thoracic outlet syndrome thoracic outlet syndrome prof. t. vidyasagaran hod, dept of vascular...
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Thoracic
Outlet
Syndrome
Thoracic
Outlet
SyndromeProf . T. VidyasagaranHOD, Dept of Vascular SurgeryVascular Surgeon, Chennai.
Prof . T. VidyasagaranHOD, Dept of Vascular SurgeryVascular Surgeon, Chennai.
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DefinitionDefinition
Upper extremity symptoms
due to compression of the
neuro vascular bundle in the
Thoracic Outlet Area
Upper extremity symptoms
due to compression of the
neuro vascular bundle in the
Thoracic Outlet Area
TOSTOS
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95 % Neurogenic
1 % Arterial
2 - 4 % Venous
95 % Neurogenic
1 % Arterial
2 - 4 % VenousVasculogenicVasculogenic
TOSTOS
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TOSTOS
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Three SpacesThree Spaces
Scalene TriangleScalene Triangle
Costoclavicular spaceCostoclavicular space
Pectoralis minor spacePectoralis minor space
TOSTOS
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TOSTOS
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Predisposing Anatomic FactorsPredisposing Anatomic Factors
Bony
Congenital narrowing - Cervical 4.5 %
Rudimentary rib
Long C7 transverse process
Acquired narrowing - Malunion
Callus
Exostosis or tumors
Bony
Congenital narrowing - Cervical 4.5 %
Rudimentary rib
Long C7 transverse process
Acquired narrowing - Malunion
Callus
Exostosis or tumors
Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS
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Scalene MuscleScalene Muscle
Neck trauma - Primary cause
Anatomy of muscle - Predisposing factor
for nerve compression
Splitting of SA
Scalene minimus
Interdigitation
Middle scalene 58 %
Neck trauma - Primary cause
Anatomy of muscle - Predisposing factor
for nerve compression
Splitting of SA
Scalene minimus
Interdigitation
Middle scalene 58 %
SASASMSM
BPBP AA
RibRib
SASASMSM
BPBP AA
Rib0.3 - 2 cms
Rib0.3 - 2 cms
VV VV
TOSTOS
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Automobile accidents
Hyperextension neck injuries
Repetitive stress injuries
Automobile accidents
Hyperextension neck injuries
Repetitive stress injuries
Neck TraumaNeck Trauma
Keyboard Jobs Arm Neck stretching
Keyboard Jobs Arm Neck stretching
Neurogenic TOSNeurogenic TOS
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SymptomsSymptoms
Young 20 - 45 years70 % WomenParesthesia
All nerves CommonestUlnar Lower chord Median Upper chord
PainHeadaches occipitalScapular pain
Trapezius Dorsal scapular nerveRhomboids
WeaknessVascular - sympathetic response
Young 20 - 45 years70 % WomenParesthesia
All nerves CommonestUlnar Lower chord Median Upper chord
PainHeadaches occipitalScapular pain
Trapezius Dorsal scapular nerveRhomboids
WeaknessVascular - sympathetic response
Neurogenic TOSNeurogenic TOS
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Clinical DiagnosisClinical Diagnosis
Supraclavicular muscle tenderness Tinel’s signs - specific signs AER - EAST Decreased sensation to light touch Adson’s 50 % normal individuals
30 % of TOS
Supraclavicular muscle tenderness Tinel’s signs - specific signs AER - EAST Decreased sensation to light touch Adson’s 50 % normal individuals
30 % of TOS
Positional Maneuvers
Pulse deficit
Positional Maneuvers
Pulse deficit
Neurogenic TOSNeurogenic TOS
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Diagnostic TestsDiagnostic Tests
Scalene muscle block 4 ml 1 % lignocaine
ASM - Tender area cephalad
94 % - with surgical decompression
Scalene muscle block 4 ml 1 % lignocaine
ASM - Tender area cephalad
94 % - with surgical decompression
Neurogenic TOSNeurogenic TOS
2 cms above clavical3 cms lateral to the midline
2 cms above clavical3 cms lateral to the midline
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X ray chest (upper thoracic)
X Ray neck - AP - oblique cervical spine
MRI
X ray chest (upper thoracic)
X Ray neck - AP - oblique cervical spine
MRI
Neurogenic TOSNeurogenic TOS
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DDDD
Neurological diseases Spinal cord tumor Multiple sclerosis
Shoulder disorders Shoulder tendinitis Myositis
Nerve compression syndrome Carpal tunnel guyen tunnel Cuboid tunnel epicondylitis
Neurological diseases Spinal cord tumor Multiple sclerosis
Shoulder disorders Shoulder tendinitis Myositis
Nerve compression syndrome Carpal tunnel guyen tunnel Cuboid tunnel epicondylitis
Neurogenic TOSNeurogenic TOS
Cervical spine pathology Cervical spine injury Disc herniation Spinal stenosis
Sympathetic diseases Raynaud’s Reflex sympathetic dystrophy
Cervical spine pathology Cervical spine injury Disc herniation Spinal stenosis
Sympathetic diseases Raynaud’s Reflex sympathetic dystrophy
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TreatmentTreatment
Non operative modalities Neck stretching Abdominal breathing Posture exercise Shoulder shrugs Lifting light weight Neck traction
Non operative modalities Neck stretching Abdominal breathing Posture exercise Shoulder shrugs Lifting light weight Neck traction Strengthening
Exercise WorsensStrengthening
Exercise Worsens
IneffectiveIneffective
Neurogenic TOSNeurogenic TOS
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SurgerySurgery
Failure of Conservative Disabling symptoms Work
RecreationDaily living
Symptoms more than a year
Failure of Conservative Disabling symptoms Work
RecreationDaily living
Symptoms more than a year
Neurogenic TOSNeurogenic TOS
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Decompression of brachial plexusDecompression of brachial plexus
Rib excision
Scalenectomy
Rib excision
Scalenectomy
PrinciplesPrinciplesNeurogenic TOSNeurogenic TOS
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ComplicationsComplications
Less than 1 %Less than 1 %
Nerve Injuries
Bleeding
Lymph leakage
Nerve Injuries
Bleeding
Lymph leakage
Neurogenic TOSNeurogenic TOS
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Post stenotic dilatation
Aneurysmal dilatation
Thromboembolic complications
Post stenotic dilatation
Aneurysmal dilatation
Thromboembolic complications
Arterial TOSArterial TOS
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Pathophysiology Pathophysiology
Significant
Permanent
Long standing
Congenital or acquired bony abnormality
10 years older than neurogenic TOS
Significant
Permanent
Long standing
Congenital or acquired bony abnormality
10 years older than neurogenic TOS
Arterial TOSArterial TOS
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DiagnosticDiagnostic
History
Examination - Pulsatile SC mass - bruit
Radiological - Cervical spine - Upper thoracic
Duplex
Arteriography DSADynamic views
Helical CT MRA
Surgical exploration
History
Examination - Pulsatile SC mass - bruit
Radiological - Cervical spine - Upper thoracic
Duplex
Arteriography DSADynamic views
Helical CT MRA
Surgical exploration
Arterial TOSArterial TOS
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Management PrinciplesManagement Principles
Surgery
Compression
Subclavian axillary artery lesions
Distal tree status
Surgery
Compression
Subclavian axillary artery lesions
Distal tree status
Arterial TOSArterial TOS
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ReconstructionReconstruction
PSD with no intramural thrombosis - No intervention
Tailoring subclavian artery
Intimectomy with tailoring subclavian artery
Vein patch closure
Resection Primary repairGraft interposition
PSD with no intramural thrombosis - No intervention
Tailoring subclavian artery
Intimectomy with tailoring subclavian artery
Vein patch closure
Resection Primary repairGraft interposition
Arterial TOSArterial TOS
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Distal EmbolismDistal Embolism
Multiple & diffuse
Various ages
Recent - Thromboembolectomy
Old - Bypass
Distal tree choked - Dorsal sympathectomy
Multiple & diffuse
Various ages
Recent - Thromboembolectomy
Old - Bypass
Distal tree choked - Dorsal sympathectomy
Arterial TOSArterial TOS
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Subclavian Axillary Vein ThrombosisSubclavian Axillary Vein Thrombosis
Paget Schroetter Syndrome
Primary Subclavian Axillary Thrombosis
Paget Schroetter Syndrome
Primary Subclavian Axillary Thrombosis
Venous TOSVenous TOS
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IncidenceIncidence
1.4 % of all DVT
25 % of all upper DVT
1.4 % of all DVT
25 % of all upper DVT
Venous TOSVenous TOS
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Clinical PresentationClinical Presentation
Young males 2 : 1
Age 30 years
Strenuous exercise - 75 %
Dominant extremity 60 - 80 %
Associated neurogenic 4 - 10 %
Young males 2 : 1
Age 30 years
Strenuous exercise - 75 %
Dominant extremity 60 - 80 %
Associated neurogenic 4 - 10 %
Venous TOSVenous TOS
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DiagnosisDiagnosis
Clinical swelling
Venous engorgement
Sudden onset
Duplex
Venography MRV
Radionuclide venography
Clinical swelling
Venous engorgement
Sudden onset
Duplex
Venography MRV
Radionuclide venography
Venous TOSVenous TOS
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TreatmentTreatment
Rest & Elevation
Systemic anticoagulation
Rest & Elevation
Systemic anticoagulation
LongTerm Morbidity
LongTerm Morbidity
Venous TOSVenous TOS
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Venous TOSVenous TOS
Restore luminal patency
Remove extrinsic compression
Intrinsic stenosis
Restore luminal patency
Remove extrinsic compression
Intrinsic stenosis
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Venous TOSVenous TOS
Thrombolytic Thrombolytic
Thrombectomy - with decompressionThrombectomy - with decompression
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ThrombolyticThrombolytic
Systemic
Catheter directed - Venographic evaluation possible
- Assess extrinsic compression immediately
- Oral anticoagulation 3 months / 1 month
- Decompression
- Balloon angioplasty & stenting
Systemic
Catheter directed - Venographic evaluation possible
- Assess extrinsic compression immediately
- Oral anticoagulation 3 months / 1 month
- Decompression
- Balloon angioplasty & stenting
Venous TOSVenous TOS
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PresentationPresentation
Duplex confirmDuplex confirm
Appropriate candidateAppropriate candidate
VenographyVenography
CD ThrombolysisCD ThrombolysisComplete lysisPositional venography
Complete lysisPositional venography
ECEC
TODTOD
No ECNo EC
AnticoagulationAnticoagulation
Intrinsic stenosisIntrinsic stenosis
TOD + Vein patch angioplastyor balloon angioplasty stent
TOD + Vein patch angioplastyor balloon angioplasty stent
Venous TOSVenous TOS
Incomplete lysisIncomplete lysis
AlgorithmAlgorithm
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Incomplete LysisIncomplete Lysis
Short occlusionShort occlusion
Operative thrombectomyorBalloon AP Stent
Operative thrombectomyorBalloon AP Stent
Long occlusionLong occlusion
AnticoagulationAnticoagulation
Persistent symptomsPersistent symptoms
SurgerySurgery
Venous TOSVenous TOS AlgorithmAlgorithm
FailureFailure
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Trinity Oration
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THANK YOU
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Scalene TriangleScalene Triangle
Commonest site of
Nerve compression
Brachial plexus
Subclavian artery
Commonest site of
Nerve compression
Brachial plexus
Subclavian artery
TOSTOS
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CostoclavicularCostoclavicular
Artery
Vein
Nerve
Artery
Vein
Nerve
TOSTOS
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Seldom involved in TOSSeldom involved in TOS
Pectoralis Minor SpacePectoralis Minor SpaceTOSTOSTOSTOS