THORACIC OUTLET SYNDROM (T.O.S.)

Lucien MATYSIAK

Vascular Surgery – L. Pasteur Hospital COLMAR - FRANCE

DEFINITION

• Thoracic outlet syndrom is the consequence of the compression of upper limbs vascular and nervous elements

ANATOMY

• The thoracic outlet is composed of five successive spaces the vascular and nervous elements go through :o The inter costo scalenic defileo The prescalenic defileo The costoclavicular spaceo The sub-pectoral tunnelo The humeral space

1) The intercosto-scalenic defile

2) Prescalenic defile

3) Costo-clavicular space

4) Pectoralis minor muscle and coracoid process

Anatomical abnormalities (1)

Present in less than 10% of T.O.S.1. Osseous congenital abnormalities

o Subnumerous cervical ribs uni- or bilateral

Anatomical abnormalities (2)

• C7 apophysis hypertrophy• First rib agenesy

• Clavicle congenital abnormalities

Anatomical abnormalities (3)

1.Osseous post traumatic abnormalitieso Clavicle1. First rib

1.Muscular and/or ligamentary abnormalitieso Difficult to reveal preoperatively

Signs and symptoms of T.O.S. (1)

1.Neurologic compressiono Pain and/or parasthesia of the neck, shoulder region,

arm or hand, depending on the root involvedo Often bilateralo Difficulty with fine motor tasks of the hando Examination reveals :

sensitive disorders muscle weakness muscle atrophy (long fingers flexors) Palpation of subclavicular area may cause pain

Signs and symptoms of T.O.S. (2)

1.Arterial compression :o Easily fatigued arms and handso Rest pain of hand and fingerso Paleness – coldness of the hando Raynaud’s phenomenono Ischemic signs, distal gangrene due to repeated

embolization, or to subclavian artery thrombosis

Signs and symptoms of T.O.S. (3)

1.Venous compressiono Pain of the upper limbso Swellingo Feeling of heavinesso Easily fatigued arm and hando Superficial vein distensiono Thrombophlebitis of the upper limb

PATIENT EXAMINATION (1)

Certain diagnostic tests are used to reproduce the compression and T.O.S. familiar symptoms1. ‘‘Hands up’’ test

In this position, the patient opens and closes his hands repeatedly : a positive test reproduces pain, heaviness or arm weakness within the first minute after beginning.

PATIENT EXAMINATION (2)

1.ADSON or scalene maneuver

The patient rotates his head towards the tested arm while the examiner extends the arm

PATIENT EXAMINATION (3)

1.ALLEN maneuver

Patient elbow flexes to 90 degrees, while the shoulder is extended horizontally and rotated laterally. The patient is asked to turn the head away from the tested arm. If radial pulse disappears, then the test is considered positive

ADDITIONNAL TESTS (1)

• Electromyography : may help to assess nervous ‘‘motor affection’’

o Standard X-Ray neck and thoracic examination looking for osseous abnormalities

o Dynamic angiogram may show the compression explores arterial complications (stenosis, aneurysms…)

ADDITIONNAL TESTS (2)• Computed Tomography – MR angiographic 3D

technique

• Dynamic phlebography

May show venous compression after arm abduction

May show aneurysms related to compression with T.O.S.

TREATMENT OF THORACIC OUTLET SYNDROM

1.MEDICAL TREATMENT

o Analgesic treatmento Anti-inflammatory non steroid drugso Muscle relaxing drugs

TREATMENT OF T.O.S.

1.PHYSICAL THERAPY (1)o Is the key of T.O.S. treatmento Its purpose :

open the costo-clavicular space fight against physiological shoulders falling attitude

o Has to be progressive, painless, bilateralo Average duration : 3 to 6 monthso If properly executed : 70 to 90% of good

results

TREATMENT OF T.O.S.

1.PHYSICAL THERAPY (2)1.Muscular relaxation

TREATMENT OF T.O.S.

1.PHYSICAL THERAPY (3)1.Correct shoulder falling attitude

TREATMENT OF T.O.S.

1.PHYSICAL THERAPY (4)1.Reinforce muscles that ‘‘open’’ the costo-

clavicular space

TREATMENT OF T.O.S.

1.PHYSICAL THERAPY (5)1.Respiratory reeducation

SURGICAL TREATMENT OF T.O.S.

Surgical treatment is indicated:• after failure of physiotherapy• in T.O.S. with venous or arterial complications

(thrombosis, aneurysms…)• in case of nervous compression• in case of symptomatic cervical rib

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Possible approaches

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Instruments

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Instruments

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Instruments

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Instruments

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Instruments

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION : Transaxillary approach (ROOS technique)1.Patient installation

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.Arm position

The secret of 1st rib resection in this techniqueis discontinued traction

5 minutes !

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.First rib liberation

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION1.First rib section

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION : Other approacheso Sus-clavicular approach

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION : Other approacheso Sub-clavicular approach

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION : Other approacheso Posterior extrapleural approach

SURGICAL TREATMENT OF T.O.S.

1.FRIST RIB RESECTION : Other approacheso Antero-lateral transpleural approach

SURGICAL TREATMENT OF T.O.S.

1.POSSIBLE ADDITIONNAL TECHNIQUES

o Thoracic sympathectomyo Cervical rib resectiono Vascular repair

INDICATIONS OF SURGICAL TREATMENT OF T.O.S.

• When failure of physiotherapy• Neurologic compressions :

o sus-clavicular approacho axillary approach

• When osseous or musculo-ligamentar abnormalities:o sus-clavicular approach

• Non complicated arterial compressions:o axillary approach

• Complicated arterial compression (thrombosis, aneurysms…):o sus-clavicular approach ± sub-clavicular approach

• Complicated veinous compressions:o difficult to choose…

SURGICAL TREATMENT OF T.O.S.

1.COMPLICATIONS OF SURGICAL TREATMENT OF T.O.S.

o Minor transcient dysesthaesia pleural entering hemo- or chylo-thorax

o Major : veinous or arterial injuries brachial plexus injuries

CONCLUSIONS

T.O.S management requires :• a good knowledge of the anatomy of the

area• a good patient questionning and

examination• the key of the treatment is physiotherapy :

when properly conducted it improves symptomatology in more than 70% cases

• surgical treatment is decided only after failure of physiotherapy