Overview of thoracic outlet syndromes
- Kaoru Goshima, MD
Kaoru Goshima, MD
- Assistant Professor, Surgery
- University of Arizona Health Sciences Center
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Jeremy M Shefner, MD, PhD
Jeremy M Shefner, MD, PhD
- Section Editor — Neuromuscular Disease
- Professor and Chair of Neurology, Barrow Neurological Institute
- Professor of Neurology, University of Arizona, Phoenix
- Clinical Professor of Neurology, Creighton University
Thoracic outlet syndrome (TOS) refers to a constellation of signs and symptoms that arise from compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle, within the confined space of the thoracic outlet . Historically, several names have been coined to describe pathology involving the thoracic outlet, including cervical rib syndrome , scalene anticus syndrome , costoclavicular syndrome , and hyperabduction syndrome . The term “thoracic outlet syndrome” was coined to collectively encompass the spectrum of syndromes related to the general region of the thoracic outlet .
Distinct terms are used to describe the predominantly affected structure, including neurogenic (nTOS) from brachial plexus compression, venous (vTOS) from subclavian vein compression, and arterial (aTOS) from subclavian artery compression . Neurogenic TOS accounts for greater than 95 percent of cases of thoracic outlet syndrome, whereas vTOS accounts for 3 percent and aTOS accounts for 1 percent of cases. Compression of the brachial plexus leads to upper extremity numbness, dysesthesia and weakness; venous compression may cause deep vein thrombosis and extremity swelling; and arterial compression can lead to distal thromboembolism, arm pain with exertion (‘claudication’) or acute arterial thrombosis [8,9].
An overview of the anatomy, pathogenesis, clinical evaluation and approach to the management of the thoracic outlet syndromes will be reviewed with an emphasis on the features that distinguish these syndromes from one another.
The thoracic outlet is bounded by the bony structures of the spinal column, first ribs, and sternum (figure 1). Compromise of the neurovascular structures that traverse the thoracic outlet occurs in three distinct spaces: the scalene triangle, the costoclavicular space, and the pectoralis minor space.
●Scalene triangle – The scalene triangle is the space most commonly involved in TOS and is the most common site of brachial plexus compression. The anterior scalene muscle, which originates from the transverse processes of the third through sixth cervical vertebrae (C3-C6) and inserts on the inner borders and superior surfaces of the first rib, forms the anterior boundary of the scalene triangle. The middle scalene muscle, which arises from the transverse processes of the second through seventh cervical vertebrae (C2-C7) and inserts broadly onto the posterior aspects of the first rib, forms the posterior wall of the scalene triangle. The superior border of the first rib forms the base of the scalene triangle. The trunks of the brachial plexus and the subclavian artery pass between the anterior and middle scalene muscles while the subclavian vein courses anteromedial to the scalene triangle. Cervical ribs and anomalous first ribs may compress the scalene triangle (figure 2).
- Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg 2007; 46:601.
- Murphy, JB. Cervical rib excision: collective review on surgery of cervical rib. Clin John B Murphy 1916; 5:227.
- Ochsner, A, Gage, et al. Scalenus anticus (Naffziger) syndrome. Am J Surg 1935; 28:669.
- Falconer, MA, Weddell, G. Costoclavicular compression of the subclavian artery and vein. Lancet 1943; 2:539.
- Wright, IS. The neurovascular syndrome produced by hyperabduction of the arms. The immediate changes produced in 150 normal controls, and the effects on same persons of prolonged hyperabduction of the arms, as in sleeping, and in certain occupations. Am Heart J 1945; 29:1.
- PEET RM, HENRIKSEN JD, ANDERSON TP, MARTIN GM. Thoracic-outlet syndrome: evaluation of a therapeutic exercise program. Proc Staff Meet Mayo Clin 1956; 31:281.
- Landry GJ, Moneta GL, Taylor LM Jr, et al. Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. J Vasc Surg 2001; 33:312.
- Cormier JM, Amrane M, Ward A, et al. Arterial complications of the thoracic outlet syndrome: fifty-five operative cases. J Vasc Surg 1989; 9:778.
- Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg 1997; 63:913.
- Sanders, RJ. Thoracic Outlet Syndrome: General Considerations. In: Rutherford's Vascular Surgery, 7th ed, Cronenwett, JL, Johnston, KW (Eds), Saunders Elsevier, 2010. p.1865.
- Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg 1992; 16:534.
- Halsted WS. AN EXPERIMENTAL STUDY OF CIRCUMSCRIBED DILATION OF AN ARTERY IMMEDIATELY DISTAL TO A PARTIALLY OCCLUDING BAND, AND ITS BEARING ON THE DILATION OF THE SUBCLAVIAN ARTERY OBSERVED IN CERTAIN CASES OF CERVICAL RIB. J Exp Med 1916; 24:271.
- Hunauld. Sur le nombre des cotes, moindre ou plus grand qu'a l'ordinaire. Memoires de I'Academie Royale des Sciences 1740:377.
- Gruber W. Ueber die Halsrippen des Menschen mit Vergleichend-anatomischen, Bemerkungen, St. Petersburg 1869.
- Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Anatomy, symptoms, diagnosis, and treatment. Am J Surg 1976; 132:771.
- Bergman R, Thompson S, Afifi A. Catalog of Human Variation, Urban & Schwarzenberg, Baltimore 1984. p.201.
- Pollack EW. Surgical anatomy of the thoracic outlet syndrome. Surg Gynecol Obstet 1980; 150:97.
- Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg 2002; 36:51.
- Wilbourn AJ. Thoracic outlet syndromes. Neurol Clin 1999; 17:477.
- Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression syndrome. Histochemical and morphometric studies. Arch Surg 1986; 121:1141.
- Sanders RJ, Jackson CG, Banchero N, Pearce WH. Scalene muscle abnormalities in traumatic thoracic outlet syndrome. Am J Surg 1990; 159:231.
- Casbas L, Chauffour X, Cau J, et al. Post-traumatic thoracic outlet syndromes. Ann Vasc Surg 2005; 19:25.
- Almeida DF, Meyer RD, Oh SJ. True neurogenic thoracic outlet syndrome in a competitive swimmer: a case report of this rare association. Arq Neuropsiquiatr 2007; 65:1245.
- Katirji B, Hardy RW Jr. Classic neurogenic thoracic outlet syndrome in a competitive swimmer: a true scalenus anticus syndrome. Muscle Nerve 1995; 18:229.
- Stapleton C, Herrington L, George K. Sonographic evaluation of the subclavian artery during thoracic outlet syndrome shoulder manoeuvres. Man Ther 2009; 14:19.
- Lee TS, Hines GL. Cerebral embolic stroke and arm ischemia in a teenager with arterial thoracic outlet syndrome: a case report. Vasc Endovascular Surg 2007; 41:254.
- Brooke BS, Freischlag JA. Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol 2010; 25:535.
- Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using electrophysiologically guided anterior scalene blocks. Ann Vasc Surg 1998; 12:260.
- Baxter GM, Kincaid W, Jeffrey RF, et al. Comparison of colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis. Br J Radiol 1991; 64:777.
- Passman MA, Criado E, Farber MA, et al. Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients. J Vasc Surg 1998; 28:869.
- Ersoy H, Steigner ML, Coyner KB, et al. Vascular thoracic outlet syndrome: protocol design and diagnostic value of contrast-enhanced 3D MR angiography and equilibrium phase imaging on 1.5- and 3-T MRI scanners. AJR Am J Roentgenol 2012; 198:1180.
- Magill ST, Brus-Ramer M, Weinstein PR, et al. Neurogenic thoracic outlet syndrome: current diagnostic criteria and advances in MRI diagnostics. Neurosurg Focus 2015; 39:E7.
- Roos DB. Historical perspectives and anatomic considerations. Thoracic outlet syndrome. Semin Thorac Cardiovasc Surg 1996; 8:183.
- Cuetter AC, Bartoszek DM. The thoracic outlet syndrome: controversies, overdiagnosis, overtreatment, and recommendations for management. Muscle Nerve 1989; 12:410.
- Christo PJ, Christo DK, Carinci AJ, Freischlag JA. Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med 2010; 11:504.
- Jordan SE, Ahn SS, Freischlag JA, et al. Selective botulinum chemodenervation of the scalene muscles for treatment of neurogenic thoracic outlet syndrome. Ann Vasc Surg 2000; 14:365.
- Danielson K, Odderson IR. Botulinum toxin type A improves blood flow in vascular thoracic outlet syndrome. Am J Phys Med Rehabil 2008; 87:956.
- Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of botulinum toxin in the treatment of this syndrome. Toxins (Basel) 2012; 4:1223.
- Torriani M, Gupta R, Donahue DM. Botulinum toxin injection in neurogenic thoracic outlet syndrome: results and experience using a ultrasound-guided approach. Skeletal Radiol 2010; 39:973.
- Finlayson HC, O'Connor RJ, Brasher PM, Travlos A. Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial. Pain 2011; 152:2023.
- Tilney ML, Griffiths HJ, Edwards EA. Natural history of major venous thrombosis of the upper extremity. Arch Surg 1970; 101:792.
- Urschel HC Jr, Razzuk MA. Paget-Schroetter syndrome: what is the best management? Ann Thorac Surg 2000; 69:1663.
- Lee JT, Karwowski JK, Harris EJ, et al. Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg 2006; 43:1236.
- Molina JE, Hunter DW, Dietz CA. Paget-Schroetter syndrome treated with thrombolytics and immediate surgery. J Vasc Surg 2007; 45:328.
- Schneider DB, Dimuzio PJ, Martin ND, et al. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty. J Vasc Surg 2004; 40:599.
- Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg 1993; 17:305.
- Urschel HC Jr, Razzuk MA. Improved management of the Paget-Schroetter syndrome secondary to thoracic outlet compression. Ann Thorac Surg 1991; 52:1217.
- Coote, H. Exostosis of the left transverse process of the seventh cervical vertebra, surrounded by blood vessels and nerves; successful removal. Lancet 1861; 1:360.
- Adson AW, Coffey JR. CERVICAL RIB: A METHOD OF ANTERIOR APPROACH FOR RELIEF OF SYMPTOMS BY DIVISION OF THE SCALENUS ANTICUS. Ann Surg 1927; 85:839.
- CLAGETT OT. Research and prosearch. J Thorac Cardiovasc Surg 1962; 44:153.
- Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet syndrome. Ann Surg 1966; 163:354.
- Gol A, Patrick DW, McNeel DP. Relief of costoclavicular syndrome by infraclavicular removal of first rib. Technical note. J Neurosurg 1968; 28:81.
- Le Forestier N, Mouton P, Maisonobe T, et al. [True neurological thoracic outlet syndrome]. Rev Neurol (Paris) 2000; 156:34.
- Sanders RJ. Results of the surgical treatment for thoracic outlet syndrome. Semin Thorac Cardiovasc Surg 1996; 8:221.
- Sanders RJ, Monsour JW, Gerber WF, et al. Scalenectomy versus first rib resection for treatment of the thoracic outlet syndrome. Surgery 1979; 85:109.
- Sanders RJ, Pearce WH. The treatment of thoracic outlet syndrome: a comparison of different operations. J Vasc Surg 1989; 10:626.
- Sanders RJ, Haug CE. Thoracic Outlet Syndrome: A Common Sequela of Neck Injuries, Lippincott, Philadelphia 1991.
- Axelrod DA, Proctor MC, Geisser ME, et al. Outcomes after surgery for thoracic outlet syndrome. J Vasc Surg 2001; 33:1220.
- Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet syndrome in Washington state workers' compensation. Neurology 2000; 54:1252.
- Jordan SE, Ahn SS, Gelabert HA. Differentiation of thoracic outlet syndrome from treatment-resistant cervical brachial pain syndromes: development and utilization of a questionnaire, clinical examination and ultrasound evaluation. Pain Physician 2007; 10:441.
- Marine L, Valdes F, Mertens R, et al. Arterial thoracic outlet syndrome: a 32-year experience. Ann Vasc Surg 2013; 27:1007.
- Taylor JM, Telford RJ, Kinsella DC, et al. Long-term clinical and functional outcome following treatment for Paget-Schroetter syndrome. Br J Surg 2013; 100:1459.
- CLINICAL EVALUATION
- Neurogenic TOS
- Venous TOS
- Arterial TOS
- Electrodiagnostic testing
- Physiologic vascular studies
- APPROACH TO MANAGEMENT
- Physical therapy
- Medical therapy
- Managing ischemia
- THORACIC OUTLET DECOMPRESSION
- Indications for surgery
- SUMMARY AND RECOMMENDATIONS