Transcript Thoracic Outlet Syndrome

Thoracic Outlet Syndrome
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1. It refers compression of subclavian vessels
and brachial plexus at the superior
aperture of the thorax.
2. The symptoms can be neurologic or( and )
vascular.
3. The pain may be atypical and predominant
in the chest wall and parascapular area,
simulating angina pectoris.
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4. Diagnosis of nerve compression can be
determining the ulnar nerve conduction
velocity( UNCV ).
5. Physiotherapy to improve posture,
strengthen shoulder girdle, and stretch
neck muscle is used initially.
6. Surgery includes extirpation the first rib,
usually through transaxillary approach.
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A. ANATOMIC
CONSIDERATIONS
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• The subclavian vessels and brachial plexus
transverse the cervicoaxillary canal into the arm.
• The outer border of the first rib divides the canal
into a proximal and a distal division.
• The proximal division is composed of the
scalene triangle and the space bounded by the
clavicle and the first rib( costoclavicular space ).
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A. ANATOMIC
CONSIDERATIONS
4. The proximal division is the most critical
for neurovascular compression. It is
bounded superiorly by the clavicle and the
subclavius muscle; inferiorly by the first
rib; anteromedially by the sternum,
clavipectal fascia and the costocoracoid
ligament; and posterolaterally the scalenus
media muscle and the long thoracic nerve.
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A. ANATOMIC
CONSIDERATIONS
5. The axilla, which is the outer division of
the cervicoaxillary canal is bounded with
pectoralis minor muscle, the coracoid
process, and the head of humerus.
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A-1 Compression Factors
1. Many factors can induce thoracic outlet
syndrome, including congenital, trauma
and atherosclerotic factors.
2. Bony abnormalities are present in 30% of
patients, such as cervical rib, bifid first rib,
fusion of first and second ribs or previous
thoracoplasty.
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A-2 Adson or Scalene Test
1. The patient is asked to (1) take and hold a
deep breath (2) extend the neck fully (3)
turn the face into one side.
2. It will tighten the anterior and middle
scalene muscles.
3. Diminution or loss of the radial pulse
suggests compression.
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A-3 Costoclavicular Test
( Military Position )
1. The back is downward and backward.
2. The costoclavicular space will be
narrowed by approximating the first rib
and the clavicle.
3. Diminution or loss of the radial pulse
suggests compression.
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A-4 Hyperabduction Test
1. The arm is hyperabducted to 180 degrees.
2. Diminution or loss of the radial pulse
suggests compression.
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A-5 Arm Claudication Test
1. The shoulder is drawn backward and
upward. The arm is raised horizontally
with the elbow flexed 90 degrees.
2. With excise of hands, pain and numbness
indicates compression.
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B. SYMPTOMS AND SIGNS
1. Symptoms of never compression is present most
frequently.
2. Pain and paresthesia are present in 95% of
patients.
3. Motor weakness is present in 10% of patients.
4. Pain is insidious in onset and involves the neck,
shoulder, arm or hand.
5. Atypical pain involving anterior chest wall and
parascapular area is called pseudoangina.
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B. SYMPTOMS AND SIGNS
5. Symptoms of vascular compression is less
common than neurologic compression.
6. Symptoms of vascular compression
includes coldness, weakness, fatigability of
the hand and arm. Pain is more diffuse in
distribution.
7. Raynaud’s phenomenon is occasionally
seen.
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B. SYMPTOMS AND SIGNS
8. Venous compression is recognized by
venous distension, edema and discoloration
of the hand and arm.
9. Thrombosis of the subclavian vein( “ effort
thrombosis ” or Paget-Schroetter syndrome )
is infrequently.
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B. SYMPTOMS AND SIGNS
10. However, objective physical findings are
more in patients with vascular compression.
11. Objective physical findings of vascular
compression are diminution or loss of the
radial pulse in tests , Raynaud’s
phenomenon, venous distension or edema…
12. Objective physical findings of neural
compression are hypoesthesia, anesthesia and
muscle weakness and atrophy.
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C. DIAGNOSIS
1. PE, history, radiographs of chest and
cervical spine, neuroloical consultation,
EMG and UNCV.
2. Pulmonary, esophageal and chest wall
causes must be ruled out.
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C-1 Nerve Conduction Velocity
1. The normal average UNCV is 72m/sec
across the thoracic outlet.
2. In patients of thoracic outlet syndrome,
the average UNCV is 53m/sec( 32-65
m/sec ) across the thoracic outlet.
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C-2 Angiography
1. Bruits in the supra- or infraclavicular
spaces suggests stenosis, and absence of
pulse denotes total occlusion.
2. Retro- or antegrade arteriograms of the
subclavian and brachial arterial systems
are indicated.
3. Phlebograph is indicated in patients of
venous stenosis or obstruction.
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C-3 Differentiated Diagnosis
• Table 42-3
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D. THERAPY
1. Physiotherapy is performed before surgery.
2. Physiotherapy includes heat massage, active
neck exercise, scalenus anticus muscle stretching,
strengthening of the upper trapezius muscle, and
posture instrusion.
3. Most patients with a UNCV above 60 m/sec
improve with phsiotherapy.
4. Most patients with a UNCV below 60 m/sec
must undergo surgery with resection of the first
rib and correction of other bony deformities.
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D. THERAPY
5. Roos et al. suggested resection of the first rib, and
a cervical rib when present, is best performed
through the transaxillary approach, with
decompression of 7th and 8th cervical and 1st
thoracic root.
6. The anterior supraclavicular, infraclavicular and
posterior approach were ever reported.
7. Posterior approach is especially important because
80% of patients are females.
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D-1 Technique of Transaxillary
Resection of First Rib
1. The patient was placed lateral position with
involved arm abducted to 90 degrees.
2. A transaxillary incision was made between
pectoralis major m. and latissimus dorsi m.
3. The insertion of the scalenus anticus m. on the
first rib was dissected and muscle is divided.
4. The first rib is divided at middle portion.
5. The scalenus media m. can not be cut from the
rib. The long thoracic nerve must be preserved.
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D-1 Technique of Transaxillary
Resection of First Rib
6. It is preferable to remove the entire first rib.
7. The periosteum should be fragmented and
destoyed to avoid callus formation and
“ regeneration “ of the rib.
8. Removal of incompletedly resected or regenerated
rib and lysis of the brachial plexus can be done
through posterior approach.
9. The anterior supraclavicular approach is used for
arterial bypass and reconstruction.
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D-2 Results
1. The results of first rib resection is good in
85%, fair in 10% and poor in 5%.
2. Uniform improvement of symptoms is
usually in patients of primarily vascular
compression.
3. There are 2 groups of patients, who have
neural compression.
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D-2 Results
4. The 1st group includes patients with ulnar
neuralgia and diminution of radial pulse. 95% of
this group are improved after first rib resection.
5. The 2nd group includes patients with atypical
pain distribution with or without pulse change in
compression tests. Although many patients can
improve after first rib resection, the fair and poor
results may mostly occur in the group.
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D-2 Results
6. No hospital mortality is related directly to
the procedure.
7. Morbidity includes pneumothorax,
hematoma and infection.
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E. PAGET-SCHROETTER
SYNDROME
1. It refers “ effort “ thrombosis of the axillarysubclavian vein inducing by excessive or
unusual use of the arm in addition to one or
more compressive elements.
2. It is usually seen in professional athletes,
Linotype operators, painters and beauticians.
3. Anticoagulants and conservative exercise can be
used to treat it.
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E. PAGET-SCHROETTER
SYNDROME
4. First rib resection is indicated for patients
with recurrent disease when returning to
work.
5. Bypass with veins and other conduits has
limited application.
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F. RECURRENT THORACIC
OUTLET SYNDROME
1. 10% of surgically treated patients have
shoulder, arm or hands pain and
pareathesia. Most patients can be relieved
with physiotherapy and muscle relaxant.
2. In 1.6% of patients, symptoms exacerbate
and persist.
3. Most recurrences occur in 3 months
postoperatively.
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F. RECURRENT THORACIC
OUTLET SYNDROME
4. Pseudorecurrence
(1) A 2nd rib was mistakenly resected for
a 1st rib
(2) A 1st rib was resected but a cerical
rib was left.
(3) A cervical rib was resected but
an abnormal 1st rib was left.
(4) A 2nd rib was resected but a rudimentary 1st
rib was left.
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F. RECURRENT THORACIC
OUTLET SYNDROME
5. True recurrence
The 1st rib was not resected completely.
6. All patients with recurrence after 1st rib
resection should undergo physiotherapy. If
symptoms persist and UNCV is still low
then re-operation is indicated.
7. Re-operation is always done through the posterior
thoracoplasty approach.
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F. RECURRENT THORACIC
OUTLET SYNDROME
8. The anterior or supraclavicular approach is
not adequate for re-operation.
9. The basic elements for re-operation are
(1) resection of recurrent or persistent bony
remnants
(2) neurolysis of the brachial plexus or
nerve roots
(3) dorsal sympathectomy of T1, T2, T3
ganglia
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F. RECURRENT THORACIC
OUTLET SYNDROME
10. The technique includes a high thoracoplasty incision, extending 3 cm
above the angle of the scapula, halfway
between the angle of the scapula and
spinous processes, and caudate 5 cm from
the angle of scapula.
11. The trapezius and rhomboid muscles are divided..
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F. RECURRENT THORACIC
OUTLET SYNDROME
12. The scapula is retracted by incision of the
LD muscle over the 4th rib.
13. The posterior superior serratus muscle
was divided and sacrospinalis muscle is retracted
medially.
14. The 1st and cervical rib must be resected, if
present subperiosteally.
15. The regenerated periosteum is extirpated.
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F. RECURRENT THORACIC
OUTLET SYNDROME
16. If excessive scar is present the it is
necessary to perform sympathectomy
initially. This involves resection of a 1inch segment of 2nd rib posteriorly to
locate the sympathetic ganglia.
17. Neurolysis is performed using a nerve
stimulator but not into the sheath.
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F. RECURRENT THORACIC
OUTLET SYNDROME
18. A J-P drain is left in the area of brachial
plexus. Depo-Medral, 80 mg, is left in the
area of brachial plexus.
19. The arm is kept in sling to be used
gently for 3 months.
20. When the problem is vascular, involving
false or mycotic aneurysms, bypass graft is
interposed. The saphenous vein is usually used.
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F. RECURRENT THORACIC
OUTLET SYNDROME
21. 7% of patients underwent 2nd re-operation
for rescarring. No death occurred. Only
one patient had infection and needed
drainage.
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