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Surgical Treatment of Thoracic Outlet Syndrome

Surgical Treatment of Thoracic Outlet Syndrome

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Surgical Treatment of Thoracic Outlet Syndrome

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  1. Surgical Treatment of Thoracic Outlet Syndrome Mary Meek, M.D. University of Arkansas for Medical Sciences

  2. Learning Objectives • Identify pertinent normal and abnormal anatomy related to the thoracic outlet • Understand the commonly used surgical techniques • Identify the accepted surgical indications • Discuss the controversies surrounding TOS surgery

  3. Overview • Normal anatomy • Abnormal anatomy • History of surgical procedures • Common surgical procedures • Accepted indications • Controversies

  4. Normal thoracic outlet • Interscalene triangle • Costoclavicular triangle • Subcoracoid Space

  5. Interscalene Triangle • Brachial plexus and subclavian artery pass posterior to anterior scalene • Subclavian vein passes anteriorly to anterior scalene • Common area of compression

  6. CostoclavicularTriange • Middle 1/3 of clavicle

  7. Subcoracoid Space • Under coracoid process deep to pectoralis minor

  8. Muscular and fibrous causes of compression • Anterior Scalene • Middle Scalene • Pectoralis Minor • Costocoracoid ligament • Costoclavicular membrane • Subclavius muscle

  9. Bony Abnormalities • 1st rib • Cervical rib • Long transverse process • Abnormal clavicle

  10. History • 1742 Hunauld identified cervical rib as a cause of TOS • 1861 Coote performed the first cervical rib resection • 1916 Murphy published results of 1st rib resection

  11. Common Surgical Procedures • Transaxillary approach • Anterior approach (Supra or Infraclavicular) • Posterior approach

  12. Transaxillary approach • Preferred for neurogenic and venous TOS • Roos 1966 : 15 patients, anterior & middle scalene, rib, sympathectomy • “Advantage”: scar, no muscle splitting, complete rib visualization, proximal vessel control

  13. Anterior approach • Preferred for arterial lesions • Preferred by some other surgeons (Eidt, personal communication)

  14. Posterior approach • Primary for lower root decompression • Common for re-operation in particular to remove rib stump when initial resection is “incomplete”

  15. Accepted indications for surgery • Definite anatomic abnormalities • Cervical rib • Abnormal insertion of costoclavicular ligament (common in Paget-Schroetter) • Vascular issues • Arterial aneurysms, embolic phenomenon • Paget-Schroetter • Nerve Conduction Velocity (NCV) < 60m/s

  16. Controversies • Neurological symptoms • Surgeons diagnose TOS 100x more than neurologists • NCV between 60-85 m/s • Traumatic causes • Re-operation • “softer” abnormalities • Anterior Scalene spasm • Raynaud’s phenomenon

  17. Summary • Definite anatomic abnormalities that can be cured by surgical resection • Common approaches are transaxillary and anterior (supraclavicular/infraclavicular) • “A chance to cut is a chance to cure” • Radiologist can be helpful with diagnosis (MRI, venography, sympathetic block) and therapy (thrombolysis)