Name
THORACIC OUTLET SYNDROME
DESCRIPTION
DETAIL
CAUSES : β’ Upper thoracic neurovascular bundle compression β’ Cervical rib β’ Taut anomalous scalene muscles β’ Elongated C7 transverse process β’ Poor posture β’ Pancoastβs tumor β’ Atherosclerotic plaques within vessels β’ Subclavian muscle β’ Fibrous and ligamentous bands β’ Costocoracoid tendon β’ Callous bone formation from fractured clavicle or first rib β’ Aberrant tissue β’ Neck trauma -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Cervical disk syndrome β’ Carpal tunnel syndrome β’ Orthopedic shoulder problems (shoulder strain, rotator cuff injury, tendinitis) β’ Cervical spondylitis β’ Ulnar nerve compression at the elbow and hand β’ Multiple sclerosis β’ Spinal cord tumor or disease β’ Angina pectoris β’ Migraine β’ Reflex sympathetic dystrophy β’ C8 radiculopathiesSPECIAL TESTS : β’ Plethysmography with previously mentioned maneuvers β’ Doppler and duplex ultrasound if venous obstruction suspected β’ Ulnar and median nerve conduction velocity studies (< 70 m/sec is abnormal) β’ Venogram and arteriogram if presents with edematous changes in upper extremity IMAGING : β’ X-ray (chest x-ray, oblique C-spine) β’ Arteriogram or venogram - if arterial or venous obstruction, aneurysm or emboli are suspected β’ CT scan - if cord compression lesions (disc and/or tumor) are suspected β’ Helical CT β’ 3-D MR angiography DIAGNOSTIC PROCEDURES : β’ Thoracic outlet syndrome (TOS) is a clinical diagnosis β’ Anterior scalene muscle injections are useful in confirming the diagnosis and in determining which patients may respond favorably to surgery
TYPENOTES
RISK FACTORS: Exuberant callus after fracture of clavicle or first rib, Exostosis of clavicle or first rib, Postural abnormalities (drooping of shoulders,scoliosis), Body building, with increased muscular bulk in thoracic outlet area outlet arGENERAL MEASURES : . Conservative . If no vascular involvement is present and/or if no loss of function or lifestyle is present due to severity of symptoms, conservative therapy may be undertaken for 2-3 months . Improvement can be expected in 60% of patients . Exercise program to promote shoulder muscle function . Physical therapy for postural faults . Cervical collar, traction . Weight loss if axillary folds are causing compression SURGICAL MEASURES : . Operative - if vascular involvement is present and/or if there is loss of function or lifestyle secondary to severity of symptoms and if conservative therapy fails after 2-3 months . Resection of fi rst rib or cervical ribs (transaxillary, supraclavicular, posterior approaches) . Excision of adhesive bands via transaxillary approach . Anterior scalenectomy ACTIVITY : . Light activity with arm and hand encouraged . No straining or heavy activity for 3 months PATIENT EDUCATION : . Physical therapy following surgery . Postural exercises . NSAIDs may improve pain . Ergonomic work station . Surgery if conservative treatment not successful DRUG(S) OF CHOICE : β’ Analgesics β’ Muscle relaxants β’ Antispasmodics POSSIBLE COMPLICATIONS : β’ Postoperative shoulder, arm, hand pain and paresthesias in 10%, usually responds to physiotherapy β’ 1.5-2% of patients will have symptomatic recurrences 1 month to 7 years postoperatively (usually within 3 months) β’ 0.5-1% of patients have brachial plexus injury, probably due to intraoperative traction β’ Re-operation indicated for symptomatic recurrence with long posterior remnant of fi rst rib (posterior approach) or with disrupted fi brous adhesions (transaxillary approach) β’ Venous obstruction or arterial emboli; usually responds to thrombolytics EXPECTED COURSE/PROGNOSIS : β’ 60% improve with appropriate physiotherapy program β’ 90% have excellent or good early results with surgery β’ 70-80% have no recurrence at 5 years and 10 years
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
X-RAY CHEST P.A. VIEW( NORMAL ), COMPLETE BLOOD COUNT, CT SCAN THORAX, MRI