Thoracic Outlet Syndrome. Vascular Case Conference WVU Dept. of Surgery Mary Carolyn C. Vinson, DO PGY-1

Transcription

1 Thoracic Outlet Syndrome Vascular Case Conference WVU Dept. of Surgery Mary Carolyn C. Vinson, DO PGY-1

2 Definition Thoracic outlet syndrome is a disease of extrinsic compression of the neurovascular structures thoracic outlet

3 Anatomy of Thoracic Outlet QuickTime and a TIFF (LZW) decompressor are needed to see this picture.

4 More Anatomy

5 Pathophysiology Brachial plexus trunk & subclavian vessels are subject to compression or irritation Three narrow base of neck toward the axilla & proximal arm. Interscalene Triangle Costoclavicular Triangle Subcoracoid Space Repetitive trauma to especially Lower trunk C8-T1 spinal nerves

6 Interscalene Triangle Triangle borders Anteriorly: anterior scalene muscle Posteriorly: middle scalene muscle Inferiorly: medial surface of the first rib Area small at rest & becomes even smaller with certain movements Fibrous bands, cervical ribs, and anomalous muscles, may further constrict this triangle

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8 Costoclavicular Triangle Borders Anteriorly by middle 3rd of clavicle Posteromedially by 1st rib Posterolaterally by upper border of scapula

9 Subcoracoid Space Is beneath the coracoid process just deep to the pectoralis minor tendon QuickTime and a TIFF (LZW) decompressor are needed to see this picture. QuickTime and a TIFF (LZW) decompressor are needed to see this picture.

10 Anatomic Factors Etiology Interscalene compression Costoclavicular compression Subcoracoid compression

11 Congenital Cervical rib Rudimentary first rib Scalene muscle abnormalities Fibrous bands Bifid clavicle First rib exostosis Enlarged C7 transverse process Omohyoid muscle abnormalities Anomalous transverse cervical artery Postfixed brachial plexus Flat clavicle

12 Traumatic Factors Fractured clavicle Humeral head dislocation Upper thorax crush injury Sudden effort of shoulder girdle muscles C-spine injuries/cervical spondylosis

13 Clinical Presentation Depends on which anatomic structure is compressed in the area of the thoracic outlet Axillary-subclavian artery Vein Paget-Schroetter syndrome, or effort thrombosis Neurogenic brachial plexus, or sympathetic nerves Clinical syndrome results from any mixture or an isolated compression of structures

14 Neurologic Presentation More common Strenuous physical exercise precipitates Pain & paresthesias 95% of patients Neck, shoulder, arm & hand Positional: arm abduction & neck hyperextension True motor weakness w/ atrophy Usually Ulnar nerve distribution : hypothenar/interosseus muscles in 10% medial arm & hand 4th & 5th fingers Sensory fibers on outside of nerve bundles 1st affected

15 Arterial Presentation Signs: Distal embolization Post-stenotic dilation or aneurysm of subclavian a. True arterial occlusion Symptoms: Pain usually diffuse & assoc. w/ coldness, weakness, easy fatigability of hand & arm Unilateral Raynaud's phenomenon 7.5% patients precipitated by hyperabduction or carrying heavy objects

16 Venous Presentation Venous obstruction less common Effort thrombosis Paget-Schroetter syndrome Signs & Symptoms Edema Discolored Aches

17 Differential Diagnosis Neurologic,vascular, pulmonary, cardiac, and esophageal disorders. More common Differential Diagnosis include herniated cervical disk cervical spondylosis peripheral neuropathies

18 Clinical Diagnosis Positive findings for all tests: or loss of the radial pulse reproduction of symptoms Adson/Scalene test: Deep Breath, fully extends neck, and turns head to the side Costoclavicular test: shoulders drawn inferiorly and posteriorly Hyperabduction test: arm is hyperabducted to 180 degrees

19 Imaging CXR & C-spine films: detect cervical ribs & degenerative changes Cervical CT performed if: osteophytic changes & intervertebral space narrowing present Angiography indicated for: Pulsating paraclavicular mass Absent radial pulse Paraclavicular bruit

20 Ulnar Nerve Conduction Velocity Points of stimulation include: Supraclavicular fossa Middle upper arm Below elbow Wrist Normal value across thoracic outlet: 72 m/sec Any value < 70 m/sec indicates compression

21 Angiogram Shows compression of subclavian artery at two levels: proximally between clavicle and cervical rib (long arrow) and distally by subclavius muscle (short arrow).

22 Venogram: R subclavian vein

23 Venogram Complete occlusion of Left subclavian vein (arrow) where it crosses the first rib

24 Treatment Physical therapy is initial treatment Many patients get relief from non-operative therapy esp. for neurogenic TOS Simple changes in posture may result in opening the thoracic outlet PT= Strengthen muscles supporting improved posture

25 Surgical Treatment for TOS Reserved for patients w/ symptoms persisting after aggressive physical therapy Equals about 5% of PTs w/ TOS require surgery There are multiple compressive forces, the first rib is the common denominator, and extirpation of this structure is the gold standard for therapy. Urschel et al. 2003

26 Surgical Outcomes > 2200 patients showed excellent or good results after operation in over 90% of cases Urschel et. al 1997 Symptoms recur in approx 10% Less than 2% require re-operation

27 Surgical Pictures 1st thoracic rib removed to decompress neurovascular structures of TOS

28 Recurrent Thoracic Outlet Syndrome Approx 1-2% of PTs have persistent or worsening symptoms after operation Most have recurrence within 3 months History, physical examination, and nerve conduction studies should preformed

29 Types of Recurrence Pseudorecurrence Cervical rib or the second rib was resected instead of the first rib First rib was resected instead of the causative cervical rib True recurrence First rib was incompletely resected Excessive scar development around the brachial plexus

30 Re-operation for Failed Initial Operation on TOS 80% of patients after re-operation = improvement in symptoms 7% required a second re-operation

31 Summary TOS mimics many other processes Compression is the causative agent 1st rib is often the culprit History PE UNVC XR CT Angio/Venogram Physical therapy Surgery Note: DVT and Arterial Occlusions are treated with Anticoagulation/Thrombectomy

32 References Thomas S. Maxey, MD, T. Brett Reece, MD, Peter I. Ellman, MD, Curtis G. Tribble, MD, Nancy Harthun, MD, Irving L. Kron, MD, John A. Kern, MD. Safety and efficacy of the supraclavicular approach to thoracic outlet decompression.ann Thorac Surg 2003;76: Harold C. Urschel, Jr, MD,, Amit N. Patel, MD. Surgery Remains the Most Effective Treatment for Paget-Schroetter Syndrome: 50 Years' Experience. Ann Thorac Surg 2008;86: Urschel HC Jr and Razzuk MA. Upper plexus thoracic outlet syndrome: optimal therapy.. Annals of Thoracic Surgery (4): Harold C. Urschel Jr and Amit Patel. Thoracic outlet syndromes. Current Treatment Options in Cardiovascular Medicine. Vol 5, No 2. April Urschel HC Jr, Razzuk MA.The failed operation for thoracic outlet Syndrome: the difficulty of diagnosis and management.ann Thorac Surg Nov;42(5):