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Thoracic Outlet Syndrome

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Topic updated on 09/04/13 6:44pm
Introduction
  • A neurovascular compressive neuropathy with either a neurogenic or vascular etiology
  • Epidemiology
    • demographics
      • occurs in females > males
  • Pathophysiology
    • neurogenic
      • caused by compression of neurovascular bundle as it passes over the first rib or through the scalene muscle 
      • causes include
        • scalene muscle abnormalities
        • scapular ptosis
        • clavicle and first rib malunion
        • cervical rib 
        • vertebral transverse process
      • causes in athletes
        • fibromuscular bands
        • abnormal pectoralis minor
        • repetitive shoulder use
        • extreme arm positions
        • weightlifting, rowing, swimming
    • vascular
      • caused by compressed subclavian vessel or aneurysm 
      • may lead to emboli in the hands
  • Associated conditions
    • Paget-Schroetter syndrome
      • thoracic outlet syndrome with compression of subclavian vein in the developed athlete due to scalene muscle hypertrophy
Presentation
  • Symptoms
    • vascular
      • arterial ischemia
      • Raynaud's phenomenon
      • venous congestion
      • cold intolerance 
    • neurologic
      • pain and swelling of upper extremities
      • ulnar nerve paresthesias
        • differentiated from more distal compression neuropathies due to sensory differences in medial brachial and antebrachial cutaneous nerves
  • Physical exam
    • provocative tests (variable reliability)
      • Wright
        • abduction and external rotation with the neck rotated away leads to loss of pulse and reproduction of symptoms 
      • Adson
        • extension of the arm with the neck extended and turned towards the affected side may result in loss of radial pulse or reproduction of symptoms with inhaling 
      • Roos
        • hands repeatedly opened and closed while holding them overhead for 1 minute can reproduce symptoms 
Imaging
  • Radiographs
    • recommended views
      • c-spine x-ray to rule out cervical rib
      • chest x-ray to rule out Pancoast tumor
  • Angiography
    • if etiology is vascular will show subclavian vessel disease or aneurysm
Studies
  • EMG and NCV
    • studies usually equivocal
Treatment
  • Nonoperative
    • physical therapy and activity modifications
      • indications
        • first line of treatment
      • technique
        • shoulder girdle strengthening, proper posture, and relaxation techniques
  • Operative
    • neurologic decompression 
      • indications
        • neurogenic etiology
        • nonoperative modalities have failed
        • progressive and severe neurologic deficits and pain
      • technique
        • address site of compression
          • repair clavicle malunion
          • transaxillary first rib resection (90% good to excellent results)
          • scalene takedown
          • pectoralis minor tenotomy
          • release of fibromuscular anomalous bands
    • vascular reconstruction (open or interventionally)
      • indications
        • subclavian aneurysm present
        • persistent insufficient vascularity
Complications
  • Emboli to the hands
    • treat with acute heparinization, embolectomy (or TPA if vessels too small), 7-10 days of heparin, followed by three months of warfarin

 

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Qbank (1 Questions)

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(OBQ06.247) A 35-year-old businessman complains of tingling and numbness in his fingers of both hands, mostly in the ring and small fingers, made worse with overhead activity. Neurologic exam and electromyography-nerve conduction study is normal. His cervical spine x-ray is shown in figure A. What is the most likely diagnosis? Topic Review Topic
FIGURES: A          

1. C5-6 cervical disk herniation
2. C6-7 cervical disk herniation
3. Bilateral cubital tunnel syndrome
4. Bilateral radial tunnel syndrome
5. Thoracic outlet syndrome

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