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Diagnosis and Treatment of Thoracic Outlet Syndrome

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Diagnosis and Treatment of Thoracic Outlet Syndrome PERIPHERAL NERVE ISSUES: CONTROI-ERSIES AND EVOLVING TREATMEh'TS 1042-3680/01 $15.00+ .00 DIAGNOSIS AND TREATMENT OF THORACIC OUTLET SYNDROME Rishi N. Sheth, MD, and Allan J. Belzberg, MD, FRCSC Thoracic outlet syndrome (TOS) is one of the for diagnosis, and defining the treatment proto- most controversial subjects in entrapment neu- col has never been undertaken. Future endeav- ropathies. Views differ regarding the patho- ors should include multicentric, randomized, genesis, diagnosis, and management of TOS. prospective clinical trials so as to ansrver these Some authorities even question its existence. questions. In spite of lack of understanding of the dis- Until the first half of the nineteenth cen- ease, clinicians often encounter patients whose tury, several terms were assigned to describe pain or neurologic deficits in the upper limb the symptom complex caused by neurovas- cannot be explained after ruling out cervical cular compression in the upper thoracic re- spine diseases and other common causes of pe- gion based on the physiologic mechanism ripheral neuropathies. The goals of this article and structure that caused the compression arc to provide a comprehensive understanding (Table 1).Such rigid classification was the basis of the syndrome by reviewing the anatomy of for explaining the pathogenesis, diagnosis, and the region and the pathomecl~anismof the dis- treatment.224"5 80 In 1956, Peet et al-' coined a ease. Diagnosis can be established confidently common term, thomcic outlet syfdr.o:w,to en- in cases where the neurologic deficits are ob- compass these various entities. It is now re- vious and tests sho~t-positive findings. Issues alized that strict classification is not practical. surrounding cases TI-here the objective find- Patients tend to have multiple abnormalities, ings are minimal are discussed. The duration of which may be responsible for the compression conservative treatment, indications for surgery, of the neurovascular bundle, and the clinical surgical approach, and patient selection for presentation is not unique to one ~yndrome.~" surgery are not standardized, and experiences vary across institutions. A number of studies in the past have shown conflicting results on the ANATOMY outcome of various surgical approaches, which has only added to the confusion. A systematic It has to be noted that TOS is a misnomer. scientific approach aimed at understanding the Anatomically speaking, the true thoracic out- pathogenesis of TOS, elucidating the criteria let is at the level of the diaphragn~.~'Early From the Department of Seurosurger!; Iohns Hopkins University School of Medicine, Baltimore, Maryland NEUROSURGERY CLINICS OF NORTH A-MERICA VOLUME 17. NUMBER 7 APRIL 2001 295 296 SHETH & BELZBERG Table 1. SYNDROMES INCLUDED UNDER THE DESIGNATION "THORACIC OUTLET SYNDROME" Cervical rib syndrome Bracllial pIe\us syndroine Costoclavicular syndroine Adson's syndrome First thoracic rib s!-ndrome Paget-Scliroetter syndrome Scalenus anticus s!-n~lromr Shoulder-girdle syn~ircmw Hyperabduction s!.~-drorne Fractured cla\.icle syndrome Cervicobracliial neuro\-ascular compression spdrome Cervical brachial compression syndrome Shoulder-arm syndrome Pectoralis ininor syndrome Effort vein t11rombor;is syndrome IHumeral head syndrome Pi~eumatichammer 51.ndrome Rucksack paralysis authors described the syndrome of neurovas- the coracoid process of the scapula. The bundle cular compression at the superior aperture of is closely related to the fibrous clavipectoral the thorax as TOS, and this incorrect term has fascia and the dense costocoracoid ligament since remained in the medical vocab~lary.~~~anteriorly. As the flat tendon of pectoralis The anatomy of this region is . complex, minor muscle ascends laterally to insert on the and understanding the relation between the upper border of the coracoid process, it crosses neurovascular structures and the surro~~nding the subcoracoid space."' The ligament and muscles and bony structures is critical in un- tendon becoine taut during hyperabduction to derstanding the cause of compression. significantly compress the space. The neurovascular complex traverses through three narroI\- straits within the tho- PATHOMECHANISM racic outlet before entering the arm (Fig. The first passage, the so-called "scalene trian- Compression of the neurovascular structures gle," is mainly formed by muscles. The thoracic as they course through the narrow passages of rib forms the base, and the anterior and middle the upper thoracic aperture before entering the scalene muscles form the anterior and poste- arm causes TOS. Any factor that compromises rior borders, respecti\.el!: The scalene muscles this narrow passage, which eventually leads to arise from the tubercles of the transverse pro- compression of neurovascular structures, can cesses of the cervical \-ertebrae and insert on be included as a possible cause of TOS. These the dorsal surface of the first rib. Although the factors can be classified as: hiatus transmits all the trunks of the brachial plexus, only the subcla1-ian artery and lower Anatomic or structural abnormalities: con- genital (cerl-ical ribs and fibromuscular trunk are closely related to the first rib. The bands) and acquired causes subclavian vein passes in front of the anterior Pl~ysiologicor dynamic factors: develop- scalene muscle." After passage through the in- mental and postural factors terscalene triangle, the neurovascular bundle Traumatic factors passes through the costoclavicular triangle. Idiopathic factors Bordered by the first rib below, the clavicle and the subclavius muscle superiorly, and the A number of hypotheses have been proposed upper border of the scapula and subscapularis to explain the mode of compression in cases muscle posteriorly, this hiatus transmits all where structural abnormalities are not obvious. the nerve trunks, the subclavian artery, and the vein. It has to be noted that the first rib is Structural Anomalies a structure common to both passages, and one of the surgical options is to resect the normal Congenital Anomalies rib so as to pave the Ivay to a wider passage. Finally, the neurovascular bundle traverses the Although congenital anomalies of all struc- subcoracoid space, a short tunnel just beneath tures that form the borders and contents of the DIAGNOSIS AND TREAT\IENT OF THORACIC OUTLET 5\?23OME 297 - C, Vertebra Figure 1. The anatomic relation of the neurovascular bundle with adjacent structures. As the brachial plexus and the axillary artery emerge between the scalenes, they loop above the first rib then pass behind the clavicle. Note that the subclavian vein lies outside the scalene triangle. The spinal nerves are numbered on the left and the vertebrae on the right. (Adapted from Travel1 JG, Simons DG (eds): Myofascial pain and dysfunction, vol 1. Baltimore, William and Wilkins, 1983: with permission.) thoracic outlet have been known to compro- to reach into the arm, which can result in mi- mise the space through which the neurovascu- crotrauma to the nerves from stre~chingand lar structures course, the common anomalies compression." are described here. Cervical ribs are supernu- Fibrous bands are the most common con- merary ribs and can be fully or partially de- genital anomaly encountered thar cause the veloped. If a cervical rib is formed partially, sy~nptomsof TOS. Various kinds of fibrous it is associated with a ligamentous extension bands have been encountered, SF?, attempts that inserts on the manubrium or the rib be- lm\-e been made to classify tbsm accord- low. Incidence varies from 0.0004% to 1.5% ing to their origin, insertion, ani associated according to various studies.' '' 31 4y Fifty per- struct~res.'~'' As these anomalous structures cent of cervical ribs occur bilaterally, and, cu- tr'I\-erse through the thoracic outl?: they tend riously, there is a female predominance. The to elevate, kink, and compress the Rtlurovascu- mere presence of this anomaly does not con- lar bundle against the surrounding anatomic fer the diagnosis of TOS because only 5% to borders of the thoracic outlet. Anonlalous mus- 10% of individuals with cervical ribs actually cular insertion and muscle hyperrrophy have develop the symptoms of TOS.4XThe presence been described to cause TOS, as :bey tend to of this anomaly creates a barrier over which trap the loxver trunk of the plexus ayd the sub- the neurovascular bundle has to acutely ascend cla\.ian artery.'j 298 SHETH & BELZBERG Acquired Anomalies and age all tend to sag the scapula, which puts These anomalies are space-0ccup.i-ing le- extra tension on the plexus." - sions and can arise from the struct&-es that Certain postures of the body tend to exac- form the borders or the thoracic outlet or from erbate or provoke the symptoms of TOS. Any structures outside the outlet. Such lesions limit position of tlie arm that stretches or compresses the neurovascular bundle into a narrow con- the plexus against the bones may consistently finement. Fractures of the clavicle leading to reproduce symptoms. Hyperabduction with external rotation of the arm is the most common malunion or formation of a large callus have position with ~\~hicllpatients associate their been reported to cause TOS by reducing the symptoms. At arm abduction above 90°, the costoclavicular space. Although uncommon, costoclavicular triangle closes, thereby com- benign or malignant tumors of the first rib or the clavicle ha\-e been described as caus- pressing the cords between the bones.71 Pa- tients usually complain that symptoms are
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