Highlights & Basics
- Thoracic outlet syndrome (TOS) refers to an uncommon but potentially disabling group of conditions characterized by symptoms that result from compression of neurovascular structures crossing through the anatomic space of the thoracic outlet.
- The main types of TOS include neurogenic, venous, and arterial. Patients may present with signs and symptoms of nerve, vein, or artery compression, or a combination of these.
- Neurogenic TOS is the most common type, followed by venous TOS and then arterial TOS. Neurogenic TOS primarily develops in people in their late teens up to the age of 60 years and is more common in women. It usually occurs in the setting of a previous injury. Initial management is usually conservative and includes physical therapy.
- Venous TOS is less common, but clinical presentation may be quite dramatic and requires prompt intervention. It is a potential cause of upper extremity deep vein thrombosis.
- Arterial TOS is relatively rare and arguably the most important to recognize, owing to the risk of limb-threatening ischemic complications.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Surface landmarks of the thoracic outlet
The subclavian vein and artery pass over the first rib and under the clavicle. The brachial plexus traverses the top of the bony circle to join the artery. The apex of the pleura (cupula) is shown on the left side.
The scalene muscle triangle is the first major level of neurovascular compression
Lateral view of the neurovascular structures traversing the thoracic outlet, with the clavicle above and the first rib below. The costoclavicular space is the second major site of neurovascular compression
The neurovascular structures pass behind the pectoralis minor muscle, a third major area of neurovascular compression. The pectoralis minor muscle is a shoulder protractor, which can overcome the rhomboids. The shoulder retracts and alters the thoracic outlet, contributing to muscle imbalance and compression of the brachial plexus
Schematic diagram summarizing the factors involved in thoracic outlet compression and the resulting signs and symptoms
The Adson maneuver tightens the anterior and middle scalene muscles, decreasing interspace and magnifying pre-existing compression of the brachial plexus and subclavian artery. The patient takes and holds a deep breath, extends the neck fully, and turns the head toward the affected side. Obliteration or decrease in the radial pulse indicates neurovascular compression at the thoracic outlet
Cervical ribs. Chest radiographs demonstrating a patient with a partial cervical rib on the right side (A) and a patient with a complete cervical rib on the left side (B)
Upper extremity venography. (A): Initial venogram showing thrombotic occlusion of the axillary-subclavian vein. (B): Completion venogram after catheter-directed thrombolysis and suction thrombectomy, with restoration of a patent axillary-subclavian vein and residual venous stenosis at the level of the first rib
Subclavian artery aneurysms. (A and B): Plain chest radiograph showing complete cervical rib on the right side (arrow) and an image from CT angiogram showing a subclavian artery aneurysm arising immediately past the point of arterial compression by the cervical rib (arrow). (C and D): Plain chest radiograph showing complete cervical rib on the right side (arrow) and a 3-D reconstruction from a CT angiogram demonstrating a subclavian artery aneurysm immediately past the point of arterial compression by the cervical rib (oval highlight). CR: cervical rib
Transaxillary first rib resection and scalenectomy. (A): Patient position. (B): Anatomical features of the thoracic outlet as viewed from the lateral approach. (C): Exposure of the first rib high in the axilla, with the associated muscles and subclavian vessels visualized. (D): Dissection along the periosteum of the first rib. (E): Middle scalene and subclavius muscles are divided and the anterior scalene is encircled prior to its division. (F): Division of the posterior first rib. ASM: anterior scalene muscle; BP: brachial plexus; C8-T1: C8 and T1 cervical nerve roots; MSM: middle scalene muscle; SCA: subclavian artery; SCV: subclavian vein; SubCM: subclavius muscle
Citations
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