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Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

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Thoracic Outlet Syndrome

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  1. Thoracic Outlet Syndrome Prof . T. Vidyasagaran HOD, Dept of Vascular Surgery Vascular Surgeon, Chennai.

  2. TOS Definition Upper extremity symptoms due to compression of the neuro vascular bundle in the Thoracic Outlet Area

  3. TOS 95 %Neurogenic 1 % Arterial 2 - 4 % Venous Vasculogenic

  4. TOS

  5. TOS Three Spaces Scalene Triangle Costoclavicular space Pectoralis minor space

  6. TOS

  7. Neurogenic TOS Neurogenic TOS Predisposing Anatomic Factors • Bony Congenital narrowing - Cervical 4.5 % Rudimentary rib Long C7 transverse process Acquired narrowing - Malunion Callus Exostosis or tumors

  8. TOS Scalene Muscle • Neck trauma - Primary cause • Anatomy of muscle - Predisposing factor for nerve compression • Splitting of SA • Scalene minimus • Interdigitation • Middle scalene 58 % SM SA SM SA V V BP A BP A Rib 0.3 - 2 cms Rib

  9. Neurogenic TOS Neck Trauma • Automobile accidents Hyperextension neck injuries • Repetitive stress injuries Keyboard Jobs • Arm • Neck stretching

  10. Neurogenic TOS Symptoms Young 20 - 45 years 70 % Women Paresthesia All nerves Commonest Ulnar Lower chord Median Upper chord Pain Headaches occipital Scapular pain Trapezius Dorsal scapular nerve Rhomboids Weakness Vascular - sympathetic response

  11. Neurogenic TOS Clinical Diagnosis • Supraclavicular muscle tenderness • Tinel’s signs - specific signs • AER - EAST • Decreased sensation to light touch • Adson’s 50 % normal individuals 30 % of TOS Positional Maneuvers Pulse deficit

  12. Neurogenic TOS Diagnostic Tests • Scalene muscle block 4 ml 1 % lignocaine • ASM - Tender area cephalad • 94 % - with surgical decompression 2 cms above clavical 3 cms lateral to the midline

  13. Neurogenic TOS • X ray chest (upper thoracic) • X Ray neck - AP - oblique cervical spine • MRI

  14. Neurogenic TOS DD Neurological diseases • Spinal cord tumor • Multiple sclerosis Shoulder disorders • Shoulder tendinitis • Myositis Nerve compression syndrome • Carpal tunnel guyen tunnel • Cuboid tunnel epicondylitis Cervical spine pathology • Cervical spine injury • Disc herniation • Spinal stenosis Sympathetic diseases • Raynaud’s • Reflex sympathetic dystrophy

  15. Neurogenic TOS Treatment Non operative modalities • Neck stretching • Abdominal breathing • Posture exercise • Shoulder shrugs • Lifting light weight • Neck traction Ineffective Strengthening Exercise Worsens

  16. Neurogenic TOS Surgery • Failure of Conservative • Disabling symptoms Work Recreation Daily living • Symptoms more than a year

  17. Neurogenic TOS Principles Decompression of brachial plexus Rib excision Scalenectomy

  18. Neurogenic TOS Complications Nerve Injuries Bleeding Lymph leakage Less than 1 %

  19. Arterial TOS • Post stenotic dilatation • Aneurysmal dilatation • Thromboembolic complications

  20. Arterial TOS Pathophysiology Significant Permanent Long standing • Congenital or acquired bony abnormality • 10 years older than neurogenic TOS

  21. Arterial TOS Diagnostic • History • Examination - Pulsatile SC mass - bruit • Radiological - Cervical spine - Upper thoracic • Duplex • Arteriography DSA Dynamic views • Helical CT MRA • Surgical exploration

  22. Arterial TOS Management Principles Surgery • Compression • Subclavian axillary artery lesions • Distal tree status

  23. Arterial TOS Reconstruction • PSD with no intramural thrombosis - No intervention • Tailoring subclavian artery • Intimectomy with tailoring subclavian artery • Vein patch closure • Resection Primary repair Graft interposition

  24. Arterial TOS Distal Embolism • Multiple & diffuse • Various ages • Recent - Thromboembolectomy • Old - Bypass • Distal tree choked - Dorsal sympathectomy

  25. Venous TOS Subclavian Axillary Vein Thrombosis Paget Schroetter Syndrome Primary Subclavian Axillary Thrombosis

  26. Venous TOS Incidence • 1.4 % of all DVT • 25 % of all upper DVT

  27. Venous TOS Clinical Presentation • Young males 2 : 1 • Age 30 years • Strenuous exercise - 75 % • Dominant extremity 60 - 80 % • Associated neurogenic 4 - 10 %

  28. Venous TOS Diagnosis • Clinical swelling • Venous engorgement • Sudden onset • Duplex • Venography • MRV • Radionuclide venography

  29. Venous TOS Treatment • Rest & Elevation • Systemic anticoagulation  Long Term Morbidity

  30. Venous TOS Restore luminal patency Remove extrinsic compression Intrinsic stenosis

  31. Venous TOS Thrombectomy - with decompression Thrombolytic

  32. Venous TOS Thrombolytic • Systemic • Catheter directed - Venographic evaluation possible - Assess extrinsic compression immediately - Oral anticoagulation 3 months / 1 month - Decompression - Balloon angioplasty & stenting

  33. Presentation Venous TOS Algorithm Duplex confirm Appropriate candidate Venography Complete lysis Positional venography CD Thrombolysis Incomplete lysis Intrinsic stenosis EC No EC TOD + Vein patch angioplasty or balloon angioplasty stent TOD Anticoagulation