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Thoracic Outlet Syndrome PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Thoracic Outlet Syndrome" by Dr Mohd Azam Haseen.

This medical PowerPoint presentation talks about Thoracic Outlet Syndrome.

Thoracic Outlet Syndrome (TOS) is a condition that occurs when the nerves, blood vessels, or both become compressed as they pass through the thoracic outlet, which is the space between the collarbone (clavicle) and the first rib. TOS can cause pain, numbness, tingling, or weakness in the neck, shoulders, arms, or hands.

There are three types of TOS. Neurogenic TOS, Arterial TOS and Venous TOS.

Tags : Thoracic Outlet Syndrome, nerves, blood vessels, Neurogenic TOS, Arterial TOS and Venous TOS, Cardiothoracic Surgery, cardiology, cardiology PowerPoint presentation

Published on : Mar 19, 2023 | Views : 1426 | Downloads : 0

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Thoracic Outlet Syndrome 1 Dr Mohd Azam Haseen Associate Professor D/O Cardiothoracic Surgery JNMC,AMU,Aligarh
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Definition It refers compression of subclavian vessels and brachial plexus at the superior aperture of the thorax. Previously known by several names like scalenus anticus, cervical rib, first thoracic rib and costoclavicular syndrome. The symptoms can be neurologic or( and ) vascular (arterial or venous). 2
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TOS - Anatomy Google Images
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ANATOMY 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 ). 5
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ANATOMY - 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. 6
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Anatomy
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TOS - Epidemiology 3 to 80 cases per 1000 Ages 20-40 Women > Men (4:1) Neurogenic TOS (90%) > Venous TOS > Arterial TOS (<1%) Cervical ribs occur in < 1% of population - 70% women - causative factor in 5-8%
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Compression Factors Congenital -- cervical rib and its fascial remnants -- bifid first rib -- fusion of first and second ribs -- rudimentary first thoracic rib -- bifid clavicle -- hypertrophied scalene muscles -- adventitous fibrous bands -- exostosis of first rib -- enlarged transverse process of C 7 9
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Compression Factors…contd Anatomical - potential sites of compression are interscalene triangle , costoclavicular space ,subcoracoid area. Traumatic – -- # clavicle -- dislocation of head of humerus -- crushing injury to upper thorax -- injury to cervical spine -- sudden unaccustomed activity of shoulder girdle muscles 10
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TOS - Symptoms Neurogenic TOS Pain and paresthesia are present in 95% of patients weakness in the hand, arm and shoulder is present in 10% of patients. neck pain and occipital headaches . Atypical pain involving anterior chest wall and parascapular area is called pseudoangina. Raynaud’s phenomenon, hand coldness and color changes are also seen frequently in NTOS Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.
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TOS - Symptoms Venous TOS Swelling of the arm, plus cyanosis is strong evidence of subclavian vein obstruction Pain often present, but may be absent Arm swelling distinguishes VTOS from ATOS and NTOS Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.
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TOS - Symptoms Arterial TOS Digital ischemia, claudication, pallor, coldness, paresthesia and pain in the hand (but rarely in the shoulder/neck) Symptoms are a result of arterial emboli from a mural thrombus in a subclavian artery aneurysm or from thrombus forming distal to subclavian artery stenosis Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.
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TOS – Physical Exam VTOS arm swelling cyanosis distended superficial veins over the shoulder and chest wall NTOS Tenderness over scalene muscles Positive provocative tests Sanders RJ, et al. J Vasc Surg, 46(3), 2007, 601-604.
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TOS – Physical Exam objective physical findings are more in patients with vascular compression. Objective physical findings of vascular compression are diminution or loss of the radial pulse in tests , Raynaud’s phenomenon, venous distension or edema… Objective physical findings of neural compression are hypoesthesia, anesthesia and muscle weakness and atrophy. 16
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Adson or Scalene Test 1. The patient is asked to take and hold a deep breath extend the neck fully and 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. 17
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Costoclavicular Test( Military Position ) The back is downward and backward. The costoclavicular space will be narrowed by approximating the first rib and the clavicle. Diminution or loss of the radial pulse suggests compression. 18
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Hyperabduction Test 1. The arm is hyperabducted to 180 degrees. 2. Diminution or loss of the radial pulse suggests compression. 19
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Arm Claudication Test The shoulder is drawn backward and upward. The arm is raised horizontally with the elbow flexed 90 degrees. With exercise of hands, pain and numbness indicates compression. 20
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Other tests Neck rotation and head tilting (ear to shoulder) eliciting pain and paresthesia down the contralateral side Upper Limb Tension Test 21
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CLOSE Fig. Upper Limb Tension Test (ULTT). Position 1: Arms abducted to 90° with elbows extended. Position 2: Dorsiflex wrists. Position 3: Tilt head to side, ear to shoulder. Each maneuver progressively increases stretch on the brachial plexus.
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TOS – Differential Diagnosis Cervical disc disease Malignancies (Pancoast/local tumors, spinal cord tumors) Peripheral nerve entrapments (ulnar or median nerve) Brachial plexitis Rotator cuff injuries Fibromyalgia, muscle spasm Neurologic disorders (MS) Chest pain, angina Vasculitis Vasospastic disorder (Raynaud’s) Neuropathic syndromes of upper extremity Talu, GK: Agri 17 (2005), 5-9.
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TOS – Diagnostic Testing Neck or chest xray Detects cervical rib or elongated C7 transverse process EMG/NCS Normal in large majority of clinically + NTOS Most common finding in NTOS is ulnar neuropathy UNCV <70m/s indicates N. compression MRI/CT Venography/venous duplex VTOS Arteriography Only indicated in ATOS Seror, O. Clin Neurophysiol 115 (2004), 2316-2322.
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Angiography Bruits in the supra- or infraclavicular spaces suggests stenosis, and absence of pulse denotes total occlusion. Retro- or antegrade arteriograms of the subclavian and brachial arterial systems are indicated. Phlebograph is indicated in patients of venous stenosis or obstruction. 25
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TOS – Treatment Conservative Management Massage, hydrotherapy and PT Behavioral modification/avoidance of provocative activities PT to strengthen muscles of the pectoral girdle and restore normal posture Improvement: 50-90%
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Conservative management Physiotherapy includes heat massage, active neck exercise, scalenus anticus muscle stretching, strengthening of the upper trapezius muscle, and posture instrusion. Most patients with a UNCV above 60 m/sec improve with phsiotherapy. Most patients with a UNCV below 60 m/sec must undergo surgery with resection of the first rib and correction of other bony deformities. Pain killers and muscle relaxants 28
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Surgical management Indications are…. -- failure of conservative management to relieve symptoms ( >3months of tt). -- thrombosis/ narrowing of axillary artery -- thrombosis of axillary vein -- atypical chest pain with normal coronaries. -- hypersympathetic activity (hyperhydrosis,reflex symp. Dystrophy,causalgia,raynaud’s ds) 29
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TOS – Treatment Surgical management Options available are .. First rib resection/cervical rib resection Scalenectomy Subclavian artery reconstruction Cervical sympathectomy
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Surgical treatment -- 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. -- The anterior supraclavicular, infraclavicular and posterior approach were ever reported. -- Posterior approach is especially important because 80% of patients are females. 31
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Technique of Transaxillary Resection of First Rib The patient was placed lateral position with involved arm abducted to 90 degrees. A transaxillary incision was made between pectoralis major m. and latissimus dorsi m. The insertion of the scalenus anticus m. on the first rib was dissected and muscle is divided. The first rib is divided at middle portion. The scalenus media m. can not be cut from the rib. The long thoracic nerve must be preserved. 32
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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. -- Removal of incompletedly resected or regenerated rib and lysis of the brachial plexus can be done through posterior approach. -- The anterior supraclavicular approach is used for arterial bypass and reconstruction. 33
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Results The results of first rib resection is good in 85%, fair in 10% and poor in 5%. Uniform improvement of symptoms is usually in patients of primarily vascular compression. There are 2 groups of patients, who have neural compression. 34
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Results The 1st group includes patients with ulnar neuralgia and diminution of radial pulse. 95% of this group are improved after first rib resection. 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. 35
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Results -- No hospital mortality is related directly to the procedure. -- Morbidity includes pneumothorax, hematoma and infection. 36
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PAGET-SCHROETTER SYNDROME It refers “ effort “ thrombosis of the axillary-subclavian vein inducing by excessive or unusual use of the arm in addition to one or more compressive elements. It is usually seen in professional athletes, Linotype operators, painters and beauticians. Thrombolysis ( for clots <6 weeks old) ,Anticoagulants and arm rest are best modality of Tt . 37
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PAGET-SCHROETTER SYNDROME -- First rib resection is indicated for patients with recurrent disease when returning to work. -- Bypass with veins and other conduits has limited application. 38
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RECURRENT THORACIC OUTLET SYNDROME 10% of surgically treated patients have shoulder, arm or hands pain and pareathesia. Most patients can be relieved with physiotherapy and muscle relaxant. In 1.6% of patients, symptoms exacerbate and persist. Most recurrences occur in 3 months postoperatively. 39
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RECURRENT THORACIC OUTLET SYNDROME -- 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. 40
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RECURRENT THORACIC OUTLET SYNDROME -- True recurrence : The 1st rib was not resected completely. All patients with recurrence after 1st rib resection should undergo physiotherapy. If symptoms persist and UNCV is still low then re-operation is indicated. - Re-operation is always done through the posterior thoracoplasty approach. - The anterior or supraclavicular approach is not adequate for re-operation. 41 F. REC
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RECURRENT THORACIC OUTLET SYNDROME 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 42
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Any Questions ??
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cervical rib is causative factor of TOS in--- Most common type of TOS is --- Treatment of TOS is mostly surgical –true/false 44