Thoracic Outlet Syndrome

• Thoracic outlet syndrome (TOS) is “upper extremity symptoms due

to compression of the neurovascular bundle in the area of the neck
just above the first rib”. (Ebraheim,2016)
• TOS is a diagnosis of exclusion based on the patient history and
symptoms. This can cause pain in the shoulders, neck and numbness
in the fingers as the arm is moved. (Sanders, 2012)
• It is a neurovascular compression neuropathy of the brachial plexus in
the thoracic outlet in the retroclavicular region with either a
neurogenic or vascular etiology. (Ebraheim,2016)
• Compression is thought to occur at one or more of the three
anatomical compartments: the interscalene triangle, the
costoclavicular space and the retropectoralis minor spaces. The
clinical presentation can include both neurogenic and vascular
symptoms. (Sanders, 2012)
• The most common causes:
- Structures may be compressed in the thoracic outlet by the cervical rib
- Anomalies of the scalenus muscles
The thoracic outlet space is created by:
•Clavicle
•First rib
•Subclavius muscle
•Costoclavicular ligament
•Anterior scalene muscle

-This space also contains the subclavian vessels and the thoracic
duct. It also contains the lower trunk of the brachial plexus (C8, T1).
Epidemiolody
• 1-2% of the population.
• Woman > Men ratio of 3:1
• due to poor muscular development and poor posture
• 20 and 60 years old
• 35 years old and younger for Vascular TOS
• Neurogenic TOS incidence is the most common (94-97%), the less common is
venous (approximately 5%), while arterial TOS is the least common (less than
1%)
• common in athletes who participates in sports that require repetetive motions
of the arm and shoulder
• baseball, swimming, volleyball, etc.
 Types of TOS

• Neurogenic
• Venous
• Arterial
Neurogenic TOS (NTOS)
is the most common type. It involves compression of the brachial
plexus trunks or cords, comprised of nerves that come from the C5-T1
spinal levels. The clinical picture is one of nerve irritation. Individuals
with this syndrome often experience pain, paraesthesias and
numbness in the neck, shoulder, arm and hand. The paraesthesias are
most often reported in all 5 fingers but worse in the fourth and fifth
digits and medial forearm. These symptoms are made worse by
elevated, overhead, or outstretched positions of the arm. Individuals
will often have pain over the trapezius and the neck, occipital
headaches and may even experience anterior chest wall pain
Causes of compression:
•Cervical rib
•Elongated vertebral transverse process (C7)
•Anomalies of the scalene muscle insertions
•First rib malunion
•Abnormal fibrous band on or near the two scalenous muscles
•Repetitive shoulder movement
•Extreme arm positions
•Abnormal pectoralis minor muscle
•Weight lifting
•Rowing
•Swimming
Venous TOS (VTOS)
is rare and occurs when the subclavian vein is compressed,
usually between the first rib and clavicle (or collarbone), causing a
blood clot. It is also called "effort thrombosis" and Paget-Schroetter
disease. Many patients suddenly develop a swollen and discolored arm
(cyanotic), and immediate treatment is critical. Patients usually require
catheter-directed thrombolysis, anticoagulation, and then surgery to
decompress the thoracic outlet.
Arterial TOS (ATOS)
is extremely rare and occurs when the subclavian artery is
compressed, usually near a cervical rib or anomalous first rib. This
compression may lead to an aneurysm (widening) of the artery and
formation of blood clots that can prevent blood flow to the arm and
hand. Patients may have sudden pain, weakness, numbness, and/or
tingling in their hands, and they almost always require surgery.
Venous and Arterial Entity
- Caused by a compressed subclavian vessel or by an aneurysm.

Where is the compression site?

•Where the brachial plexus passes over the first rib.
- Usually at site of scalene triangle
- The brachial plexus and subclavian artery pass through the triangle
(subclavian vein does not pass through the triangle)
•Under the clavicle by the subclavius tendon
•Underneath the conjoined tendon inserting into the coracoid process
DIAGNOSIS:
•Symptoms are usually vague
•Pain in the shoulder and neck that usually radiates to the forearm and hand
(paresthesia radiating along the arm)
•Loss of sensation of the little and ring fingers
•May be some vascular symptoms such as arterial ischemia, venous congestion,
Raynaud’s phenomenon (changing colors of the hands or chronically reduced pulse)
•Look for ulnar nerve sensory changes and intrinsic weakness
•Look to see if the patient has intolerance to cold (Raynaud’s phenomenon)
•Sometimes the pt will have a forward dropping posture
Differential Diagnosis:
•C8 radiculopathy or ulnar nerve compression at the elbow
- Combination of weakness involving the median and ulnar nerve
innervated muscles may confirm a more proximal injury to the brachial
plexus
•Rule out double crush syndrome with carpal tunnel syndrome and
thoracic outlet syndrome
- Compression of the medial antebrachial cutaneous nerve could
occur with compression of the thoracic outlet.
Provocative Tests:
Three Tests:
1. Adson's Test
2. Wright Test
3. Roo's Test

Note: Provocative Tests have a high rate of false positives and are of
limited clinical value if used alone.
•Adson’s Test
- Most commonly used test
- Abduct, extend and externally rotate the arm while feeling the radial
pulse
- Rotate the head towards the tested arm and may also extend the neck
- Decreased interscalene space by tensing of the middle and anterior
scalenus muscles
- This test is positive if the pulse disappears with reproduction of the
symptoms
- Radial pulse obstruction is not specific
Adson's Test or Maneuver
•Wright Test or Maneuver
Wright advocated “hyperabducting” the arm so that the hand is brought
over the head with the elbow and arm in the coronal plane with the shoulder
laterally rotated. He advocated doing the test in the sitting and then the supine
positions. Having the patient take a breath or rotating or extending the head and
neck may have an additional effect. The pulse is palpated for differences. This
test is used to detect compression in the costoclavicular space and is similar to
the costoclavicular syndrome test. Examiners have modified this test over time
so that it has come to be described as follows. The examiner flexes the patient’s
elbow to 90° while the shoulder is extended horizontally and rotated laterally .
The patient then rotates the head away from the test side. The examiner
palpates the radial pulse, which becomes absent (disappears) when the head is
rotated away from the test side. The test done in this fashion has also been
called the Allen maneuver. The pulse disappearance indicates a positive test
result for thoracic outlet syndrome.
 B.Modified Wright test or
A. Wright test maneuver (Allen maneuver)
•Roos Test (Elevated Arm Stress Test” or “EAST”)
- Elevated arm stress test
- Raise both arms up and hold this position for one minute
- Open and close the fingers for three minutes while holding them
overhead
- Test is positive if there is reproduction of pain and numbness of the
shoulders as well as fatigue
Roo's Test
Imaging
•Cervical spine may show a cervical rib
•An MRI may reveal congenital anomalies
•Chest x-ray may show a Pancoast tumor (apical lung tumor) that could
put pressure on the brachial plexus causing ulnar nerve symptoms
•EMG and Nerve Studies
- Results are usually not very helpful
•Vascular Studies
- May identify a vascular form or thoracic outlet syndrome
Treatment
•Physical therapy
- Strengthen the shoulder girdle muscles
- This is usually the first form of treatment
•Maintain proper posture
•Activity modification
•Correction of postural imbalances is needed
Medications:
Doctor may prescribe anti - inflammatory medications, pain
medications or muscle relaxant to decrease inflammation, reduce pain,
and encourage muscle relaxation.
Surgery
Decompression is indicated in cases of intractable pain, neurological
deficit, or persistent vascular insufficiency in addition to failure of nonoperative
treatment
Surgeries
• Resection of the first rib or cervical rib if present
- there is a 90% good - excellent result with transaxillary resection of the first rib
• Release or excise the anterior and middle scalene muscles
• Excision of any abnormal structures
• Surgery can be done through a transaxillary or supraclavicular approach
END.