Thoracic outlet syndrome

Thoracic outlet syndrome

• 1.
  Thoracic Outlet Syndrome
• 2.
  TOS is acollective term given for 6 syndromes: i. Cervical rib syndrome ii. Scalenus anticus syndrome iii. Costoclavicular syndrome iv. Hyperabduction syndrome v. Pectoralis minor syndrome vi. First thoracic rib syndrome
• 3.
  Causes:  This syndromeis caused due by compression of brachial plexus or subclavian artery and or vein in the region near the thoracic outlet.  Commonly accepted medical diagnosis include: i. Neurogenic TOS ii. Vascular TOS: Arterial or venous iii. Nonspecific TOS
• 4.
  Sites of entrapment •Interscalene triangle • Costoclavicular space • Axillary interval
• 5.
  Epidemiology/Etiology  TOS affectsapproximately 8% of the population and is 3-4 times as frequent In woman as in men between the age of 20 and 50 years.  Congenital factors: • Cervical rib • Prolonged transverse process • Anomalous muscles • Fibrous anomalies (transversocostal, costocostal) • Abnormalities of the insertion of the scalene muscles • Fibrous muscular bands • Exostosis of the first rib • Cervicodorsal scoliosis • Congenital uni- or bilateral elevated scapula • Location of the A. or V. Subclavian in relation to the M. scalene anterior
• 6.
   Acquired conditions: •Postural factors • Dropped shoulder condition • Wrong work posture (standing or sitting without paying attention to the physiological curvature of the spine) • Heavy mammaries • Trauma • Clavicle fracture • Rib fracture • Hyperextension neck injury, whiplash • Repetitive stress injuries (repetitive injury most often form sitting at a keyboard for long hours)  Muscular causes: • Hypertrophy of the scalene muscles • Decrease of the tonus of the M. trapezius, M. levator scapulae, M.rhomboids • Shortening of the scalene muscles, M. trapezius, M. levator scapulae, pectoral muscles
• 7.
  Clinical Presentation Arterial TOSVenous TOS Neurogenic TOS Nonspecific TOS •Young adult with vigorous arm activity •Pain in the hand •Claudication •Pallor •Cold intolerance •Paresthesias •S/s usually appear spontaneously •Younger men with vigorous arm activity •Cyanosis •Feeling of heaviness •Paresthesia in fingers and hand (result of edema) •Edema of the arm •Hx of neck trauma •Pain, paresthesia, numbness, and/or weakness •Occipital headaches •S/s present day and/or night •Loss of fine motor skills •Cold intolerance (possible Raynaud's phenomenon) •Objective weakness •Compressors*: s/s day>night •Hx of neck trauma •Pain, paresthesia, and "feeling" of weakness •Occipital headaches •Nocturnal paresthesias that often wake patient •Loss of fine motor skills •Cold intolerance (possible Raynaud's phenomenon) •Subjective weakness •Releasers*: s/s night>day
• 8.
  Examination  History  PhysicalExamination[15][16]  Observation  - Posture - Cyanosis - Edema - Paleness - Atrophy  Palpation  - Temperature changes - Supraclavicular fossa - Scalene muscles (tenderness) - Trapezius muscle (tenderness)
• 9.
   Neurological Screen MMT & Flexibility of following muscles: - Scalene - Pectoralis major/minor - Levator scapulae - Sternocleidomastoid - Serratus anterior
• 10.
  Special Tests  ElevatedArm Stress/ Roos test  Adson’s  Wright’s  Cyriax Release  Supraclavicular Pressure  Costoclavicular Maneuver  Upper Limb Tension  Cervical Rotation Lateral Flexion
• 11.
  Diagnostic Procedures  Electrodiagnosticevaluation and imaging  Nerve conduction studies ( Nerve conduction studies usually reveal decreased ulnar sensorial potentials, decreased median action potentials, normal or close to normal ulnar motor and median sensorial potentials)  Electromyography  venography and arteriography  Cervical spine and chest x-rays  MRI
• 12.
  Medical Management  Nonsteroidalanti-inflammatory drugs  Botulinum injections to the anterior and middle scalenes have also found to temporarily reduce pain and spasm from neurovascular compression
• 13.
  Physiotherapy Management  patienteducation  Correct impaired posture  Mobilize restricted neurological tissue  Mobilize restricted joints, connective tissue, and muscle  Improve muscle performance  Correct faulty breathing pattern  Progress functional independence
• 14.
  Surgical management  Scalenectomy Removal of first rib  Removal of cervical rib  breast-reduction surgery