally discovered CR on the symptoms of TOS, so that if symptoms develop, the patients can undergo prompt and appropriate workup and treatment.

Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a condition caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. The incidence of TOS is reported as 0.3 to 2% in the general population. There are three distinct types of TOS: neurogenic (95%), venous (4%), and arterial (1%). Treatment algorithms depend on the type of TOS. Arterial and venous TOS often present urgently with arterial or venous thrombosis, which is fairly easily identified by thorough history taking and a physical examination. Diagnosis is also aided by duplex ultrasonography. Restoration of arterial or venous flow can often be readily accomplished by thrombolysis. More important, however, is the diagnosis of the underlying structural component involved in the development of symptoms. Although statistically the most common, neurogenic TOS is often the most difficult to diagnose and treat. There are good data indicating that appropriately selected patients benefit from surgical therapy for neurogenic TOS as well. To prevent recurrence of symptoms, patients must undergo first rib resection and anterior scalenectomy, as well as resection of any rudimentary or cervical ribs. Regardless of the type of TOS encountered, proper therapy requires a thorough diagnostic evaluation and multimodal treatment. Keywords: thoracic outlet syndrome, arterial thoracic outlet syndrome, neurogenic thoracic outlet syndrome, venous thoracic outlet syndrome, TOS, effort thrombosis, thoracic outlet decompression

A New Anatomical Variation in the Brachial Plexus Roots and its Implications for Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (TOS), compression of proximal portions of the brachial plexus as they course through the superior thoracic outlet, is the most common type of TOS, and often results in pain, paresthesia, and paresis in the upper extremity. Typically impingement occurs as the neurovasculature passes between the anterior and middle scalene muscles, and this classic relationship is the foundation for clinical diagnosis. Positional testing, such as Adson's test, relies on vascular compromise of the subclavian artery in this space. Here we report an anatomical variant in which the superior trunk of the brachial plexus pierces the anterior scalene, while the subclavian artery travels without entrapment. Thirty cadavers at Midwestern University were assessed to determine the frequency of this variant. Twelve variations from classic anatomy were observed. In 10 (33.3%), the superior trunk pierced the anterior scalene muscle, and in one, the middle trunk also pierced the muscle belly. All cases occurred unilaterally, and almost exclusively on the left side. The high frequency of this variation and its potential to predispose patients to neurogenic TOS by compressing the superior and/or middle trunk suggests that current diagnostic methods may be insufficient to identify those who suffer from TOS symptoms. Due to a lack of vascular compromise, patients with this variant would likely not display a positive Adson's sign. Ultrasound may be used to determine whether this variation is present in patients who suffer from TOS symptoms but are without a diagnosis based on traditional positional testing.

Robotic First Rib Resection

Thoracic outlet syndrome is a complex disease, presenting with multiple symptoms arising from a possible combination of subclavian vein, subclavian artery, or brachial plexus compression. Multiple techniques have been used for first rib resection, some of which are no longer used. Current common techniques use a supraclavicular, transaxillary, or infraclavicular approach, each of which has its limitations. Minimally invasive transthoracic approaches have been slow to gain popularity owing to limitations in current video-assisted thoracoscopic surgery instrumentation and technology. We describe a minimally invasive and successful transthoracic approach utilizing the da Vinci robotic system with excellent results and minimal morbidity. The described approach incorporates first rib resection and division of the scalene muscles with removal of the rib in a nonpiecemeal fashion, with clear visualization of the entire rib and the need for minimal dissection around the subclavian vessels and brachial plexus.

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.

Thoracic Outlet Syndrome—Postural Type: Ultrasound Imaging of Pectoralis Minor and Brachial Plexus Abnormalities

Thoracic outlet syndrome (TOS) is a controversial diagnosis that sometimes is referred to as disputed or nonspecific neurogenic TOS because diagnostic test results typically are negative or inconclusive [1-10]. A review of the pathomechanics and associated dysfuncional body habitus suggests that use of the term “postural TOS” is more appropriate for this ommon type of presentation [10]. Postural TOS is thus recommended in cases without bjectifiable neurologic or vascular abnormality. In contrast, the less-common type of TOS nvolves compromise of the neurovascular bundle (NVB), which includes the brachial lexus (BP), the axillary or subclavian artery, and the axillary or subclavian vein [1-8,10]. Compression in all types of TOS may occur superiorly at the interscalene space, the costoclavicular space, or beneath the pectoralis minor muscle (PMM). The PMM location is recognized as a common and important site of compression in both the postural and nonpostural types of TOS [1-3,9-13]. The findings on an electrodiagnostic examination (EDX) typically are normal in patients with postural TOS because there is no axonal damage and no significant conduction block or demyelination [1,8,10]. Results of blood-flow studies usually are normal as well, and although they may reveal mild vascular compromise during stress maneuvers [1,2], this finding may not be clinically significant because it also can be seen in asymptomatic persons [1,7-9]. In addition, it is important to consider differential diagnoses and rule out the following conditions: cervical radiculopathy, peripheral nerve entrapment (median or ulnar), peripheral polyneuropathy, cervical cord lesion, or superior sulcus (Pancoast) tumor. The EDX may reveal the first 3 categories, but cervical magnetic resonance imaging (MRI) and a chest radiograph will be needed if the other conditions are considered. Neuromuscular ultrasound (NMUS) is a new imaging modality for examining nerve structures within the thoracic outlet area [14,15]. NMUS has unique applications for the postural type of TOS; as some researchers have noted, “evaluation of proximal nerves is often problematic when using electrodiagnostic techniques and may be more easily studied with ultrasound” [16]. My experience with this type of postural TOS [1,2,9,12,17,18] suggests that the PMM is contributory, and NMUS now appears to support these prior clinical impressions. Palpation of increased tension and trigger points in the PMM, combined with shoulder protraction, suggests that the PMM has shortened. The hypothesis herein is that the effects of a tight PMM can be observed to affect the NVB and explain the symptoms. The goal of this article is to present and analyze imaging findings in patients with TOS who were examined with NMUS while in neutral and stress positions, while monitoring for symptoms.

Current management of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a condition caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. There are three distinct types of TOS: neurogenic (95%), venous (4%-5%), and arterial (1%). Treatment algorithms depend on the type of TOS. Although statistically the most common type, neurogenic TOS can often be the most difficult to diagnose and treat. We have good follow-up data indicating that appropriately selected patients benefit from surgical intervention. Arterial and venous TOS often present more urgently with arterial or venous thrombosis. The thrombosis is typically recognized expeditiously by thorough history taking and physical examination, augmented by duplex ultrasonography. The restoration of blood flow, be it venous or arterial, often can be accomplished readily by thrombolysis. The key, however, comes in diagnosing the underlying structural component involved in the development of symptoms. To prevent recurrence, patients must undergo first rib resection and anterior scalenectomy, as well as resection of any rudimentary or cervical ribs. In the case of arterial TOS, the subclavian artery often requires reconstruction as well. Regardless of the type of TOS encountered, proper treatment requires a multidisciplinary approach.

Vascular thoracic outlet syndrome

In the methods section of the article on vascular thoracic outlet syndrome (TOS) by Geven et al. [1], the authors point out that their indication for the diagnosis of ‘vascular TOS’ was an abnormal PPG study indicating signs of vascular compression of the subclavian artery. I question the labeling of the patients described here as having ‘vascular’ TOS. As the authors point out in their opening paragraph, there are two types of vascular TOS, arterial and venous. Because these two types are totally different from each other, the terms arterial TOS and venous TOS should be employed and the term ‘vascular’ eliminated. Venous TOS is manifested by symptoms of swelling and cyanosis, while arterial TOS by symptoms of ischemic fingers and arm claudication. Neurogenic TOS is identified by symptoms of paresthesia, weakness, and pain, not only in the upper extremity, but usually in the neck as well. Further, arterial TOS is almost always associated with a cervical rib or anomalous first rib. The symptoms of arterial TOS are usually the result of emboli from subclavian artery thrombosis, either from subclavian artery stenosis or subclavian artery aneurysm with mural thrombus. Only 6 of the 32 patients in this study had cervical ribs. Unfortunately, the authors fail to describe their patients’ symptoms which would help define the type of TOS they were treating. However, since all operations were transaxillary rib resections and none were arterial repairs, it can be assumed that none of these patients had arterial TOS and probably the large majority, if not all, of the patients had neurogenic TOS. Confusion regarding the differentiation between arterial and neurogenic TOS is common because many patients with neurogenic TOS have symptoms of coldness and color changes in their hands along with their other symptoms. These symptoms do not establish a diagnosis of arterial or vascular TOS. They are the result arteriolar vasoconstriction brought on by sympathetic nerve stimulation from compression of the sympathetic nerve fibers that accompany the C7 and C8 nerve roots [2]. Thus, these symptoms are those of neurogenic TOS

Thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. We provide a review of this difficult-to-treat disorder, including a brief overview, clinical presentations, surgical anatomy, treatment options, and outcomes. TOS represents a spectrum of disorders encompassing three related syndromes: compression of the brachial plexus (neurogenic TOS), compression of the subclavian artery or vein (vascular TOS), and the nonspecific or disputed type of TOS. Neurovascular compression may be observed most commonly in the interscalene triangle, but it also has been described in the costoclavicular space and in the subcoracoid space. Patients present with symptoms and signs of arterial insufficiency, venous obstruction, painless wasting of intrinsic hand muscles, paresthesia, and pain. A careful and detailed medical history and physical examination are the most important diagnostic tools for proper identification of TOS. Electromyography, nerve conduction studies, and imaging of the cervical spine and the chest also can provide helpful information regarding diagnosis. Clinical management usually starts with conservative treatment including exercise programs and physical therapy; when these therapies fail, patients are considered for surgery. Two of the most commonly used surgical approaches are the supraclavicular exposure and the transaxillary approach with first rib resection. On occasion, these approaches may be combined or, alternatively, posterior subscapular exposure may be used in selected patients. TOS is perhaps the most difficult entrapment neuropathy encountered by neurosurgeons. Surgical intervention is indicated for vascular and true neurogenic TOS and for some patients with the common or nonspecific type of TOS in whom nonoperative therapies fail. With careful patient selection, operative intervention usually yields satisfactory results.