Thoracic outlet syndrome

Amna Ramzan MBBS (Dr. Ramzan of University of Texas Health Science Center has no relevant financial relationships to disclose)
Sameera Salman Ghauri MBBS (Dr. Ghauri of University of Texas Houston Health Science Center has no relevant financial relationships to disclose.)
Thy Nguyen MD (Dr. Nguyen of the University of Texas Health Science Center has no relevant financial relationships to disclose.)
Parveen Athar MD (Dr. Athar of the University of Texas Health Science Center has no relevant financial relationships to disclose.)
Kazim Sheikh MD (Dr. Sheikh of University of Texas Houston Health Science Center has no relevant financial relationships to disclose.)
Randolph W Evans MD, editor. (Dr. Evans of Baylor College of Medicine received honorariums from Allergan and DepoMed for speaking engagements.)
Originally released November 9, 2005; last updated May 17, 2016; expires May 17, 2019

This article includes discussion of thoracic outlet syndrome, TOS, true neurologic or neurogenic thoracic outlet syndrome, non-neurogenic thoracic outlet syndrome, arterial thoracic outlet syndrome, traumatic thoracic outlet syndrome, and venous thoracic outlet syndrome. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Thoracic outlet syndrome is a controversial entity that has been overdiagnosed in past years. The nonspecific or disputed form of neurogenic thoracic outlet syndrome is far more common than the true neurogenic syndrome. True neurogenic thoracic outlet syndrome can result from an anomalous cervical band stretching from the tip of an abnormal C7 transverse process to the first rib or a cervical rib impinging on the lower brachial plexus. A clinical pattern of medial finger numbness, intrinsic hand muscle weakness, and atrophy may be supported by electrophysiological and radiological studies in true thoracic outlet syndrome cases.

Key points

 

• Thoracic outlet syndrome is a controversial clinical entity that is commonly overdiagnosed.

 

• True neurogenic thoracic outlet syndrome is extremely rare. The syndrome can result from an anomalous cervical band stretching from the tip of an abnormal C7 transverse process to the first rib or a cervical rib, impinging on the lower brachial plexus or T1 spinal root.

 

• Sensory symptoms over the medial side of the hand or fingers and intrinsic hand muscle weakness and atrophy, particularly involving thenar eminence, are typical symptoms of true neurogenic thoracic outlet syndrome.

 

• Management includes conservative measures and surgical intervention.

Historical note and terminology

The term thoracic outlet syndrome (TOS) is a misnomer as there are truly multiple forms of this syndrome, and the term thoracic outlet syndromes should be used instead. There has been great confusion and controversy about thoracic outlet syndromes due to different manifestations of the syndromes. Many physicians doubt the existence of thoracic outlet syndromes, whereas other physicians dispute the diagnosis and optimal treatment. Diagnostic heterogeneity of thoracic outlet syndromes has led to great variance of incidences ranging from 3 to 80 cases per 1000 in the population.

Perhaps the first notion of thoracic outlet syndrome occurred in the 2nd century AD with the first mention of a cervical rib by Galen (Roos 1996). Over time, greater recognition of both vascular and neurologic types of thoracic outlet syndromes developed slowly until the early 1900s, when detailed clinical studies were presented. In 1910, Murphy performed the first rib resection and reported efficacy (Roos 1996). Later, in 1927, Adson first reported scalenotomy without cervical rib resection in the management of thoracic outlet syndromes. The term "thoracic outlet syndrome" was coined by Peete in 1956, although his definition encompassed all the forms and causes of neurovascular compression at the neck. New approaches for first rib resection gained popularity after Clagett's description of the posterior periscapular approach in 1962 and of the transaxillary approach in 1966 (Roos 1996). Over the last 4 decades, further changes in management approaches have led to the introduction of other procedures, including a supraclavicular approach for first rib resection and cervical band sectioning procedures (Nasim et al 1997).

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