THORACIC OUTLET SYNDROME : ANATOMY, SYMPTOMS, DIAGNOSTIC

EVALUATION AND SURGICAL TREATMENT

Prof., Dr. Scs. Povilas Pauliukas

The thoracic outlet is called the space through which the neurovascular bundle: subclavian vein, subclavian artery

and brachial plexus (nerves) are passing from the neck to the armpit. This space must be sufficiently broad to allow

freely pass all the brachial plexus nerves, subclavian artery and subclavian vein through it. If the thoracic outlet is

too narrow, the nerves, artery and vein are compressed in it and corresponding problems and symptoms develop. A

complex of emerging problems and symptoms in such case is called the thoracic outlet syndrome (TOS).

The main anatomic structures limiting the thoracic outlet space are: the clavicle, the first rib (space between

these two bony structures is called in latin the costoclavicular space), the subclavius muscle, situated in the

costoclavicular space, the anterior and posterior scalene muscles. Very seldom a neurovascular bundle can be

compressed in the armpit in the athletes due to the hypertrophied abnormal pectoralis minor muscle.

Figure 1 illustrates the anatomic structures, limiting the thoracic outlet. The subclavius muscle is not shown in

this picture to allow better visualization of the neurovascular bundle, passing the thoracic outlet (subclavius muscle

will be shown in the following pictures). Figure 1

Figure 2 illustrates the thoracic outlet anatomical structures in detail.

Figure 2

Figure 1: Anatomy of the thoracic outlet

This picture is only a schematic drawing of the thoracic outlet

anatomy. The subclavius muscle and vertebral artery are not

shown in this picture. These anatomical structures will be

shown in the following pictures. The brachial plexus nerve

roots and the subclavian artery are passing through the gap

between the anterior and medius scalene muscles (cervical

outlet). The subclavian vein passes in front of the scalene

muscles and they can not compress it. All three neurovascular

structures: subclavian vein, subclavian artery and brachial

nerve plexus can be compressed between the clavicle and the

first rib. The subclavius muscle and the lower part of anterior

scalenus muscle (inserting to the first rib) are situated in the

costoclavicular space and they additionally reduce this space.

Some authors attribute to the thoracic outlet syndrome

compression of the neurovascular bundle between the

pectoralis minor muscle and chest wall. This situation in

clinical practice is encountered rarely.

Figure 2: Anatomy of the thoracic outlet

The subclavius muscle is shown in this picture. It

originates from the first rib in the medial corner

of the costoclavicular space and inserts to the

lateral (shoulder) part of the clavicle. It reduces

the space between the clavicle and the first rib.

The subclavian vein is situated in the medial,

most narrow corner of the costoclavicular space

and it is compressed against the first rib by the

subclavius muscle and the clavicle. The anterior

scalenus muscle can not compress the

subclavian vein, because the vein passes in front

of it. The anterior scalenus muscle can compress

the subclavian artery, the vertebral artery and

the brachial nerve plexus roots.

All three scalene muscles are depicted in figure 3.

Figure 3

When the gap between the anterior and medius scalene muscles (spatium interscalenum) is too narrow or absent for

passing of the subclavian artery and brachial plexus, they are compressed by these two muscles, especially when the

muscles contract and squeeze the nerves and arteries. The vertebral artery does not pass the gap between the scalene

muscles (spatium interscalenum), but it is situated very close to the anterior scalenus muscle and in cases of brachial

nerve plexus compression with the abnormal scalene muscle, abnormally inserting to the vertebral column or to the

first rib, it is compressed by this muscle together with the brachial plexus. That’s, why many patients with symptoms

of brachial nerve plexus roots compression (neurogenic thoracic outlet syndrome) have symptoms of vertebrobasilar

insufficiency (insufficiency of blood flow in vertebrobasilar region of the brain, supplied with the blood by vertebral

arteries). When the vertebral artery is compressed by the scalenus anterior muscle against the vertebral column, it is

compressed at the entrance into the cervical outlet (spatium interscalenum) and it is wise to attribute such

compression of vertebral arteries to the cervical outlet syndrome, especially due to the fact, that scalenectomy cures

both problems at once: the neurogenic symptoms and symptoms of vertebrobasilar insufficiency.

Normally, the vertebral artery enters its bony vertebral canal (canalis transversarius) at the sixth cervical

vertebra. The anterior scalenus and longus colli muscles attach to the transverse process of the sixth cervical vertebra

just above the vertebral artery entrance into the bony canal, leaving the free triangle space in the neck for the

vertebral artery to pass from its origin on the subclavian artery to the entrance of the vertebral bony canal at the

transverse process of the 6-th cervical vertebra (Figure 4). Normally, the vertebral artery is not compressed against

the vertebrae by the scalenus anterior muscle, the longus colli muscle and between them. However, when the anterior

scalenus muscle abnormally attaches to the transverse process of the 7-th cervical vertebra, the vertebral artery is

entrapped between this muscle and the transverse process of the 7-th cervical vertebra. The same situation arises

when the vertebral artery enters bony vertebral canal abnormally at higher level: at the transverse process of the 5-th,

4-th, or even 3-rd cervical vertebrae. In these cases, the vertebral artery is compressed against the transverse

processes of the 6-th cervical vertebra and above situated vertebrae until the vertebral artery enters the bony canal.

Therefore, the deviation of the vertebral artery from its normal course in the neck, or deviation of the scalene muscles

anatomy from normal, creates the conflict between the anterior scalene muscle and the vertebral artery, causing

compression of vertebral artery and symptoms of vertebrobasilar insufficiency. Due to the fact, that scalene muscles

anomalies typically are bilateral, symmetrical, as a rule, both vertebral arteries are compressed by the anterior scalene

muscle in cases of cervical outlet syndrome, which is also typically bilateral, on both sides. Another very important

pathogenetic mechanism of impaired blood flow through the vertebral arteries and of vertebrobasilar insufficiency is

the spasm of vertebral arteries. Vertebral arteries are arteries of muscle type, not elastic: they have smooth muscles in

their walls and can contract. They react to compression by contraction of their walls and reduce their lumen

sometimes twice or even more times. Duplex scanning of vertebral arteries in such cases reveals narrow, spastic, with

diminished blood flow, vertebral arteries. A spasm of vertebral arteries causes the paroxysm of vertebrobasilar

insufficiency, sometimes even a vertebrobasilar stroke. Clinical manifestations of such spastic paroxysm of vertebral

Figure 3: Cervical outlet (spatium interscalenum)

All three scalene muscles, the brachial nerve plexus, the

subclavian artery, the vertebral artery and the subclavian vein

are depicted in this picture. The anterior and medius scalene

muscles originate from the first rib. The posterior scalenus muscle

originates from the second rib. The anterior scalenus muscle

inserts to the transverse processes of the third-sixth cervical

vertebrae. The scalenus medius muscle inserts to the transverse

processes of all cervical vertebrae. The posterior scalenus muscle

inserts to the transverse processes of the three lowest cervical

vertebrae. Due to the fact, that anterior and medius scalene

muscles both originate from the first rib and insert to the

transverse processes of the same cervical vertebrae, they are very

prone to the developmental anomalies: they can be as a one solid

muscle mass not divided into the separate muscles (brachial

plexus and subclavian artery penetrate through the muscle in such

cases), an additional scalenus minimus muscle can develop, they

can attach to the first rib with the common tendon etc.

arteries are headaches, dizziness, nausea, sometimes even vertigo episodes, visual and hearing disturbances (tinnitus,

noise in the ears, visual blurring, scotomas, visual field defects etc.)

Figure 4 illustrates the anatomy of a normal vertebral artery triangle left by the longus colli and scalenus

anterior muscles for the free passage of the vertebral artery from its origin on the subclavian artery to the bony canal

at the transverse process of the 6-th cervical vertebra.

Figure 4

On the left side, the anterior scalenus muscle is removed to show the place of its insertion onto the first rib (the

tubercle of scalenus anterior muscle).

The overwhelming majority of patients with cervical outlet syndrome have combined symptoms of vertebrobasilar

insufficiency and of compression and irritation of brachial plexus nerve roots. In some patients, dominate

vertebrobasilar symptoms, in other – symptoms of compression and irritation of nerve roots. Therefore, some of these

patients seek doctor’s advice and help for vertebrobasilar insufficiency, some – for irritation of brachial plexus nerve

roots. Doctors should know that symptoms of vertebrobasilar insufficiency are very common in patients with cervical

outlet syndrome and that scalenectomy cures these symptoms ceasing the compression and irritation of vertebral

artery by anterior scalenus muscle. The problem is that most doctors are unfamiliar with the thoracic outlet

syndrome and particularly - with the cervical outlet syndrome. Consequently, many patients, suffering from the

thoracic outlet and cervical outlet syndromes, despairingly are trying to find their diagnosis visiting and consulting

many doctors of various specialities, performing countless sophisticated examinations like magnetic resonance

imaging, CT scans etc. The correct diagnosis usually is established only when the patient finds the doctor, who not

only knows the symptoms of the thoracic outlet and cervical outlet syndromes, but also is able to diagnose them and

to correct the problem. Generally, vascular surgeons operate patients with thoracic outlet and cervical outlet

syndromes and they are best familiar with symptoms, diagnostics and treatment of these patients. As an example,

how it is difficult to find the correct diagnosis and help from doctors, even in the USA, is an article on the internet,

written by the patient with the thoracic outlet syndrome from the New York City, who was seeking the diagnosis and

help from doctors. The patient was consulted by many doctors of various specialities, a lot of examinations, including

three magnetic resonance imaging were done for her and the diagnosis was established only when she has addressed

the vascular surgeon, familiar with the thoracic outlet syndrome and operating these patients. Indeed, the worst

situation is, when the patient cannot find the correct diagnosis. He cannot know what the cause of his symptoms is

and consequently, he cannot get the help. Following illustration is an article about the thoracic outlet syndrome,

written by Dr. Carlos Selmonosky, who is an expert in the thoracic outlet syndrome in the USA. He stressed in this

article, that “One of the most unfortunate complications is a misdiagnosis or no diagnosis because patients fail

to receive adequate therapy”.

Figure 4: Anatomy of the vertebral artery triangle

Normally, the longus colli and anterior scalenus muscles

conjugate and attach to the transverse process of the 6-th

cervical vertebra, creating the muscle roof for the vertebral

artery, entering the hole in the transverse process of the 6-th

cervical vertebra. These two muscles create the lateral

borders of vertebral artery triangle. At the top of this

triangle is the transverse process of the 6-th cervical

vertebra. The first rib forms the bottom of this triangle. This

triangle is free of muscles and left for the free vertebral

artery passage from its origin on the subclavian artery to its

entrance into the bony vertebral canal at the transverse

process of the 6-th cervical vertebra. Problems arise when

the course of vertebral artery in the neck is abnormal (high

entrance of vertebral artery into the bony vertebral canal at

the 5-th, 4-th, o even 3-rd cervical vertebrae, or abnormal

lateral branching of vertebral artery from the subclavian

artery under the scalenus anterior muscle), or abnormal

anatomy of the anterior scalenus muscle.

Dr. Carlos Selmonosky has his internet site for thoracic outlet syndrome: http://www.tos-syndrome.com/. American

Thoracic Outlet Syndrome Association also has its internet site at: www. atosa.org.

Due to the fact, that even in the USA many doctors are unfamiliar with symptoms and diagnostics of TOS, still

there is unknown what percent of population has the TOS. Opinions vary on this point, but most authors agree, that

the TOS is a frequent problem and it is encountered in as many as 1-8 % of population. Usually young, 20 - 40 years

old people have this problem and the neurogenic (due to compression and irritation of brachial nerve plexus) variant

of TOS is encountered in women 4 times more frequently than in men. Venous variant of TOS (subclavian vein

thrombosis due to its compression) is more common in males than in females. Arterial TOS (subclavian artery

thrombosis or aneurysm formation due to its compression) has no gender predilection. Hence, the thoracic outlet

syndrome can be: 1) neurogenic; 2) venous and 3) arterial. Neurogenic TOS is the most common variant of TOS and

is encountered in 95 % of all clinical TOS cases. Venous variant of TOS is encountered in 4 % of clinical cases and

arterial TOS variant is infrequent and is encountered only in 1 % of clinical TOS cases. Such big difference in the

frequency of clinical manifestations of neurogenic and vascular (venous and arterial) TOS is due to the high

sensitivity of nerves for compression and irritation. Compression of nerves causes numbness, tingling and even

unbearable pain and consequently, patients seek doctor’s help. The subclavian vessels: artery and vein are

compressed almost as often as nerves, but the patient doesn’t feel the compression of vein or artery until it

thromboses. When the subclavian artery or vein thromboses, a vascular complication of TOS manifest and it is a

vascular emergency: the patient needs an urgent treatment. In cases of cervical outlet syndrome (when brachial

plexus nerve roots are compressed in the scalene triangle (gap between the anterior and medius scalene muscles), the

upper nerve roots (fifth to seventh) are most forcefully compressed. When the compression of brachial plexus is

between the clavicle and the first rib in the costoclavicular space (in the true thoracic outlet), usually most forceful

compression experience the lower roots (8-th cervical and first thoracic roots) of the brachial nerve plexus. This

feature determines the differences in pain, tingling, numbness distribution areas in the arm as well as muscle motor

weakness distribution differences in cervical and thoracic outlet syndromes. Thereby, according to the symptoms

distribution, diagnosis of cervical and thoracic outlet syndromes can be distinguished and established. Most authors

define two kinds or levels of thoracic outlet syndrome: the upper (corresponding to the gap between the anterior and

medius scalene muscles in the neck) and the lower thoracic outlet syndrome (actual thoracic outlet syndrome in the

costoclavicular space). D. Ranney1 suggested to denominate the upper thoracic outlet as a cervical outlet, because

actually it is in the neck and brachial plexus nerve roots and subclavian artery pass the gap between the scalene

muscles (spatium interscalenum) in the neck, not in the actual thoracic outlet.

Figure 5

Subclavian vein can be compressed between the clavicle and the first rib (in the thoracic outlet), not in the cervical

outlet. All three elements of neurovascular bundle (vein, artery and neural plexus) can be compressed in the thoracic

outlet. Only the subclavian artery and nerve roots of the brachial plexus can be compressed in the cervical outlet. The

vertebral artery can be compressed by the scalenus anterior muscle against the cervical vertebrae or their transverse

processes as well. This particular situation arises when the scalenus anterior muscle is abnormal, or the course of

vertebral artery in the neck is abnormal (it enters the bony vertebral canal higher than normally: at the 5-th, 4-th or

even 3-rd cervical vertebrae or it originates from the subclavian artery more lateral than normally. I shall write

separately about the vertebral artery compression with the scalenus anterior muscle later, because this situation and

this pathology is very important: it is encountered in patients relatively frequently and it considerably diminishes

blood flow in the vertebrobasilar region of the brain and causes symptoms of vertebrobasilar insufficiency from mild

up to the vertebrobasilar stroke.

Compression of the upper (5-7-th cervical nerve) roots between the anterior and medius scalene muscles (in the

spatium interscalenum) most of the authors, writing on this topic, denominate as an upper thoracic outlet syndrome

and the true thoracic outlet between the clavicle and the first rib they denominate as a lower thoracic outlet and

symptoms arising from compression of the neurovascular bundle in it they denominate as a lower thoracic outlet

syndrome.

I support D. Ranney’s1 proposal to distinguish these two totally different anatomical regions (levels) into two

separate definitions: cervical outlet and thoracic outlet and to denominate symptoms arising from the compression

of neurovascular bundle in these two regions as a cervical outlet syndrome and thoracic outlet syndrome, because

the cervical outlet is in the neck: it is the gap between the anterior and medius scalene muscles and the brachial nerve

plexus together with subclavian artery is compressed in the neck, not in the true thoracic outlet. The true thoracic

outlet is between the clavicle and the first rib and all three structures of the neurovascular bundle (subclavian vein,

subclavian artery and brachial nerve plexus) can be compressed here.

Symptomatology, diagnostics and especially the surgical treatment greatly differ between these two separate

entities and therefore it is wiser not to relate and to confuse them together and to denominate them by different

names: cervical outlet syndrome and thoracic outlet syndrome. That’s, why I adhere to such denomination of these

two separate pathological entities earlier, and later in this article I shall refer to them as a cervical outlet syndrome

and thoracic outlet syndrome.

Figure 6 illustrates the anatomy of the cervical outlet.

Figure 5: Anatomy of the thoracic outlet

(View from the armpit)

The thoracic outlet and all three elements of the neurovascular

bundle: subclavian vein, subclavian artery and brachial nerve

plexus are seen from the armpit. The subclavius muscle,

situated between the clavicle and the first rib is clearly seen. It

occupies the most narrow medial corner of the costoclavicular

space, where the subclavian vein passes it.

The subclavian vein passes in front of the anterior scalenus

muscle (through the spatium antescalenum) and can not be

compressed by this muscle in the cervical outlet (spatium

interscalenum).

The pectoralis minor muscle can compress the neurovascular

bundle in the armpit in case of its hypertrophy as this problem

is encoutered in some athletes. Such situation is relatively rare.

Figure 6

Figure 7 shows the anatomy of the cervical and thoracic outlets in detail.

Figure 7

Different congenital developmental anomalies: anomalous clavicle, anomalous first rib, cervical ribs, elongated

anomalous transverse process of the seventh cervical vertebra, anomalous fibrous and cartilaginous bands etc.

account for the thoracic outlet syndrome. In some clinical cases no congenital anomalies exist in the thoracic outlet,

except the congenital narrow space between the clavicle and the first rib. It is important to stress, that cartilaginous

cervical ribs and fibrous bands are invisible on the plain roentgenograms and that only bony structures are visible on

them. That’s, why normal plain roentgenograms do not rule out the existence of all congenital anomalies in the

thoracic outlet, especially cartilaginous cervical ribs and fibrous bands. These latter structures are well visualized

with magnetic resonance imaging. If the cervical rib exists, it originates from the seventh cervical vertebra and

conjugates with the first rib usually by the joint. Such a rib greatly diminishes the space between the clavicle and the

first rib (thoracic outlet) and creates a predisposition for the development of the thoracic outlet syndrome. In these

cases the subclavian artery and the brachial plexus are compressed by the clavicle against the cervical rib because the

neurovascular bundle must sling over the cervical rib in order to reach the armpit.

Figure 6: Anatomy of the cervical outlet

(View from the side)

The arm, shoulder joint, scapula and the clavicle together

with the muscles are removed in this picture. Only the

chest and the neck with the deep muscles are left.

It is clearly seen, that the gap between the anterior and

medius scalene muscles is in the neck and that the

compression of the brachial nerve plexus and subclavian

artery in this gap is in the neck and that this gap should be

called the cervical outlet.

The nerves and artery in this vertical gap are compressed

between the two scalene muscles in the sagital direction,

meanwhile in the thoracic outlet all three structures of the

neurovascular bundle are compressed in the horizontal

gap between the clavicle and the first rib in the vertical

direction.

Figure 7: Anatomy of the cervical and thoracic

outlet

All anatomical structures of the cervical and thoracic

outlets are depicted in detail in this picture.

Superficial muscles are removed from the front of the

neck and chest for better visualization of the cervical

and thoracic outlets. Part of the clavicle is also

removed for better visualization of the thoracic outlet

and its content: subclavian vein, subclavian artery

and brachial nerve plexus, passing through it. The

subclavius muscle is left intact. It occupies part of the

costoclavicular space. The subclavius muscle narrows

the most tight medial corner of the costoclavicular

space, where the subclavian vein passes from the neck

to the armpit.

V, VI, VII, VIII – the 5, 6, 7, 8-th brachial plexus

cervical nerve roots.

I - the first thoracic nerve root.

Figure 8 illustrates the normal anatomy of the bones, limiting the thoracic outlet.

Figure 8

Ribs and their equivalents are colored in red. Fishes have ribs in the neck. In mammals, including the man, ribs in the

neck region withered away due to the fact, that they are living on the land and need to rotate and flex the neck. Only

remnants (rudiments) of the ribs: the anterior parts (processus costarius) of the transverse processes and their anterior

tubercles remained in the neck region. They are colored in red in this picture, the same color as the ribs. Derangement

of fetal embryogenesis causes development of cervical ribs, mostly from the processus costarius of the seventh

cervical vertebra transverse process.

Figure 9 illustrates the lateral view of the bones, limiting the thoracic outlet.

Figure 9

Figure 8: Bones limiting the thoracic outlet

Bones of the shoulder girdle are shown in green color. Scapula,

the shoulder girdle with the arm are fixed to the skeleton only by

the medial end of the clavicle to the sternum.

The position of the scapula, clavicle and the shoulder girdle

depends on the tone and strength of the shoulder girdle muscles

and on the posture. Limp posture with depressed, rounded

shoulders reduce the space between the clavicle and the first rib

and can produce the symptoms of thoracic outlet syndrome due to

compression of brachial plexus. Correction of the posture and

physical therapy can be helpful in such cases.

However, the physical therapy and correction of posture can be

helpful only in the thoracic outlet syndrome, but not in the

cervical outlet syndrome, because they correct only the space

between the clavicle and the first rib, not between the scalene

muscles. In case of cervical outlet syndrome neither the physical

therapy, nor the posture correction or massage of the muscles can

help. Conversely, they can worsen the symptoms of cervical outlet

syndrome due to strengthening of the muscles, because the nerve

roots, subclavian artery and the vertebral artery are compressed

in this case by the muscles against the vertebral bodies or between

the muscles.

Figure 9: Lateral view of the bones, limiting the thoracic outlet

Bones of the shoulder girdle are shown in green color. Scapula,

shoulder joint, all the shoulder girdle and arm are fixed to the skeleton

(to the sternum) only by the medial end of the clavicle. Therefore, the

position of the scapula, clavicle and all the shoulder girdle depends on

the tone and strength of the shoulder girdle muscles and on the posture.

Limp posture with depressed, rounded shoulders reduce the space

between the clavicle and the first rib and can produce the symptoms of

thoracic outlet syndrome due to compression of the brachial plexus.

Correction of the posture and physical therapy can be helpful in such

cases.

However, the physical therapy and correction of the posture can be

helpful only in thoracic outlet syndrome, but not in cervical outlet

syndrome, because they correct only the space between the clavicle and

the first rib, not between the scalene muscles. In case of cervical outlet

syndrome neither the physical therapy, nor the posture correction or

massage of the muscles can help. Conversely, they can worsen the

symptoms of cervical outlet syndrome due to strengthening of the

muscles, because the nerve roots, subclavian artery and the vertebral

artery are compressed in this case by the muscles against the vertebral

bodies or between the muscles.

The roentgenogram of 22 year old girl with fully developed unilateral left cervical rib is shown in the figure 10.

Figure 10

The girl has had pain and numbness of the left arm and hand from the adolescence. The left hand became weak,

clumsy. She could not pick small things with the left hand. The body of the girl became “S” shaped due to the

deviation and distortion of the spinal column. The pain of the left arm became unbearable. She addressed me because

of the left arm pain. Inspection of the girl revealed the cervical rib on the left side of the neck. Roentgenogram

confirmed the fully developed cervical rib on the left side and rudimentary undeveloped cervical rib on the right side.

The Wright’s and Roos tests were strongly positive on the left side. The left arm and hand became weak and painful

just shortly after starting Roos test. She was unable to perform Roos test with the left hand even for one minute,

meanwhile she had not experienced any uncomfortable feelings in the right arm and hand during the Roos test. The

pulse disappeared in the left arm in the Roos test position (the subclavian artery was totally compressed and occluded

in the costoclavicular space on the left side) and the pulse was present and normal in the right arm in all positions

including Roos abduction-external rotation position of the arm.

The Roos test is performed with the arms in abduction-external rotation position as it is shown in figure 11. The

patient is asked to close and open the hands for 3 minutes in this position of the arms and to describe all sensations,

that develop.

Figure 11

The girl was operated. The left first rib together with the cervical rib were removed, using the Roos technique,

through the axillary approach. (Removal of the cervical accessory rib alone, without the first rib, through the

supraclavicular anterior approach is unsatisfactory and usually is not adequate for decompression of the thoracic

Figure 11: Position of the arms for the Roos test

The arms are flexed in the elbow joints by 90 degree and abducted to the

frontal plane of the body. Both hands are closed and opened steadily for

3 minutes and patient is asked to describe all sensations that develop.

Normally, in the absence of thoracic outlet syndrome, patient does not

experience any discomfortable sensations during 3 minute such test. In

case of thoracic outlet or cervical outlet syndrome, patient usually is

unable to complete the 3 minute such test due to development of

weakness and numbness of arms, pain in the arms and neck. This test

provokes and reproduces the usual symptoms, which are torturing the

patient.

Figure 10: Roentgenogram of the cervical ribs

The roentgenogram shows fully developed left cervical rib, which

originates from the seventh cervical vertebra and has a joint at the

place where it attaches to the first rib.

The rudimentary short cervical rib, attached by the joint to the first

rib, is seen on the right side as well. The first ribs have a joint

processes at the places of insertion of the cervical ribs.

The right cervical rib was asymptomatic: no brachial plexus

compression symptoms were on the right side. Meanwhile, there

were dramatically expressed symptoms of the compression of

brachial plexus on the left side due to the narrowing of the thoracic

outlet by the fully developed cervical rib. The left cervical rib has

been pushing the cervical part of the spinal column to the right,

because there was no counteraction by the short undeveloped right

cervical rib. Therefore, the spinal column acquired a “S” shaped

distortion: the thoracic part of it deviated to the left, as a

compensation to the deviation of the cervical part of the spinal

column to the right. Therefore, the posture and the shape of the girl

were awfully distorted. This distortion is clearly seen on the

roentgenogram.

outlet. The removal of both: first and cervical ribs decompress thoracic outlet adequately and creates enough space

for passing of neurovascular bundle through it).

Operation and postoperative period were uneventful. The pleura was not entered and opened during the

operation. The girl was discharged from the hospital on the third postoperative day.

All symptoms, which were torturing the girl, disappeared after the operation. The pain and numbness in the left

arm and hand disappeared. The pulse in the left arm was present in all arm positions, including abduction and

elevation (Wright’s and Adson’s positions). The posture of the girl improved after the operation. She was able to

stretch her body and spinal column into the straight position, what was impossible before the removal of the

accessory cervical rib. I advised her to exercise the spinal column and the body together with the physiotherapy

specialist to get her spinal column straight and erect.

After the one year follow up she was absolutely healthy with normal posture, straight spinal column, free of

thoracic outlet symptoms.

In case of equal bilateral accessory cervical ribs no deviation of spinal column develop, just restriction of neck

movements exists. In case of unilateral cervical rib or when they are bilateral, but not equal in length, the deviation

and distortion of spinal column and body posture develop. That’s, why it is wise to remove them as early as they are

diagnosed and when the symptoms of thoracic outlet syndrome manifest. It is desirable to remove them in the

childhood or in the adolescence.

Figure 12 illustrates unequal in length bilateral accessory cervical ribs: the left - fully developed cervical rib

with the joint at the insertion onto the first rib and the right - undeveloped cervical rib, directly fused to the first rib. Figure 12

This patient after the operations is free of symptoms. The pain, numbness and paresthesias of the arms and hands

disappeared. The erectness of spinal column and the body shape of the woman after one year follow up period

improved considerably, however the patient failed to straighten her body completely. Therefore, the conclusion is,

that patients with unilateral and unequal in length cervical accessory ribs should be operated as early, as possible,

before the deviation and distortion of the spinal column and the body develops.

Figure 13 illustrates the roentgenograms of patient with bilateral symmetrical accessory cervical ribs before and

after the removal of first and cervical ribs on both sides by the two-staged operation.

(Before operations) Figure 13 (After the operations)

Figure 12: Fully developed left cervical rib with the joint between it

and the first rib and undeveloped right cervical rib fused with the

right first rib without the joint

Due to the asymmetrical development of both cervical ribs, the spinal

column deviated to the right in the neck region and to the left – in the

chest region (it is clearly seen on this roentgenogram). The posture

and the shape of the woman were awfully distorted.

Thoracic outlet syndrome (brachial plexus nerve compression)

symptoms were more expressed on the left side, though they were

present and on the right side. Therefore, two- staged operation was

performed for this patient: the left first and cervical ribs were

removed first, and at the second operation the right first rib together

with the cervical rib were removed.

Figure 13: The roentgenograms of the patient with equal bilateral cervical ribs before and after the two-staged

removal of both cervical and first ribs. The white arrows on the right point to the stumps of the removed cervical ribs

and the blue arrows point to the stumps of the removed first ribs. The spinal column of the patient was almost straight

due to the equal length of the symmetrical accessory cervical ribs. The reason for seeking the doctor’s help was the

pain and numbness in both arms and hands, sensitivity of the hands to the cold exposure. Two-staged operation was

performed: at first, the right first and cervical ribs were removed and one month later, the left first and cervical ribs

were removed. All thoracic outlet syndrome (brachial nerve plexus compression) symptoms cleared on both sides.

Thoracic outlet syndrome symptoms can arise and manifest not only due to the accessory cervical ribs, but they

can be present even in the absence of the cervical ribs: in cases of too narrow costoclavicular space, due to

hypertrophied first rib, or due to the callus of fractured clavicle as it was in operated by me and published in the

journal clinical case2. The subclavian artery was compressed and crushed between the first rib and callus of

pseudoarthrosis of the fractured clavicle in that patient and subsequently thrombosis of the subclavian artery and

acute ischemia of the arm developed. Emergency operation was performed for that patient: first rib was removed on

the diseased side, the clavicle was reunited using the bone transplant and metallic plate, and autovenous bypass from

common carotid artery to the brachial artery was created. The arm and hand were saved. Anatomically too narrow

costoclavicular space without any other anatomical accessory abnormalities resulted in chronical mangling of the

subclavian artery between the clavicle and first rib in another operated by me patient3. Chronical mangling and

crushing of the subclavian artery resulted in aneurysm formation and thrombus embolization from the aneurysm of

the subclavian artery to the distal arteries of the left arm and hand in that patient. Subsequently, the thrombosis of the

left subclavian artery aneurysm and distal arteries of the left arm developed and acute ischemia of the left arm and

hand occurred. Emergency operation was performed for that patient: the aneurysm of the left subclavian artery was

removed, thrombectomy of thrombosed arteries was performed and an extraanatomical bypass from the left common

carotid artery to the left axillary artery was created.

Embryological explanation for the development of thoracic and cervical outlet anomalies Development of cervical ribs and malformation of first ribs are being linked to errors of bodily segmentation in early

embryological development. Cervical rib development is determined by the formation of the spinal nerve roots. The

regression of the C5 through the C7 ribs is occasioned by rapid development of the enlarging roots of the brachial

plexus in the region of the limb bud. In cases of a cervical C7 rib there is generally “prefixed” brachial plexus with

only a small neural contribution from the T1 nerve root to the brachial plexus. As a corollary, in the “postfixed”

brachial plexus in which there is a contribution of the T2 nerve root to the brachial plexus, the first thoracic rib is

often rudimentary, having been inhibited in its development by the unusual nerve growth. This embryologically

determined morphologic interdependence is evident with other structural relationships at the thoracic outlet.

Cervical ribs are inheritable by autosomal dominant way. Therefore, there is a considerable likelihood of

encountering the cervical ribs in children of patients having cervical ribs.

During development, the C7 rib forms, then regresses to the C7 transverse process. Various stages in this

evolution range from a complete C7 rib to rudimentary forms associated with a fibrocartilagineous band. The only

radiologic indication of this residual band may be an enlarged C7 transverse process.

Milliez4 emphasized the influence of neurovascular structure development on the ultimate configuration of the

scalene muscle mass. The scalenic muscle mass is only differentiated into specific scalene muscles by the traversing

of the neurovascular bundle. The persistence of certain muscle inclusions in the brachial plexus, as well as of muscle

groups that traverse various elements of brachial plexus, is related to the original mass of the scalene muscle being

variously fragmented by the passage of these developing structures as the limb bud develops. This separation of

muscle bundles interdigitating between the neurovascular structures accounts for the muscular bridges seen between

the anterior and middle scalene muscles that often penetrate the brachial plexus. Sanders and Roos5 demonstrated in

their anatomical dissections that these abnormalities of scalene fragmentation are seen quite frequently in the adult.

The causes of thoracic outlet syndrome can be divided into: 1) anomalies of the first rib or cervical rib

(including the residual fibrous band from an incomplete cervical rib; 2) anomalies of scalene muscle development or

insertion; 3) subclavius muscle anomalies; 4) anomalies of the clavicle; 5) anatomical anomalies (e.g. narrow

costoclavicular space) not clearly identifiable as a developmental variation.

Makhoul and Machleder6 in 200 consecutive transaxillary procedures for thoracic outlet syndrome have found

the following anatomical anomalies: 8,5 % of operated patients have had a cervical rib; 10% of patients had

accessory scalenus minimus muscle; 19,5% of patients had anomalous subclavius muscle; 43% of patients (the

biggest group) had an anomaly of scalene muscle development or insertion; 19% of patients had no discernible

anomaly from the axillary surgical approach. Nevertheless, their symptoms cleared after the removal of the first rib.

These cases were treated as a narrow costoclavicular space without any discernible congenital anatomic anomaly.

Fully developed cervical ribs with joints at the insertion to the first rib has 0, 2 % of population. In a study of 40

000 consecutive chest x-rays in American army recruits, Etter7

encountered 68 (0,17%) complete articulated cervical

ribs and 98 anomalous first ribs (0,25 %). Adson8 reviewed his experience with cervical ribs by radiologic study at

Mayo clinic. He identified an incidence of 0,56% or 5,6 patients per thousand with cervical ribs. Of these 28% were

male and 72% were female. 47% of cervical ribs were bilateral. The right side was involved in 23% and the left side

in 30% of unilateral cervical rib cases. Forty five percent of cases in this Mayo clinic group was symptomatic.

Firsov9 in the Soviet Union reported fluorographic examination of 510 893 people and observed 1379 cervical ribs,

for an incidence of 0,27%. Women accounted for 76,8% and men for 23,2% of cervical rib cases; 33% of cervical

ribs were bilateral. Hence, the Firsov’s data are very similar to the Etter’s and Adson’s data. Therefore, 02%-025%

incidence of cervical ribs in population is accurate.

The fact, that incidence of cervical ribs in women is 3,3 time higher than in men, explains the fact, that neurogenic

variant of thoracic outlet syndrome in women is 4 times more common than in men and that the ratio of operations

for neurogenic thoracic outlet syndrome in women and men is 4:1.

The abdominal, thoracic and cervical musculature develops from the hypomeric portion of the paraxial and

epaxial mesoderm, with the scalene and prevertebral muscles in the neck corresponding to the intercostal and

ventrolateral abdominal muscles in the thorax and abdomen respectively10

. In the embryo, plates of axially running

muscle segments differentiate into the discrete muscle groups seen in adult.

The subclavian artery, which is the artery of the seventh cervical segment, and the spinal nerves from C5 to T1

pierce the muscle plates in the cervical segment much the same as the intercostal nerve and artery do in the thoracic

segments. The growth of the limb bud and development of pectoral girdle then lead to the particular structural

changes seen in this region.

Therefore, the anomalies of scalene muscles are very frequent and encountered in clinical practice very often.

The scalene muscle can be as a solid mass without any differentiation into anterior, middle and posterior scalene

muscles. In such cases subclavian artery and brachial plexus roots are piercing the scalene muscle mass and are

compressed by muscle fibers. The interscalene gap (spatium interscalenum) can be too narrow and tight or abnormal

with crossing insertions of scalenus anterior and middle muscles onto the first rib or with “V” shaped interscalene gap

due to common insertion with the common tendon onto the first rib. In such cases, brachial nerve plexus and

subclavian artery are compressed in the interscalene gap. Sanders and Roos5, studying the anatomy of the interscalene

triangle, found interdigitating fibers between the scalene muscles through the brachial plexus in 75% of dissections in

patients with thoracic outlet syndrome and in 40% of consecutive cadaver dissections. Their data suggest that scalene

muscle anomalies are very common in human being and that they have very big clinical importance in thoracic outlet

syndrome etiopathogenesis.

As I mentioned earlier, the thoracic outlet and cervical outlet syndromes differ greatly by their clinical

symptoms, diagnostic evaluation disparities and particularly differ their surgical treatment. Therefore, I shall describe

them separately: at first the thoracic outlet syndrome and later – the cervical outlet syndrome.

There are three types of thoracic outlet syndrome: venous, arterial and neurogenic. The most common of them

is neurogenic TOS. It is encountered in 95% of all TOS cases. Venous TOS is encountered in 4% of cases and arterial

TOS is encountered in 1% of all TOS cases.

Venous thoracic outlet syndrome

Venous thoracic outlet syndrome is a complex of symptoms arising due to chronic compression of subclavian vein in

the costoclavicular space and subsequent its thrombosis. In 1875, James Paget11

described the symptoms resulting

from subclavian vein thrombosis. Nevertheless, he misunderstood the cause and ethiopatogenesis of the arm swelling

and thought that it is due to the vein imflammation and vasospasm. In 1884, L. Schroetter12

correctly identified that

thrombosis of subclavian and axillary vein causes the complex of symptoms described by Paget and attributed these

upper extremity venous symptoms to the compression or thrombosis of subclavian vein at the thoracic outlet. In 1949,

E. Hughes13

applied a term Paget-Schroetter’s syndrome to delineate the clinical picture of symptoms arising due to

subclavian vein thrombosis. From that time, the symptoms arising due to subclavian vein thrombosis and their

clinical manifestation are called Paget-Schroetter’s syndrome.

The frequency of spontaneous (primary) subclavian vein thrombosis due to thoracic outlet syndrome is 2 per

100 000 population per year14

.

Venous TOS results from repetitive subclavian vein compression in the costoclavicular space between the

subclavius muscle or costoclavicular ligament against the first rib and tends to occur in the more active dominant

extremity. Usually, subclavian vein thrombosis occurs after the intensive work or physical activity in young,

physically active adults aged 25-40 years. Repetitive compression of subclavian vein damages its internal layer

(intima) and thrombus formation on the damaged intima occurs15-25

. As a rule, these patients have neurogenic TOS as

well. Acute thrombosis of subclavian vein almost completely blocks the venous return from the arm and results in

swelling, bluish color and painfulness of the involved arm. Subsequent thrombosis of axillary, brachial veins and all

other veins in the involved arm results from the prominent venous outflow block and venostasis in the involved arm.

In extreme cases, venous gangrene (phlegmasia coerulea dolens) of the involved arm develops due to cessation of

blood circulation in the arm, because of blood venous return block.

Clinical diagnosis is easy and usually does not create any problems. The involved arm and hand is swollen,

bluish, firm. During the days, collateral veins on the involved arm and on the upper part of the involved side of the

chest appear. Duplex scanning of the veins in the involved extremity reveals thrombosed, with thrombus in the lumen

deep veins of the involved arm, absent blood flow in the thrombosed deep veins. The final diagnosis is established by

ascending venography of the involved arm, which reveals thrombosed deep veins of the extremity, delineates the

starting point and the extension of the thrombus in the deep veins of the axilla and the arm and demonstrates the

collateral veins returning the blood from the arm.

Most authors are prone to treat these patients by thrombolytic therapy or heparinization22-25

. Some of them

additionally employ the device for thrombus fragmentation ad thrombus elimination by suction with Angiojet device

(Possis Medical Inc, Minneapolis, Minnesota, USA) 26

.

Other authors, including me, are advocates of a single-stage radical surgical treatment. During the same

operation, the first rib is removed and thrombectomy from the deep veins of the arm is performed. Such operation

eliminates the cause of subclavian vein thrombosis and restores the lumen and passage of blood in the deep veins of

the arm at the same time27-29

. This type of treatment is better, because it resolves both problems at the same operation:

the tightness of thoracic outlet and thrombosis of subclavian vein, and its results (early and late) are better than results

of treatment with thrombolytic agents or heparinization alone, without the first rib removal. Two staged treatment

with thrombolysis in acute phase, and later removal of the first rib 30

, is inferior to the single-stage radical surgical

treatment as well.

Arterial thoracic outlet syndrome Subclavian artery can be compressed in the cervical outlet (interscalene gap) or in the true thoracic outlet between

the clavicle and the first rib or cervical rib, if present. The compression of the subclavian artery in the cervical outlet,

as a rule, is asymptomatic, because its compression between the muscles in the interscalene gap has no sequelae.

Muscles are soft and compression of the subclavian artery between them is not felt by the patient. This compression

between the muscles does not result in the aneurysm formation or thrombosis of the subclavian artery. Meanwhile,

the repetitive compression and crushing of subclavian artery between the two bones: the clavicle and the first or

cervical rib causes its intimal (internal layer) and medial layer degeneration and aneurysm formation or acute its

thrombosis. This results in acute ischemia of the involved arm. I have never met in my clinical practice the cases of

arm ischemia due to the cervical outlet syndrome, but I have operated several patients with acute arm ischemia due

to the subclavian artery thrombosis as a result of true thoracic outlet syndrome 2, 3

. Compression and mangling of

the subclavian artery in the interscalene gap (cervical outlet) causes another problem: irritation of the sympathetic

nerves passing inside the arterial wall of the subclavian artery, which later supplies sympathetic innervation to the all

arterial tree of the arm and hand and this causes the spasm of small arteries in the hands and their fingers: Raynaud’s

syndrome develops. Patient fingers and hands are bluish in color and very sensitive to the cold. Exposure of the hands

to the cold causes vasoconstriction (spasm of the arteries) and hands become pale, cold and painful. Vasoconstriction

and Raynaud’s syndrome can be caused by compression and irritation of the brachial plexus inside the cervical outlet

as well, because fibers of sympathetic nerves passes through the cervical outlet inside the brachial plexus.

Compression and irritation of brachial plexus inside the cervical outlet (interscalene gap) irritates sympathetic fibers,

present in the brachial plexus, and later spreading to all the arterial tree of the arm and hand. Scalenectomy (removal

of anterior scalene muscle) ceases the compression and irritation of the brachial plexus and subclavian artery and of

all the sympathetic fibers, present in both these structures: Raynaud’s syndrome, as a rule, disappears. Therefore,

scalenectomy in cervical outlet arterial syndrome is justified only for the treatment of Raynaud’s syndrome, to stop

the irritation of sympathetic nerves, present in the brachial plexus and in the wall of the subclavian artery, not for the

compression of the subclavian artery itself. Typically, patients with irritation of sympathetic fibers and Raynaud’s

syndrome have neurogenic cervical outlet or thoracic outlet syndrome (symptoms of compression and irritation of

brachial plexus itself). Significant part of patients, having neurogenic cervical outlet syndrome, have compression of

vertebral arteries as well. Neurogenic cervical outlet syndrome typically is bilateral and compression of vertebral

arteries is bilateral as well. These patients have symptoms of vertebrobasilar insufficiency up to the vertebrobasilar

stroke (in cases of prolonged spasm of vertebral arteries). Vertebral arteries are not merely compressed, but they react

to the compression by spasm. This spasm of vertebral arteries causes not only pronounced symptoms of

vertebrobasilar insufficiency, but it can be even the cause of vertebrobasilar stroke. Typically, these patients seek

doctor’s help because of vertebrobasilar insufficiency symptoms, not for symptoms of brachial plexus compression,

though they have symptoms of brachial plexus compression as well. The problem is, that most physicians are

unfamiliar with thoracic and particularly with the cervical outlet syndromes, they do not know their symptoms and

treatment. That’s, why patients cannot obtain adequate diagnostic procedures and receive adequate treatment.

In cases of thoracic outlet syndrome, the subclavian artery is compressed and mangled between two bones: the

clavicle and the first rib. Therefore, the damage to the arterial wall is significant and aneurysm formation of

subclavian artery results in the age of 25-40 years, because the thorax completely develops and forms up to the 25

years and people in such age are most active physically. Therefore, mangling and traumatizing of their subclavian

arteries between these two bones is most intensive in that age.

Patient does not feel the process of compression and mangling of the subclavian artery until the development of

subclavian artery thrombosis (or its aneurysm thrombosis), or the thrombus embolisation from the aneurysm to the

distal arteries of the arm. Acute ischemia of the arm develops in such cases. Only then, patients addresses the hospital

or the physician. Physician’s obligation in this situation is to establish the correct diagnosis and to provide adequate

treatment for the patient. Emergency diagnostic evaluation and surgery is needed in such cases. Anterior-posterior

plain view roentgenogram of thorax and neck should be taken and emergency angiography of diseased subclavian

artery through the femoral route should be performed. Presence of subclavian artery aneurysm, or thrombosis of

subclavian artery, particularly with embolisation to the distal arteries of the arm, indicate the presence of mangling of

subclavian artery between the clavicle and first rib or cervical rib, if present, and existing arterial thoracic outlet

syndrome. Roentgenogram of the chest is helpful only if cervical rib or abnormal first rib or clavicle is seen on it. If

no deformities or bone anomalies are seen in the thoracic outlet, it does not preclude the existence of thoracic outlet

syndrome due to the too narrow costoclavicular space. Magnetic resonance tomography of the thoracic outlet is

helpful in such cases, if performed by adequate computer program and mode by qualified magnetic resonance

tomography staff. After the establishment of arterial thoracic outlet syndrome diagnosis and subclavian artery

thrombosis or embolisation from the subclavian artery to the distal arm arteries, the emergency operation should be

undertaken: typically, first rib resection through the axillary approach and revascularization procedure, depending on

the underlying cause of arm ischemia is performed at the same operation.

I have operated patient with such situation. The case report is published on the internet3.

Best treatment results of these patients are obtained by vascular surgeons, because they are best familiar with

the revascularization procedures and their tactics.

Neurogenic thoracic outlet syndrome

Neurogenic thoracic outlet syndrome is a complex of symptoms arising due to compression of brachial plexus

between the clavicle and first or cervical rib, if present. Usually, the lower roots of brachial plexus (8-th cervical and

first thoracic) are most intensively compressed and suffer more prominently. Therefore, symptoms usually are most

expressed in the area of distribution of nerves, which are constituted by the fibers coming from C8-Th1 roots (medial

or ulnar side of the arm). Nevertheless, all brachial plexus roots are compressed in most cases: just the intensity of

compression can vary in lower and upper roots of brachial plexus. Only those nerves, which branch from the brachial

plexus higher than thoracic outlet and innervate neck, upper portion of the back, between the shoulder-blades

(scapulae) and upper portion of the chest anteriorly cannot be compressed in the true thoracic outlet. They can be

compressed only in the cervical outlet (interscalene gap). All other brachial plexus roots can be compressed in the

cervical outlet as well. Keeping in mind this peculiarity and obtaining the existing patient’s symptoms, one can

diagnose which of neurogenic outlet syndromes is present: thoracic or cervical.

Patients with neurogenic thoracic outlet syndrome experience tingling, numbness and pain in the arms. In more

advanced cases muscle atrophy and weakness develop in the area of distribution of affected nerves.

Electromyography is an unreliable test and should not be used for diagnosing thoracic or cervical outlet

syndromes. Electromyographic changes appear only in late stages of thoracic outlet syndrome and they always mean

pronounced pathologic changes in the nerves and muscles, which should be avoided. Patients should be operated in

earlier stages of the disease, before the development of nerve dystrophies and muscle atrophies.

Below there are four postulates, established in thoracic outlet syndrome and written by David Roos:

1. Patients, having thoracic outlet syndrome, have anatomical congenital anomalies, predisposing them to the

development of thoracic outlet syndrome. Trauma, physical stress, profession are provoking factors for the

thoracic outlet syndrome;

2. 95% of patients with tight thoracic outlet develop neurogenic thoracic outlet syndrome symptoms, 4% -

develop venous symptoms and only 1 % of patients develop arterial symptoms of thoracic outlet syndrome;

3. Therefore, all tests demonstrating compression of subclavian artery has only the significance in

demonstrating the compression of subclavian artery, not of brachial plexus. Patient does not feel the

compression of subclavian artery until it develops aneurysm or embolisation from the aneurysm into the

distal arteries of the arm, or aneurysm becomes acutely thrombosed. Consequently, compression of the

subclavian artery and pulse disappearance in the arm are not the diagnostic criteria for the neurogenic

thoracic outlet syndrome, because patient address the physician not because of subclavian artery

compression, but because of brachial plexus compression. Brachial plexus compression can exist in cases

with no compression of subclavian artery in the same patient;

4. Effective treatment of thoracic outlet syndrome is surgical: elimination of anatomical congenital anomalies,

causing compression and irritation of brachial plexus.

Diagnostic evaluation

Anamnestic data, inspection of the patient and objective assessment of patient symptoms are very important in

establishing the diagnosis. Plain chest and neck roentgenograms visualize anatomic bone abnormalities: accessory

cervical ribs, abnormal first rib or abnormal clavicle. Absence of bone abnormalities on roentgenograms does not

exclude the presence of thoracic outlet syndrome. Cartilaginous or fibrous abnormal anatomic structures, which can

be the causes of thoracic outlet syndrome, are not visible on the plain roentgenograms. Laboratory analyses are not

diagnostic and are performed only as a preoperative assessment of patient status. Electromyographic tests are of

minimal value in establishing the diagnosis and in decision making as to operate the patient or not. All diseases,

which can mimic the compression of brachial plexus: cervical disk herniation, cervical spine spondylosis or

osteochondrosis, arthrosis of the shoulder joint etc should be ruled out. Neurologic examination of sensory and motor

disturbances as well as of muscle reflex changes are essential in establishing the diagnosis.

Most reliable test in establishing thoracic outlet syndrome diagnosis is an Elevated Arm Stress Test (EAST) as

depicted in figure 11. Patients with thoracic outlet syndrome in this position during the test develop progressive

distress and reproduction of their usual symptoms: fatigue, heaviness, paraesthesias and pain in the involved arm and

they finally drop the arm to the lap, unable to complete the three minute exercise in this arm position.

Treatment

Surgical treatment of thoracic outlet syndrome remains the most definitive approach to permanent cure, but it should

be employed only when more conservative measures prove ineffective. Mild symptoms of TOS require no special

treatment, but the patient is advised to minimize activities or arm positions that precipitate the symptoms. Moderate

symptoms may also respond to avoidance of aggravating activities. Nevertheless, other measures may be required as

well, such as nonnarcotic medication for pain control, muscle relaxation and light physical therapy.

The decision of when to advise surgical treatment for TOS patients is simple: if the patient can control his

symptoms by non-surgical methods to the extent that he is normally active, able to work effectively, and sleep well,

surgery is not indicated. If these symptoms, however are severe enough to interfere with his general activities, job,

sleep, or simply make him feel miserable, and conservative measures have failed, surgery is indicated to restore his

limb and life back to normal.

The only type of surgical treatment that offers relief for patients with advanced TOS uncontrollable by

conservative measures is the elimination of mechanical irritation or compression of neurovascular structure,

responsible for the symptoms. Currently, the most effective means of accomplishing this is to resect the first thoracic

rib and all congenital anomalies in the thoracic outlet, such as cervical rib or fibromuscular bands, to remove the

triggering causes, responsible for the symptoms. Presently, the easiest, safest and most complete exposure to

accomplish this is by the use of transaxillary approach as proposed by David Roos.

Surgical treatment

Surgical treatment of TOS was begun in 1861, when H. Coote in London removed accessory cervical rib for the

patient, suffering arm pain. The second operation for TOS (removal of accessory cervical rib) was performed by

French surgeon J. Perier in 1890. F. Bramwell in 1903 was the first, who understood, that even in the absence of

accessory cervical rib, the costoclavicular space can be too narrow and can compress the brachial plexus.

Consequently, TOS can be present even in the absence of accessory cervical rib. Australian surgeon Thomas Murphy

in 1910 was the first, who removed the first thoracic rib for the thoracic outlet syndrome and cured patient from the

pain, caused by compression of brachial nerve plexus. Then, it was a long period of time when the surgical treatment

of TOS was neglected. Only in 1962 O. Clagett restored enthusiasm for surgical treatment of TOS, proposing the

posterior thoracotomy approach for the removal of the first thoracic rib. David Roos was the surgeon, who made a

revolution in the surgical treatment of TOS by developing and proposing the transaxillary approach for the removal

of the first thoracic rib as well as removal of accessory cervical rib and all other congenital abnormal anatomical

structures in the thoracic outlet in 1966. This approach is the most popular approach for removal of the first thoracic

and accessory cervical ribs in nowadays all around the world.

Personally, I use exclusively this D. Roos transaxillary approach for all true thoracic outlet syndrome cases: for

arterial 2, 65

, venous and neurogenic.

I shall describe in this article the most important aspects of this operation only in short, because most patients

want to know how the operation is performed, what are the risks and dangers of this operation.

Technique of the operation

Patient is intubated and placed in a straight lateral position with the symptomatic side uppermost, then tilted back

slightly towards the surgeon, who stands behind the patient (figure 14). The second assistant stands cephalad to the

surgeon to elevate and control the upper extremity for exposure at appropriate times. He abducts the brachium 900

from the thorax and holds the forearm in a double wrist-lock, which is the most comfortable and effective grip to

elevate the shoulder intermittently during the operation. The surgeon must instruct the assistant to elevate the arm and

shoulder slowly and gently, with a “light touch “to avoid

sudden or prolonged stretching of the brachial plexus.

Figure 14

Figure 15 illustrates the schematic representation of the important anatomic structures in the thoracic outlet from the

right armpit view.

Figure 15

Figure 16 illustrates the schematic representation of the important anatomic structures in the thoracic outlet while

cutting the first rib with bone shears. It is important for surgeon to be very careful for preserving the brachial plexus,

particularly the first thoracic root from damaging, while exposing, denuding, cutting and removing the first rib. First

thoracic root is protected during the rib cutting with special spatula, as it is showed in figure 16.

After the first and cervical rib (if present) removal, the wound is closed. Drainage of pleural cavity may be

required if the pleura was inadvertently opened during the first rib stripping. In most instances, good lung inflation

and expansion is sufficient even in opened pleura cases and wound can be closed airtight, if the wound hemostasis is

absolute.

Figure 15: Schematic representation of the

important anatomic structures in the

thoracic outlet

Skin incision is made over the third rib below

the hairline of the axilla between pectoralis

major and latissimus dorsi muscles.

Subclavian vein is depicted in blue,

subclavian artery - in red and brachial

plexus - in yellow colors. Scalene muscles

are depicted in brown color. Anterior

scalene muscle passes between the

subclavian artery and vein and inserts to the

first rib.

Figure 14: Position of the patient on the operation table and

position of the second assistant and of his arms and hands in

elevation of patient’s arm

Picture clearly indicates the patient’s position on the table and the

second assistant’s position in regard to the patient. Symptomatic

arm is elevated by the assistant with a double wrist-lock grip, when

the operation proceeds to the thoracic outlet deep in the armpit.

Figure 16

Cervical outlet syndrome

Cervical outlet syndrome is by far more prevalent in comparison to the thoracic outlet syndrome and is encountered

in 5-10% of population. The problem is that most physicians are unfamiliar with the symptoms, diagnostics and

treatment of this widespread health trouble. Many patients with cervical outlet syndrome symptoms are

unsuccessfully seeking the true diagnosis and help. These patients have neurogenic symptoms due to the compression

of brachial plexus nerve roots in the interscalene gap, but most of them suffer by far more prominently because of

vertebrobasilar insufficiency (insufficiency of blood flow through the vertebral arteries to the brain stem and to the

occipital region of the brain hemispheres). The most common symptoms of vertebrobasilar insufficiency are:

dizziness, vertigo episodes, fatigue, visual disturbances (diplopia, blurring of the vision, skotomas, sometimes even

blindness), noise in the ears, deafness. Many patients have cardiac symptoms: paroxysmal tachycardias, arhytmias,

extrasystolias, heartaches. Almost all of them have symptoms resulting from insufficient brain blood flow:

nervousness, sleep disorders, mental retardation and exhaustion, memory deterioration. Some patients develop even

frank vertebrobasilar strokes with paralysis. The overwhelming majority of these patients can be cured and can be

healthy, if the correct diagnosis would be established and adequate surgical treatment would be provided to them by

qualified and experienced in this field surgeon. Compression of brachial plexus roots manifest as numbness, tingling,

pain in the arms, upper chest, face, neck, between the scapulae. However, most patients with cervical outlet syndrome

suffer by far more from vertebrobasilar insufficiency than from neurogenic symptoms and they are seeking doctor’s

help because of vertebrobasilar insufficiency symptoms. Some of these patients have Raynaud’s syndrome in the

upper extremities due to the compression and irritation of sympathetic fibers in the interscalene gap, passing in the

brachial plexus roots and in the wall of subclavian artery. Hands of these patients are cold, bluish, extremely sensitive

to the cold exposure and react to the cold by contraction of small arteries and arterioles. After exposure to the cold,

hands become pale, cold, and even painful. Scalenectomy (removal of scalenus anterior muscle) cures all the

symptoms: vertebrobasilar insufficiency, neurogenic symptoms and Raynaud’s syndrome. The most important

clinical expression of cervical outlet syndrome is vertebrobasilar insufficiency due to the compression (by

scalenus anterior muscle: inside the muscle or between the muscle and spinal column) and spasm of vertebral

arteries in the cervical outlet. The health problem typically is bilateral, symmetrical, because, as a rule, cervical

outlet syndrome is bilateral, symmetrical as well as compression of vertebral arteries with scalenus anterior muscle is

bilateral too.

My intensive experience in diagnosing and operating cervical outlet syndrome in patients (over 1 000 operations)

enable me to state the following postulates:

Compression of vertebral arteries with scalenus anterior muscle is the most common sequela of cervical outlet

syndrome. Nerve roots of brachial plexus can be compressed, but can be not compressed in cervical outlet

syndrome. Therefore, most of patients with cervical outlet syndrome have symptoms of vertebrobasilar

insufficiency and complain of them.

Consequently, duplex scanning and color doppler studies of vertebral arteries and assessment of their flow are

mandatory in evaluation of these patients, especially if the patient is intended to be operated. During the

operation, vertebral artery must be exposed, explored totally from the origin on the subclavian artery up to its

Figure 16: Schematic illustration of safe dividing

of the posterior part of the first rib

Eighth cervical and first thoracic roots of brachial

plexus are protected with special spatula while

dividing the first rib.

These nerve roots should be clearly seen by the

surgeon, while stripping and cutting the first rib.

5,6,7,8 – cervical nerve roots

1 – first thoracic root.

entrance into the vertebral column not to leave uncorrected its problem while removing scalenus anterior

muscle, because left unrepaired vertebral artery problem results in remaining vertebrobasilar symptoms after

the operation. Repetitive second time operation for correction of vertebral artery pathology is by far more

complicated and dangerous than to repair its problem while removing scalenus anterior muscle.

Patients having symptoms of vertebrobasilar insufficiency and who for this reason have had angiographic

evaluation of vertebral arteries and their data have not suggested vertebral artery pathology, should be

evaluated by duplex and color doppler studies, because angiography can be misleading if performed in

standard fashion (vertebral arteries can appear normal in the anterior-posterior standard view on angiograms,

because they will be compressed minimally due to relaxation of deep neck muscles while patient lying on the

angiography table and because the main mechanism of vertebrobasilar insufficiency is the spasm of vertebral

arteries in response to their compression and irritation by scalenus muscle). Duplex scanning and color

doppler in experienced hands are very sensitive and accurate tools for diagnosing compression of vertebral

arteries by scalenus muscle. They permit to obtain the qualitative and quantitative analysis of blood flow

disturbances in vertebral arteries as well as alterations of vertebral artery lumen.

The main diagnostic tool for cervical outlet syndrome is duplex scanning and color doppler studies of

vertebral arteries.

Isolated neurogenic cervical outlet syndrome symptoms without symptoms of vertebrobasilar insufficiency

usually manifest after the whiplash injury to the neck scalenus muscles during the car accident or similar

injury. Scalenectomy is curative in these patients.

Some patients with cervical outlet syndrome have Raynaud’s syndrome due to the compression and irritation

of sympathetic fibers in the brachial plexus and arterial wall of subclavian artery. Scalenectomy cures the

Raynaud’s syndrome in these patients.

Many of patients with cervical outlet syndrome suffer from intensive headaches and, as a rule, are treated as a

migrenous patients. Considerable part of these patients have symptoms of vertebrobasilar insufficiency as

well. Scalenectomy cures the headache and the symptoms of vertebrobasilar insufficiency in these patients.

Diagnostic evaluation

Neurogenic cervical outlet syndrome is diagnosed in accordance with appropriate symptoms and their distribution:

pain, tingling and numbness in the neck, arms, upper chest, upper back, sometimes in the face and head region,

tightness and stiffness of the muscles in the neck, upper back, upper chest, arms. Diagnosis is confirmed by the

positive Roos test in elevated arms position as it is showed in figure 11. This test is a reliable diagnostic tool in

establishing the cervical and thoracic outlet syndromes. Typically, this test provokes and enhances the existing

neurogenic symptoms of cervical outlet syndrome. If this test is negative, strong suspicion for cervical outlet

diagnosis should emerge. Patients having cervical outlet syndrome typically have taut painful scalenus anterior

muscle: pressure by finger on it above the clavicle provokes the pain and the muscle is felt as a taut roll.

Typically, in case of cervical outlet syndrome, subclavian artery as well as roots of brachial plexus is

compressed between the scalenus muscles. Therefore, disappearance or diminution of pulse in the wrist during

Adson’s maneuver or Roos test strongly supports the cervical outlet syndrome diagnosis. Symptoms of

vertebrobasilar insufficiency are very characteristic for cervical outlet syndrome as well. Raynaud’s syndrome or

phenomenon are very common in these patients too. Wrist and palm arteries are very spasmatic in these patients and

this spasm can be demonstrated by sphygmomanometer or by continuos wave doppler apparatus.

Other instrumental investigations: electromyography, nerve conduction studies, assessment of evoked potentials

are of minimal value in establishing the cervical and thoracic outlet syndrome diagnoses, because they are positive

only in delayed cases when pronounced morphologic changes in nerves are present. Patients should be operated

earlier, before the appearance of such delayed pronounced and not reversible changes in nerves.

The main and crucial point in evaluation of the patient is to distinguish the cervical outlet syndrome from

thoracic outlet syndrome, because in the cervical outlet syndrome scalenectomy through the supraclavicular

approach is required and in the thoracic outlet syndrome – first rib resection through the transaxillary approach is

required. Consequently, different approaches and different surgical procedures are required in these both different

outlet syndromes.

Patient should ask two questions for surgeon before deciding to have the operation: 1) how many such

operations the surgeon have performed and 2) what are the results and personal surgeon’s complications in these

operations. Only then, patient can decide to entrust or not his health or even the life to that surgeon.

Scalenectomy and first rib resection procedures are not risky and dangerous or otherwise difficult for the

experienced surgeon and their results are gratifying if the diagnosis was made correct and the procedure is performed

adequately and professionally.

Arterial cervical outlet syndrome (compression of vertebral artery with scalenus anterior muscle)

Anterior scalenus muscle is prone to the development anomalies. It can originate more medially than normal on the

first rib or insert lower than normally to the spine, to the transverse process of seventh vertebra or can be as a one

solid mass together with the medius scalenus muscle. These development anomalies create problems for brachial

plexus nerve roots, passing the interscalene gap, and can compress the vertebral artery against transverse processes of

cervical vertebrae. Normally, vertebral artery originates from subclavian artery just medial from the medial border of

the scalenus anterior muscle. In case, the vertebral artery originates more lateral than normally from subclavian artery

(so called lateral branching of vertebral artery), it falls into conflict with scalenus anterior muscle and is compressed

by it. The same problem arises when the scalenus anterior muscle originates more medial than normally on the first

rib and compresses the vertebral artery. Vertebral artery is compressed when it enters bony canal of cervical vertebrae

higher than normally. Normally vertebral artery enters bony canal at the sixth cervical vertebra (into transverse

process of the sixth cervical vertebra). Scalenus anterior muscle starts to attach to the sixth transverse process and

attaches to the fifth, fourth and the third cervical vertebrae. That’s, why vertebral artery passes the neck in the bony

canal (it is preserved by the bony canal from the compression and entrapment by muscle fibers and tendons). If the

vertebral artery enters bony canal higher than normally (into fifth, fourth, or even third cervical vertebrae), it

inevitably falls into conflict with the scalenus anterior muscle and is compressed by it against the cervical vertebrae.

Compression of vertebral artery narrows its lumen and diminishes blood flow through it. Another, even more

important factor of blood flow diminution through the vertebral arteries is their spasm. Compression of vertebral

artery by the muscle causes its spasm and it can be very severe, up to the almost total occlusion of vertebral artery.

This results in deep fall of blood flow through the vertebral arteries and consequently - brain perfusion and results in

development of obvious ischemic vertebrobasilar stroke symptoms including paralysis. Usually, symptoms of

vertebrobasilar insufficiency are not so dramatic and manifest as dizziness, sometimes vertigo episodes, nausea,

equilibrium and visual disturbances, tinnitus or noise in the ears, headache, poor memory, rapid mental tiredness,

vegetodystonic symptoms, cardiac rhythm disorders: extrasystolia, tachycardia, heartaches etc.

Figure 17 represents the compression of both subclavian and both vertebral arteries by scalenus anterior muscle

as seen on the MRA (magnetic resonance angiography).

Figure 17

Both vertebral arteries and both subclavian arteries are compressed and narrowed by scalenus anterior muscle. Both

vertebral arteries originate from subclavian arteries more laterally than normally, together with the thyreocervical

trunk under the scalenus anterior muscle and are compressed by them (so called lateral branching of vertebral

arteries). Both subclavian arteries are compressed and narrowed by scalenus anterior muscle. It means that the gap

between the scalene muscles (spatium interscalenum) is too narrow.

Figure 18 represents the same patient and the same arteries as in figure 17 but the image is obtained by

computer reconstruction of CT angiography.

Figure 17: Arterial cervical outlet sindrome: compression

of both subclavian and both vertebral arteries by scalenus

anterior muscle (magnetic resonance angiography)

1- The right vertebral artery

2- The left hypoplastic vertebral artery

3- Sites of compression of the left subclavian and left

vertebral arteries

4- Sites of compression of the right subclavian and

vertebral arteries.

The left vertebral artery from the embryological period is

compressed by scalenus anterior muscle. Therefore, she has

low blood flow from that period and due to this reason it

did not develop to the normal lumen and stayed narrow,

hypoplastic.

Figure 18

The diagnostic evaluation of arterial cervical outlet syndrome is based on the duplex scanning and color doppler

studies. The surgeon, operating this pathology, can diagnose compression and various other anomalies of vertebral

arteries best. The establishment of correct diagnosis is very important, because without correct diagnosis is

impossible the adequate treatment. The surgery for cervical outlet syndrome is very effective and, as a rule, patients

after the operation are completely healthy. Scalenectomy clears symptoms of vertebrobasilar insufficiency and

neurogenic symptoms due to the compression of brachial plexus roots as well.

Physician must know that compression of vertebral artery and of brachial plexus in cervical outlet syndrome are

usually combined and symptoms in patients exist from both these problems. The task for the physician is to sort and

to understand these symptoms arising from these two closely related problems: vertebral artery and brachial plexus

compression.

Below, I shall illustrate the capabilities of duplex scanning and color doppler studies in diagnostic evaluation of

cervical outlet syndrome (compression of vertebral arteries with scalenus anterior muscle).

Figure 19 illustrates uncolored duplex scan image and spectral blood flow analysis of the vertebral artery,

compressed with the scalenus anterior muscle due to its abnormal attaching to the seventh cervical vertebra. Figure

18 is the image of the same artery at the same site, just with switched on the color doppler. The vertebral artery is

compressed against the transverse process of the seventh cervical vertebra by abnormal pedicle of the scalenus

anterior muscle attaching to this transverse process. The vertebral artery is tightly narrowed at this site and this is

seen on the blood flow curve (high systolic and diastolic blood flow velocity values, abnormal curve with high level

of turbulence in the blood flow). The same features are seen and in the image with switched on color doppler (figure

20). Only the proximal part of vertebral artery is seen on the image, because higher it hides under the muscle. Very

intensive turbulence in vertebral artery (yellow and blue color) is seen on color doppler image. Blue color means that

even reversed blood flow in the whirls inside the vertebral artery is present. Upstream, in the bony canal, blood flow

in the same vertebral artery is slow (figure 21), but it is still with pronounced turbulence (flow curve descends below

the zero line during all the cardiac cycle).

Figure 18: Computer reconstructed image of CT

angiography (the same patient and the same arteries as in

the figure 17)

1- The right vertebral artery

2- The left hypoplastic vertebral artery

3- Site of compression of the left vertebral artery

4- Site of compression of the left subclavian artery

5- Site of compression of the right vertebral artery

6- Site of compression of the right subclavian artery

Both vertebral arteries originate from subclavian arteries

more laterally than normally, together with the

thyreocervical trunk under the scalenus anterior muscle and

are compressed by them (so called lateral branching of

vertebral arteries). The orifices of both vertebral arteries are

on the posterior aspect of the subclavian arteries and during

the compression are partially closed. Both subclavian

arteries are compressed and narrowed by scalenus anterior

muscle as well. It means that the gap between the scalene

muscles (spatium interscalenum) is too narrow.

Figure 19

Figure 20

Figure 21

In cases of high vertebral artery entrance into the bony canal (when it enters the bony canal higher than at the 6-th

cervical vertebra) always there is a conflict between the vertebral artery and muscles: scalenus anterior, longus colli

and longus capitis muscles. The vertebral artery is compressed by these muscles against the cervical vertebrae.

Consequently, high entrance of vertebral artery into the bony vertebral canal always is a pathology and always

interferes with blood flow in the vertebral artery.

Duplex scanning clearly defines not only the neck anatomy: muscles, vertebrae, blood vessels etc, but visualizes

the vertebral artery and its lumen as well.

Figure 19: Compression of the vertebral artery

with the abnormal scalenus anterior muscle at

the transverse process of the 7-th cervical

vertebra (black-white B ultrasound mode with

doppler blood flow measurement and spectral

blood flow analysis).

Note the very impressive turbulence of the blood

flow seen on the curve in the figure 19. The

blood flow in the compressed narrowed part of

the vertebral artery is fast (over 120 cm/sec).

All these features mean hemodynamically

significant narrowing of vertebral artery at the

site of compression.

Figure 20: Compression of the vertebral

artery with the abnormal scalenus anterior

muscle at the transverse process of the 7-th

cervical vertebra (the same artery and the

same site as in figure 19, just the color doppler

is switched on).

Blood whirls in the vertebral artery are colored

in blue, what means that blood flow in the

whirls is in reversed direction (very high

turbulence).

Blood flow velocity and the blood flow spectral

analysis curve are the same as in the figure 19.

Figure 21: Blood flow in the same vertebral

artery as in the figures 19 and 20 at the upper

level (inside the bony canal in the spinal

column)

Blood flow velocity in the vertebral artery

above the obstruction is low, its curve is

flattened, poststenotic. However, it is still

markedly turbulent (blood flow curve descends

below the zero line, what means reversed blood

flow in the whirls).

Next five pictures illustrate the vertebral artery, compressed with the abnormal pedicle of scalenus anterior

muscle, attaching to the seventh transverse process of cervical vertebra. The compression of vertebral artery is mainly

with tendinous border of that abnormal pedicle, clearly seen on echo images. Figure 22 is the image, obtained with

color doppler. Compression of the vertebral artery close to its orifice is clearly seen as narrowing of its lumen at the

place of compression. During the cardiac contraction (systole) blood spurt is injected through the narrowed,

compressed part of vertebral artery, seen as yellow spurt on that picture. Yellow whirls of turbulent blood (yellow

rings) are flowing upstream. Before the obstacle, the whirls during cardiac systole are colored even in blue color,

because blood flow in these whirls assume reversed direction. Doppler probe is placed exactly on the narrowed

vertebral artery place and therefore linear blood flow in that place is accelerated (131 cm/sec in the systole).

Figure 22

Figure 23

Figure 24

Figure 23: The same vertebral artery at the same site

as in the figure 22, just with the color doppler

switched off (a probe moved about 2-3 mm cephalad

after the compression)

You can see the tendinous white border of the

additional abnormal pedicle of scalenus anterior

muscle, attaching to the transverse process of the

seventh cervical vertebra (on the image with color

doppler, fig.22, this site corresponds to the significant

narrowing of the vertebral artery).

Blood flow curve is very similar to the curve recorded

in fig. 22, just the turbulence is more pronounced.

Figure 24: Blood flow features 1 cm after (cephalad)

to the compression of vertebral artery. The same

vertebral artery as in figures 22, 23

Blood flow in the vertebral artery distal to the site of

compression is abnormal, very turbulent. Blood flow

curve is abnormal too. Dense turbulence is seen on the

curve.

Figure 22: Left vertebral artery is compressed by

abnormal additional pedicle of scalenus anterior

muscle, attaching to the transverse process of the 7-th

cervical vertebra (color doppler image)

There is a high turbulence at the site of compression.

Turbulent whirls of blood flow are seen as yellow and

blue spots and rings in the artery. The blue color

means that blood flow in the whirls in that place is in

reversed direction. The spurt of blood flow (yellow

color) is injected during the cardiac contraction

(systole) into the vertebral artery through the

compressed, narrowed its part.

Blood flow curve indicates high linear blood flow in

the systole and intensive turbulence during all the

cardiac cycle.

Figure 25

These two cases of compressed vertebral artery by scalenus anterior muscle illustrate the effectiveness and

informativeness of duplex scanning and color doppler in evaluation of external (extravasal) compressions of vertebral

arteries. These ultrasound studies are superior to the angiographic studies, because they provide not only the anatomic

and morphologic data, but hemodynamic data as well. They enable the examiner not only to diagnose the pathology

of vertebral artery, but also to determine its hemodynamic significance. Of course, the examiner must be well trained

and experienced in this field. Otherwise, misdiagnosis or diagnostic failures will be inevitable.

In conclusion, the clinical diagnosis is established relying on anamnestic data, clinical inspection and evaluation of

patient, ultrasound studies. Angiographic evaluation is excessive and less informative than ultrasound studies of

vertebral arteries.

Surgical treatment

Intensiveness of vertebrobasilar symptoms is the main factor in making decision as to operate or not the patient with

the cervical arterial outlet syndrome (compression of vertebral arteries). Light and mild symptoms can be managed

medically without an operation. Severe symptoms are the indication for surgical treatment – removal of scalenus

anterior muscle. The operation is simple and easy for patient and surgeon, provided the surgeon has enough

experience in these operations. In my practice, the patient makes the decision to have the operation or not. The duty

of surgeon is to provide all the information for the patient about his illness and the ways his problem can be managed.

As my extensive experience in this field of surgery indicates, most patients select the surgical treatment, because they

want to be completely healthy and surgery makes it real.

Supraclavicular approach is used for this operation. This approach enables to remove completely the anterior

scalenus muscle and to free from compression and inspect visually the roots of brachial plexus and vertebral artery.

Vertebral artery is accessible from its origin up to its entrance into the bony canal in the spine independently from the

height of its entrance.

The main and most important guarantee of successful treatment of these patients, including surgical treatment,

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