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Thoracic outlet syndromeHighlights

SummaryOverview

Basics

Definition

Epidemiology

Aetiology

PathophysiologyClassification

Prevention

Primary

Secondary

Diagnosis

History & examination

Tests

Differential

Step-by-step

Guidelines

Case history

TreatmentDetails

Step-by-step

Guidelines
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History & exam

Key factors hx of cardiovascular or thoracic surgery

hx of repetitive jobs or hobbies pain in neck, head, shoulder, arm, and/or hand paraesthesias in arms, hands, and/or fingers subcutaneous venous collateral around shoulders

(Urschel's sign) motor weakness
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excessively cold hand(s) excessively sweaty hand(s) absent pulse with positional arm change

positive Adson's (scalene) test positive costoclavicular test positive hyperabduction test positive Roos test positive stretch test positive upper limb tension tests

Other diagnostic factors swollen, blue or purple arms, hands, and/or

fingersHistory & exam details

Diagnostic tests

1st tests to order cervical spine x-ray CXR nerve conduction velocity EMG

Tests to consider Doppler ultrasound of subclavian blood vessels subclavian vein venogram
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subclavian artery arteriogramDiagnostic tests details

Treatment details

Acute

isolated neurological compression

sensorimotor symptoms onlyo physiotherapyo first and/or cervical rib resection sympathetic symptoms sensorimotor

symptomso first and/or cervical rib resectiono concomitant dorsal sympathectomyo pharmacological interventions

isolated vascular compression

first and/or cervical rib resection with venous compressiono thrombolysis prior to rib resection with aneurysmo aneurysm excision with graft with arterial thrombosis and/or distal embolio thrombectomy + embolectomy + arterial

repair or replacement + dorsal sympathectomy
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combined neurological and vascularcompression

first and/or cervical rib resection

dorsal sympathectomy pharmacological therapy with venous compressiono thrombolysis prior to rib resection with aneurysmo aneurysm excision with graft with arterial thrombosis and/or distal embolio thrombectomy + embolectomy + arterial

repair or replacement

Ongoing

recurrence reoperation

Treatment details

Summary Compression of 1 or more of the neurovascular

structures traversing the superior aperture of the

chest. May affect neurological or vascular structures, or

both, depending on the component of theneurovascular bundle predominantly compressed.
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Patients may present with signs and symptoms ofnerve, venous, arterial, or sympathetic compressionor any combination thereof.

Primarily develops spontaneously in people aged20 to 40 years, most being women, due to eitherabnormal cervical anatomy or external compressingfactors.

For patients presenting with venous or arterialocclusion, prompt transaxillary resection isconsidered on evaluation of the patient's history and

physical examination. For patients with nerve compression, surgery is

considered only after failure of conservativemanagement and physiotherapy.

For uncomplicated, non-traumatic sympatheticcompression, usually first rib resection alone with

neurovascular decompression relieves thesymptoms. Dorsal sympathectomy is considered forthose patients with concomitant sympatheticsymptoms.

DefinitionThoracic outlet syndrome (TOS) refers tocompression of 1 or more of the neurovascularstructures traversing the superior aperture of thechest.[1] The thoracic outlet is the area between theneck and shoulder, over the top of the thorax, andunder the clavicle. Knowledge of the thoracic outlet
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anatomy and the 4 major areas of compression iscardinal for the physician to diagnose any type ofTOS.[2] [3]

Compression factors in the thoracic outlet with the signs

and symptoms producedRedesigned with colour and 3Daffects by Rachel Montano
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Bony circle consists of sternum in front, first rib laterally, andits attachment to vertebra posteriorlyReprinted withpermission from Elsevier


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CompressionReprinted with permission from Netter Images


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CompressionRe

printed with permission from Netter Images


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CompressionReprinted with permission from Netter Images

EpidemiologyTOS primarily develops spontaneously in people aged 20 to 40 years, mostbeing women, due to either abnormal cervical anatomy or externalcompressing factors (e.g., large breasts, poor posture, repetitive workconditions). It can also develop subsequent to trauma, in which case ithappens equally in both sexes and can happen at any age (e.g., in a car

accident).[11] [12][13] [14] [15]

AetiologyManifestations may be neurological or vascular, orboth, depending on the component of theneurovascular bundle predominantly compressed.

The diagnosis is suspected from the clinical pictureand is usually substantiated by determining the ulnarnerve conduction velocities. Many factors may causecompression of the neurovascular bundle at thethoracic outlet, but the basic factor is derangedanatomy, to which dynamic, static, congenital,
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traumatic, and occasionally atherosclerotic factorsmay contribute.[16]

Cross-section of neurovascular structures traversing thethoracic outlet with clavicle above and first rib

belowReprinted with permission from ElsevierBonyabnormalities are present in about 30% of thepatients, either as cervical rib, articulated or bifid first

rib, fusion of first and second ribs, claviculardeformities, or previous thoracoplasties.[17]
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Cervical rib on left is fused to first rib and elevates theneurovascular structures, decreasing the space andincreasing the compressionReprinted with permission from


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Elsevier Cervical rib abnormalitiesReprinted with permission from


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Netter ImagesCervical rib abnormalitiesReprinted with permission fromNetter Images


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Cervical rib abnormalitiesReprinted with permission fromNetter Images

Dynamic factors

There is an unusually wide latitude of motion inthe components of the shoulder joint. A moderatedegree of motion takes place at the sternoclaviculararticulation, this being one of the few universal jointsin the body. The acromioclavicular articulation lets


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the inferior angle of the scapula move laterally, about45, during elevation of the arm. Finally, thearticulation between the humerus and scapula allows

the widest range of motion of any joint in the body.These movements, involving changes in relativeposition of regional structures, may result incompression or impingement on vessels and/ornerves. For example, when the arm is in fullhyperabduction above the head, the axillary artery isbent 180 from its position when the arm is at the

side. This motion pulls the vessel across the coracoidprocess and head of the humerus, as across a pulley,causing arterial compression.

Static factors

Vigorous work or muscular exercise mayincrease muscular bulk, thereby reducing the spacethrough which the artery, vein, and nerves must pass.On the other hand, a reduction in muscle mass andtone may cause middle-aged sagging of localstructures. That this sagging is the more important

factor is indicated by the greater frequency of thesesyndromes in middle-adult life.


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Neurovascular structures pass behind pectoralis minor muscle,another major area of compression. Pectoralis minor is ashoulder protractor, which can overpower the rhomboids.The shoulder retracts and alters the thoracic outlet

contributing to muscular imbalance and compression of thebrachial plexusReprinted with permission from Elsevier

Congenital factors


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A cervical rib, a bifid clavicle, or a bonyprotuberance on the first rib may cause pressure onthe vessels or nerves when the arm is in certain

positions. Also there may be a fascial band behindthe scalenus anticus or an abnormal insertion of thescalenus medius on the first rib.

Scalene muscle triangle is the second major level ofcompressionReprinted with permission from Elsevier

Traumatic factors


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The most common traumatic causes of thesesyndromes are fractures of the clavicle andsubacromial dislocation of the humeral head.

Occasionally, a crushing injury of the upper thoraxmay unduly stretch parts of the brachial plexus and/orthrombose the artery or vein.

Arteriosclerotic factors

The degree of activity and effort that is welltolerated by a healthy, flexible artery may causethrombosis in a vessel that is narrowed and sclerotic.This situation has been observed in several people intheir 6th and 7th decades of life, whose shouldergirdles were anatomically normal for their age, butwhose arteries were hardened and relatively

inflexible.[18] This is a rare occurrence.

PathophysiologyThe anatomical relationships provide potential areasof pressure leading to neurovascular-vascularcompression syndrome. The subclavian artery leaves

the thorax by arching over the first rib behind thescalenus anticus muscle and in front of the scalenusmedius muscle. It then passes under the clavicle andfinally enters the axilla beneath the pectoralis minormuscle. The subclavian vein has an identical course,except that it passes anteriorly rather than posteriorly
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to the scalenus anticus muscle. The brachial plexusfollows the route of the subclavian artery, but it lies alittle more posteriorly and laterally.

The axillary-subclavian vein traverses the tunnelformed by the clavicle and subclavius muscleanteriorly, the scalenus anticus muscle laterally, thefirst rib posterior-inferiorly, and the costoclavicularligament medially.[5]Abnormalities of any of thesestructures, whether congenital, traumatic, or distorted

by unusual exercise or physical stress, may narrowthe tunnel anatomically. The most common defect isthe congenital insertion of the costoclavicularligament far laterally on the first rib.[7]
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Costoclavicular ligament inserts much farther laterally on the

first rib causing vein occlusionReprinted with permissionfrom Elsevier

Classification

Neurological compression

The symptoms of nerve compression most frequentlyobserved are pain, paraesthesias (numbness andtingling), and motor weakness. Pain andparaesthesias are segmental in 75% of cases, with90% involving the ulnar nerve distribution.[4] Theonset of pain is usually insidious and commonly


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involves the neck, shoulder, arm, and hand. The painand paraesthesias may be precipitated by strenuousphysical exercise or sustained physical effort with the

arm in abduction and the neck in hyperextension.Sympathetic nerves in the thoracic outlet may becompressed alone or in combination with peripheralnerves and blood vessels. The sympathetic nervesare intimately attached to the artery as well as beingadjacent to the bone. They may be compressed orirritated in primary or recurrent TOS.

Cone ofnerve roots (C5-T1) tracking inferiorly towards the thoracic


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outlet, joining each other as the brachial plexusReprintedwith permission from Elsevier

Vein compression

Paget-Schroetter syndrome, or 'effort' thrombosis ofthe axillary-subclavian vein, is most often secondaryto TOS.[5] It usually occurs in patients secondary toexcessive arm activity in the presence of 1 or morecompressive elements in the thoracic outlet.[6] It isone of the most frequently mismanaged syndromes;

the concentric constriction of the vein from externalcompression on venography is often misinterpretedby the interventional radiologist or cardiologist as astenotic lesion. This misdiagnosis leads to the veinbeing dilated with a pericutaneous venous balloonangioplasty (PVA) and, because it always recoils,

subsequent stent insertion. Many patients receivingsuch treatment for a compressive lesion occlude inthe short term, making further managementdifficult.[7] Vein bypass grafts fail because of lowvenous pressure.[8]


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Subclavian vein and artery pass over first rib and under

clavicle. Brachial plexus traverses top of bony circle to jointhe artery. Apex of the pleura (cupula) shown on leftsideReprinted with permission from Elsevier

Arterial compression

Aneurysm (with emboli) or occlusion of the arterymay occur. The diagnosis is suspected by the history,physical examination, and Doppler studies, and isconfirmed with arteriography.[1] [9]Treatmentdepends on its degree of involvement. Symptoms ofarterial compression include coldness, weakness,


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easy fatigability of the arm and hand, and pain that isusually diffuse.[10]

Primary prevention

Lifestyle should be modified to minimise compression and trauma to thethoracic outlet through the following methods:

Maintaining good posture

Optimising posture (including core stability)

Avoiding repetitive jobs, or taking frequent breaks(rotating activity) during repetitive jobs

Using ergonomic workstations.

Secondary preventionIn addition to optimising posture and work practices, patients can reducerecurrence by:

Core strengthening

Strengthening the shoulder girdle

Keeping open the space between the clavicle andfirst rib using physical manoeuvres and stretches


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Loosening the neck muscles (stretching thepectoralis)

Modifying behaviour (losing weight, correctingsleep positions).

MonitoringTOS can recur 1 month to 10 years after initial rib resection.[57] Patientsshould be advised to monitor for signs of compression of thoracic outletneurovascular structures.

Patient InstructionsPatients should be aware of the high risk of recurrence and contact theirphysician if they have any symptoms: aching or burning pain often associatedwith paraesthesia, involving the neck, shoulder, parascapular area, anteriorchest wall, arm, and hand. Patients should also adhere to any exercises asdirected by their physiotherapist.

Optimising and maintaining posture, avoiding repetitive working practices,losing weight, and correcting sleeping positions can reduce compression tothe thoracic outlet and so reduce the likelihood of recurrence.

Complications

Complicationhide all

Post-sympathectomy neuralgia

Pain typically appears in the shoulder and upper armhistory usually substantiates this if the symptoms ocTests show increased sympathetic activity and sugg


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the non-sympathectomised adjacent dermatomes. Rof nerve fibres or increased response of peripheral nSymptoms can be resolved in 3 to 6 weeks with con

PrognosisSymptoms may recur from 1 month to 10 years after initial rib resection. Inmost instances, recurrence is within the first 3 months.[57] Symptomsconsist of aching or burning pain often associated with paraesthesia,involving the neck, shoulder, parascapular area, anterior chest wall, arm, andhand. Vascular lesions are uncommon and consist of causalgia minor andinfected false aneurysms.

PhysiotherapyAll patients with symptoms of neurovascular compression after first ribresection should start physiotherapy. If symptoms persist and conductionvelocity remains below normal, reoperation is indicated.

ReoperationTwo distinct groups of patients require reoperation:

Pseudorecurrences happen in patients who neverhad relief of symptoms after the initial operation.Cases can be separated aetiologically as follows: 1)the second rib was mistakenly resected instead of thefirst, 2) the first rib was resected leaving a cervical

rib, 3) a cervical rib was resected leaving anabnormal first rib, or 4) a second rib was resectedleaving a rudimentary first rib[61]

The second group includes patients whosesymptoms were relieved after the initial operation but


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who developed recurrence because a significantpiece of the first rib was left in place at the initialoperation, and a small subgroup whose first rib was

completely resected but developed excessive scarformation involving the brachial plexus.[46]Reoperation for recurrent TOS is preferably performed through the posteriorthoracoplasty approach to provide better exposure of the nerve roots andbrachial plexus, thereby reducing the danger of injury to these structures, aswell as providing adequate exposure of the subclavian artery andvein.[58] This approach also provides a wider field for easy resection of anybony abnormalities or fibrous bands, and allows extensive neurolysis of thenerve roots and brachial plexus, which are not always accessible through the

limited exposure of the transaxillary approach. The anterior or supraclavicularapproach is inadequate for reoperation.

Case history #1A 30-year-old woman presents with pain in her neck,shoulder, arm, hand, chest, and somewhat down herback. She describes her pain as a dull aching,

bilateral, and greater on the right. She works as acomputer operator and first noticed symptoms about2 years ago. Along with the pain, she has developedsevere numbness in her right arm and hand, whichfrequently wakes her at night. She has a history ofhyperhidrosis since birth. She notices that she drops

things and has marked difficulty working over herhead. Common household tasks have become verydifficult for her (e.g., vacuuming, sweeping, mopping).Cold exacerbates her symptoms. Physicalexamination reveals 3+ supraclavicular tenderness


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on the right and 1+ on the left. She has a positiveAdson's sign on the right and a positive Roos test onthe right in 5 seconds. Her grip is 2 out of 5 on the

right, with a 1 out of 5 interossi on the right. Herconduction velocities across the right side are 40m/second and 55 m/second on the left, both wellbelow the normal of 85 m/second. She has had 2courses of physiotherapy without improvement of hersymptoms.

Case history #2A 23-year-old man presents with swelling and pain inhis left arm after exercising with upper extremity leverweights. Symptoms started 75 minutes after theexercises. The arm turned reddish, and he described

it as 'feeling different than it ever had before'. He hasRaynaud's phenomenon with marked cold sensitivityand writing increases his symptoms. Physicalexamination shows no supraclavicular tenderness.He has a venous collateral over his left shoulder. Hehas a 4+ bilateral Adson's sign and a 4+ Roos test on

the left with mild anterior deltoid pain in 5 seconds.His grip is 4 out of 5 bilaterally and his interossi are 4out of 5 bilaterally. A Doppler 2 days later wasunremarkable, but CT scan with contrastdemonstrated a clot in his left subclavian vein. Thediagnosis of Paget-Schroetter syndrome secondary


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to TOS was confirmed. He was given heparin and thevein was ballooned to relieve the clot. An angiogramafter this suggested the vein had opened. He was

started on enoxaparin for 2 weeks and switched towarfarin.

Differential diagnosis

Condition

Differentiating

signs/symptoms Differentiating

Carpal tunnel syndrome Pain and

numbnessprimarily inthe wrists;night-time

worsening ofsymptoms.

Electrodiain the med

Cubital tunnel

syndrome Pain and

numbness

primarily inthe elbowthrough thering and little

Electrodiathe elbow
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fingers.

Herniated cervicalintervertebral disc

Pain inupperextremities,specificallythe back,radiating

downthrough thebuttocks andlegs,possibly withmusclespasms.[39]

MRI cervic

Ruptured cervical disc Pain down

medialaspect of thearm.

MRI cerviccontents.

Cervical spondylosis Stiffness in

upper neck,loss ofbladder or

Cervical s


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bowelcontrol,urinary or

bowelretention.

Vascular occlusion,

embolism, or

insufficiency

Severe chestpain.

Angiogram

Coronary artery disease Chest pain. Coronary

vessel.

Myocardial infarction

Severe chestpain,dyspnoea,pallor,diaphoresis,andcardiogenic

shock.

ECG in STanatomicain non-STdepressio

Angina pectoris Chest ECG show
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pressure orsqueezingpromoted by

exercise oremotionalstress.

wave inve

Primary Raynaud's

phenomenon

Blue or

purple colourin hands orfingers.

Diagnosis

Superior pulmonary

sulcus carcinoma Severe chest

pain. CT chest d

Superior sulcus tumour Shoulderand elbowpain.[40]

CT chest d

History & examinationKey diagnostic factorshide allhx of cardiovascular or thoracicsurgery (common)
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Past surgical operations that could have causedcompression on the neurovascular structuresbetween the first rib and clavicle (e.g., median

sternotomy).hx of repetitive jobs or hobbies (common) For example: computer operators, beauticians,

linotype operators, mail sorters, card dealers,pump operators, athletes (particularly, football,baseball, and volleyball players, swimmers anddivers, weightlifters, gymnasts).

pain in neck, head, shoulder, arm, and/orhand (common)

Present in all TOS compression types.paraesthesias in arms, hands, and/orfingers (common)

Present primarily in nerve compression TOS.

subcutaneous venous collateral aroundshoulders (Urschel's sign) (common)

Present primarily in venous compression TOS.motor weakness (common)

Present primarily in arterial or nerve compressionTOS.

excessively cold hand(s) (common) Present primarily in arterial compression TOS

(Raynaud's phenomenon).excessively sweaty hand(s) (common)


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Present primarily in sympathetic compressionTOS.

absent pulse with positional arm

change (common) Present primarily in arterial compression TOS.

positive Adson's (scalene) test (common) Tightens the anterior and middle scalene

muscles, thus decreasing the interspace andmagnifying pre-existing compression of thesubclavian artery and brachial plexus. The patient

takes and holds a deep breath, extends the neckfully, and turns the head towards theside.[31] View image

Obliteration or decrease of the radial pulsesuggests compression.

positive costoclavicular test (common) Shoulders are drawn downwards and backwards.

This narrows the costoclavicular space byapproximating the clavicle to the first rib and thustends to compress the neurovascularbundle.[32] View image

Changes in radial pulse with production of

symptoms indicate compression.positive hyperabduction test (common) Hyperabducting the arm to 180 pulls the

components of the neurovascular bundle aroundthe pectoralis minor tendon, the coracoid
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process, and the head of the humerus.[32] Viewimage

If the radial pulse is decreased, compression

should be suspected.positive Roos test (common) Both arms are placed at right angles to the

shoulder, and the forearms are at right angles tothe upper arms. Both hands are opened andclosed as fast as possible to see if symptomsoccur.[33]

Test is given on physical examination todetermine what symptoms the patient isexperiencing with reference to their thoracicoutlet (e.g., arms start to hurt, hands becomenumb, hands change colour).

positive stretch test (common)

The arm is abducted 90 with elbow extension,palm facing forwards, and thumb pointing up tothe ceiling. The patient then laterally flexes thehead to the opposite side. This stretches theplexus.

A positive test is uncomfortable pulling of inner

arm sometimes into forearm or even into hand onabduction. The patient may developparaesthesias or heaviness of the extremity. Apositive test of lateral flex is exacerbation of thesymptoms.

positive upper limb tension tests (common)
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A series of tests of all tissues in the upper limbwith a preferential focus on the median nerve andits associated plexus and roots.[34] They involve

shoulder abduction, wrist suspension andextension, shoulder lateral rotation, elbowextension, and neck lateral flexion away ortowards test side.

Provides physical evidence of stretch of median,radial, and ulnar nerves. Allows side-to-sidecomparison and response compared with normal

extremity movement.

Other diagnostic factorshide allswollen, blue or purple arms, hands, and/orfingers (common)

Present primarily in venous compression TOS.

Risk factorshide all

Strong

cervical rib or bony abnormalities Abnormalities in bone structure, or the presence

of a cervical rib, can compress the neurovascularstructures between the first rib and clavicle.

trauma Skeletal anatomy or upper extremity shifting (as a

result of a traumatic incident or accident) cancreate a sudden onset of symptoms due to


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compression of the neurovascular structuresbetween the first rib and clavicle.

poor posture

Compression can occur as a result of poorposture, or hunching of the upper shoulders andback, due to the anatomy of the thoracic outletbending in such a way that the claviclecompresses the neurovascular structures on thefirst rib.

repetitive activity (shoulder-hand occupations,

athletes) Repetitive activity, including work conditions,

sports, or hobbies, cause the enlargement of thescalenus anticus (and other) muscle,compressing the neurovascular structures.

median sternotomy Operations consisting of opening of the sternum

too wide can result in TOS due to stretching ofthe neurovascular structures between the first riband clavicle.

large breasts or implants Compression can occur as a result of large

breasts, due to the weight on the shoulders,which pulls the clavicle down on theneurovascular structures.

obesity


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Compression can occur as a result of obesity,which narrows the space in the thoracic outlet.

pregnancy

Weight gain narrows the thoracic outlet space.age 20 to 40 yearsfemale genderhx of poliomyelitis

Weakening of the shoulder muscle lets theclavicle down to compress the neurovascularstructures in the thoracic outlet.

Diagnostic tests

1st tests to orderhide all

Test

cervical spine x-ray

These bony abnormalities are present in about 30%

CXR


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Bony abnormalities are present in about 30% of pati

nerve conduction velocity

Any value


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subclavian vein venogram

Contrast dye is injected in the vein to reveal presencthrombosis.

subclavian artery arteriogram

Dye and a camera are used to visualise the blood flo

Step-by-step diagnostic approachPatients may present with signs and symptoms of nerve, venous, arterial, orsympathetic compression, or any combination thereof. Physicians should beguided by the patient's symptomatology as to which route(s) to investigate.

History and examinationMany historical factors can predispose patients to compression of thethoracic outlet: cervical ribs or bony abnormalities, trauma, poor posture,

repetitive activity, a median sternotomy, having large breasts or breastimplants, obesity, pregnancy, and poliomyelitis.

Nerve compression

A careful history and physical examination arerequired for accurate diagnosis. Most frequently

observed symptoms for nerve compression are pain;paraesthesias in neck, head, shoulder, arm, andhand; and motor weakness. When patients aged over60 years have nerve compression symptoms, causessuch as degenerative or traumatic cervical spine, and


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cardiac or pulmonary pathologies should besuspected and considered in the differentialdiagnosis.[1]

There may be multiple points of compression ofthe peripheral nerves between the cervical spine andhand, in addition to the thoracic outlet.[19] In thesecases, less pressure is required at each site toproduce symptoms. For example, a patient may haveconcomitant TOS, ulnar nerve compression at theelbow, and carpal tunnel syndrome. This

phenomenon has been called 'multiple crush'syndrome.[20]

Multiple crush syndromesFrom the collection of Dr Harold C.Urschel JrSympathetic compression
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Symptoms include excessive cold or warm,sweaty upper extremities. Atypical chest pain cansimulate cardiac pain (pseudoangina).[21] Many

arterial compressions result in more severesymptoms because of the additive or synergisticsympathetic stimulation. Trauma is frequentlyassociated with sympathetic maintained painsyndrome or reflex sympathetic dystrophy.Sympathetic hyperactivity, also known as complexregional pain syndrome, may be a sympathetic

response to pain rather than overt compression of thesympathetic chain. In that circumstance, identificationand correction of the pain generator halts thesympathetic overactivity.Venous compression (Paget-Schroetter syndrome, effort thrombosis) Viewimage

Symptoms include pain and swelling in an armand/or hand, blue or purple colour of hands andarms, and increase in subcutaneous venouscollateral around the shoulders (Urschel's sign).

Thrombosis is caused by trauma or occupationsrequiring repetitive muscular activity (e.g.,

professional athletes, computer operators, painters,beauticians).[1] [22] The combination of coldenvironmental temperature and traumatic factors(such as carrying skis over the shoulder) tend toincrease the proclivity for thrombosis.[23] Elements
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occlusion of the vessels in different arm positionsseems redundant to an adequate clinical examinationin most cases. Arterial TOS is almost always

associated with a cervical rib. Diagnosis can be confirmed by history, physical

examination, Doppler studies, and arteriography.[30]

ManoeuvresThe Adson's (scalene), costoclavicular, hyperabduction, Roos, stretch, andupper limb tension tests are used to narrow identification of the nature of the

thoracic outlet compression.[31] [32][33] [34] Adson's (scalene) test: tightens the anterior and

middle scalene muscles, thus decreasing theinterspace and magnifying pre-existing compressionof the subclavian artery and brachial plexus. Thepatient takes and holds a deep breath, extends theneck fully, and turns the head towards the side. View

image Costoclavicular test: shoulders are drawn

downwards and backwards. This narrows thecostoclavicular space by approximating the clavicle tothe first rib and thus tends to compress theneurovascular bundle. View image

Hyperabduction test: hyperabducting the arm to180 pulls the components of the neurovascularbundle around the pectoralis minor tendon, thecoracoid process, and the head of the humerus. Viewimage
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Roos test: both arms are placed at right angles tothe shoulder, and the forearms are at right angles tothe upper arms. Both hands are opened and closed

as fast as possible to see if symptoms occur.

Stretch test: the arm is abducted 90 with elbowextension, palm facing forward, and thumb pointingup to the ceiling. The patient then laterally flexes thehead to the opposite side. This stretches the plexus.

Upper limb tension tests: a series of tests of alltissues in the upper limb with a preferential focus onthe median nerve and its associated plexus androots. They involve shoulder abduction, wristsuspension and extension, shoulder lateral rotation,elbow extension, and neck lateral flexion away or

towards test side.

ImagingBony abnormalities are present in about 30% of patients, either as cervicalrib, articulated or bifid first rib, fusion of first and second ribs, claviculardeformities, or previous thoracoplasties.[17]An initial cervical spine x-ray orCXR can reveal this and is the initial diagnostic test for all patients with TOS.

If subclavian blood vessel compression is suspected, a venogram,arteriogram, or Doppler ultrasound should be ordered depending on the likelyvascular structure affected, to demonstrate the obstruction or compression.

Nerve conduction studies


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All patients with nerve compression have nerve conduction studies. Motorconduction velocities of the ulnar, median, radial, and musculocutaneousnerves can be reliably measured. Improved and adapted to clinical use, thetechnique of measuring nerve conduction velocities can be used to evaluatepatients with thoracic outlet compression.[35] [36] [37] The patient is placed

on the examination table with the arm fully extended at the elbow and inabout 20 of abduction at the shoulder to facilitate stimulation over the courseof the ulnar nerve. The ulnar nerve is stimulated at the 4 points by a specialstimulation unit that imparts an electrical stimulus at all points to obtainmaximal response.[36]Any value less than 70 m/second indicatesneurovascular compression. View imageNeurophysiologists can add an additional reference point at the origin of theC8 nerve root, just above the posterior first rib, to record paraspinous muscleEMGs and take medial antebrachial cutaneous nerve measurements. They

can also obtain EMGs of the first dorsal interosseous muscle (the ulnarnerve) and abductor pollicis brevis (the median nerve). Interpreting areas ofabnormality can help identify the area(s) of compression. Electrodiagnosticstudies are not confirmatory, but are indicators of brachial plexusimpingement.[38]

EMG of other muscles can measure the electrical activity of muscles at restand during contraction. The test should be normal to eliminate otherneuromuscular disorders (e.g., carpal tunnel and cubital tunnel syndromes).

Treatment Options
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Patient group

Treatment line Treatmenthide all

isolatedneurologicalcompression

sensorimotorsymptomsonly

1st physiotherapy Initially, most patients,

except those withvascular and motor nerveproblems, are treatedconservatively withphysiotherapy.[36] [42] [43] Core strengtheningtherapies help to improveposture and realignmusculoskeletalstructures. Patients withnerve conduction velocity

>60 m/second areespecially likely tobenefit. The primarygoals of physiotherapyare to open up the spacebetween the clavicle and
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except those withvascularand motor nerveproblems, are treatedconservatively withphysiotherapy.[36] [42] [43] Core strengtheningtherapies help to improveposture and realignmusculoskeletalstructures. Patients withnerve conduction velocity

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except those withvascular and motornerveproblems, are treatedconservatively withphysiotherapy.[36] [42] [43] Core strengtheningtherapies help to improveposture and realignmusculoskeletalstructures. Patients withnerve conduction velocity

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Treatment approachFor patients with nerve compression TOS, surgery isconsidered only after failure of conservativemanagement and of physiotherapy. For patientspresenting with venous or arterial occlusion, prompttransaxillary resection is considered based on historyand physical examination.

Transaxillary first rib resection. (A) Division of scalenusanticus muscle (SA), (B) division of first rib and anteriorresection, (C) posterior resection of first rib, (D) resectionof head and neck of rib, (E) identification of dorsalsympathetic chain, (F) division through lower stellate

ganglion above T1 and below T3 ganglia. A: subclavianartery; BP: brachial plexus; SA: scalenus anticus muscle;SM: sternocleidomastoid muscle; V: subclavianveinReprinted with permission from Churchill-Livingstone

All patients are treated with a first and/or cervical ribresection if conservative management and


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physiotherapy are not effective.

SurgicalapproachesFrom the collection of DrHarold C. Urschel

JrArterial aneurysm or venous occlusion mayadditionally require a bypass graft.

Neurological compressionSensorimotor symptoms

Most patients, except those with vascular andmotor nerve problems, are initially treatedconservatively with physiotherapy.[36] [42] [43] Corestrengthening therapies help to improve posture andrealign musculoskeletal structures. Patients withnerve conduction velocities 60 m/second or more areespecially likely to benefit from this approach.Physiotherapy is used to open up the space betweenthe clavicle and first rib, improve posture, strengthenthe shoulder girdle, and loosen the neck

muscles.[1] This is accomplished by pectoralisstretching, strengthening the muscles between theshoulder blades, good posture advice, and activeneck exercises (including chin tuck, flexion, rotation,lateral bending, circumduction).[43]
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