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THORACIC OUTLET SYNDROM (TOS)
Thoracic outlet syndrome (TOS) occurs when the blood vessels or nerves in the thoracic outlet area between the neck and armpit are compressed. The thoracic outlet contains several narrow spaces through which the nerves and vessels pass. Physical therapy is the primary treatment for TOS and aims to open the spaces and correct shoulder positioning. Surgery to remove part of the first rib may be considered if physical therapy fails or for complications involving blood vessels or nerves. Proper diagnosis involves patient examination maneuvers to reproduce symptoms and imaging tests to identify anatomical abnormalities.
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THORACIC OUTLET SYNDROM (TOS)
- 1. THORACIC OUTLET SYNDROM(T.O.S.) Lucien MATYSIAK Vascular Surgery – L. Pasteur Hospital COLMAR - FRANCE
- 2. DEFINITION Thoracic outletsyndrom is the consequence of the compression of upper limbs vascular and nervous elements
- 3. ANATOMY The thoracicoutlet is composed of five successive spaces the vascular and nervous elements go through : The inter costo scalenic defile The prescalenic defile The costoclavicular space The sub-pectoral tunnel The humeral space
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- 7. 4) Pectoralis minormuscle and coracoid process
- 8. Anatomical abnormalities (1)Present in less than 10% of T.O.S. Osseous congenital abnormalities Subnumerous cervical ribs uni- or bilateral
- 9. Anatomical abnormalities (2)C7 apophysis hypertrophy First rib agenesy Clavicle congenital abnormalities
- 10. Anatomical abnormalities (3)Osseous post traumatic abnormalities Clavicle First rib Muscular and/or ligamentary abnormalities Difficult to reveal preoperatively
- 11. Signs and symptomsof T.O.S. (1) Neurologic compression Pain and/or parasthesia of the neck, shoulder region, arm or hand, depending on the root involved Often bilateral Difficulty with fine motor tasks of the hand Examination reveals : sensitive disorders muscle weakness muscle atrophy (long fingers flexors) Palpation of subclavicular area may cause pain
- 12. Signs and symptomsof T.O.S. (2) Arterial compression : Easily fatigued arms and hands Rest pain of hand and fingers Paleness – coldness of the hand Raynaud’s phenomenon Ischemic signs, distal gangrene due to repeated embolization, or to subclavian artery thrombosis
- 13. Signs and symptomsof T.O.S. (3) Venous compression Pain of the upper limbs Swelling Feeling of heaviness Easily fatigued arm and hand Superficial vein distension Thrombophlebitis of the upper limb
- 14. PATIENT EXAMINATION (1)Certain diagnostic tests are used to reproduce the compression and T.O.S. familiar symptoms ‘‘ 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.
- 15. PATIENT EXAMINATION (2)ADSON or scalene maneuver The patient rotates his head towards the tested arm while the examiner extends the arm
- 16. PATIENT EXAMINATION (3)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
- 17. ADDITIONNAL TESTS (1)Electromyography : may help to assess nervous ‘‘motor affection’’ Standard X-Ray neck and thoracic examination looking for osseous abnormalities Dynamic angiogram may show the compression explores arterial complications (stenosis, aneurysms…)
- 18. 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.
- 19. TREATMENT OF THORACICOUTLET SYNDROM MEDICAL TREATMENT Analgesic treatment Anti-inflammatory non steroid drugs Muscle relaxing drugs
- 20. TREATMENT OF T.O.S.PHYSICAL THERAPY (1) Is the key of T.O.S. treatment Its purpose : open the costo-clavicular space fight against physiological shoulders falling attitude Has to be progressive, painless, bilateral Average duration : 3 to 6 months If properly executed : 70 to 90% of good results
- 21. TREATMENT OF T.O.S.PHYSICAL THERAPY (2) Muscular relaxation
- 22. TREATMENT OF T.O.S.PHYSICAL THERAPY (3) Correct shoulder falling attitude
- 23. TREATMENT OF T.O.S.PHYSICAL THERAPY (4) Reinforce muscles that ‘‘open’’ the costo-clavicular space
- 24. TREATMENT OF T.O.S.PHYSICAL THERAPY (5) Respiratory reeducation
- 25. SURGICAL TREATMENT OFT.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
- 26. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Possible approaches
- 27. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Instruments
- 28. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Instruments
- 29. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Instruments
- 30. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Instruments
- 31. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Instruments
- 32. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION : Transaxillary approach (ROOS technique) Patient installation
- 33. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION Arm position The secret of 1 st rib resection in this technique is discontinued traction 5 minutes !
- 34. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION First rib liberation
- 35. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION First rib section
- 36. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION : Other approaches Sus-clavicular approach
- 37. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION : Other approaches Sub-clavicular approach
- 38. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION : Other approaches Posterior extrapleural approach
- 39. SURGICAL TREATMENT OFT.O.S. FRIST RIB RESECTION : Other approaches Antero-lateral transpleural approach
- 40. SURGICAL TREATMENT OFT.O.S. POSSIBLE ADDITIONNAL TECHNIQUES Thoracic sympathectomy Cervical rib resection Vascular repair
- 41. INDICATIONS OF SURGICALTREATMENT OF T.O.S. When failure of physiotherapy Neurologic compressions : sus-clavicular approach axillary approach When osseous or musculo-ligamentar abnormalities: sus-clavicular approach Non complicated arterial compressions: axillary approach Complicated arterial compression (thrombosis, aneurysms…): sus-clavicular approach ± sub-clavicular approach Complicated veinous compressions: difficult to choose…
- 42. SURGICAL TREATMENT OFT.O.S. COMPLICATIONS OF SURGICAL TREATMENT OF T.O.S. Minor transcient dysesthaesia pleural entering hemo- or chylo-thorax Major : veinous or arterial injuries brachial plexus injuries
- 43. CONCLUSIONS T.O.S managementrequires : 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