Conservative Treatment of Thoracic Outlet Syndrome: A Narrative Review (original) (raw)
Related papers
Journal of Manual & Manipulative Therapy, 2010
Thoracic outlet syndrome (TOS) is a frequently overlooked peripheral nerve compression or tension event that creates difficulties for the clinician regarding diagnosis and management. Investigators have categorized this condition as vascular versus neurogenic, where vascular TOS can be subcategorized as either arterial or venous and neurogenic TOS can subcategorized as either true or disputed. The thoracic outlet anatomical container presents with several key regional components, each capable of compromising the neurovascular structures coursing within. Bony and soft tissue abnormalities, along with mechanical dysfunctions, may contribute to neurovascular compromise. Diagnosing TOS can be challenging because the symptoms vary greatly amongst patients with the disorder, thus lending to other conditions including a double crush syndrome. A careful history and thorough clinical examination are the most important components in establishing the diagnosis of TOS. Specific clinical tests, whose accuracy has been documented, can be used to support a clinical diagnosis, especially when a cluster of positive tests are witnessed.
Treatment of Thoracic Outlet Syndrome: Long-term Results
World Journal of Surgery, 2001
Thoracic outlet syndrome (TOS) refers to a complex of symptoms in the upper extremity caused by compression of the neural and vascular structures at some point between the interscalene triangle and the inferior border of the axilla. A review of our experience in treating this controversial syndrome is presented. Between 1989 and 1997 a series of 23 patients (5 men, 18 women) were operated on for TOS. The average age of the patients was 26.4 years (range 17-60 years). All patients complained of pain typically in the shoulder and proximal upper extremity with radiation to the neck, and most had paresthesias and numbness in the forearm and hand. Their symptoms had been present for 8 months to 9 years (mean 2.6 years). All were evaluated by history, physical examination, radiographs of the chest and cervical spine, electromyography, and nerve conduction studies; computed tomography, magnetic resonance imaging, angiography, and myelography were conducted selectively. When TOS was suspected, a cooperative concept was utilized employing the aid of the neurologist, orthopedist, and occasionally a cardiologist. The initial treatment was physical therapy for a minimum of 6 weeks. If no relief occurred they underwent surgery. In all patients in the present series the first rib was removed through a transaxillary approach. A cervical rib was also removed in four cases. Postoperatively, they were evaluated by questionnaire and reexamination. Nineteen (82.6%) had complete relief, and four had partial relief of symptoms. Complications included pneumothorax and temporary brachial paralysis in one case each. We concluded that careful selection of patients for surgery can yield satisfactory results, and a coordinated team of thoracic surgeons, neurologists, and physical therapists is important for management of these patients.
Reevaluating the Pathogenesis and Classification of Thoracic Outlet Syndrome
Academia Letters, 2022
The author has no conflict of interest to declare. Since 1956, with the publication of a paper by Peet, a diverse group of patients with symptoms in the shoulder and upper extremity who present with pain, numbness, tingling, and swelling, have been classified under the umbrella of "Thoracic Outlet Syndrome" ("TOS") (1). Conventionally, TOS has been thought to be characterized by compression of the neurovascular structures that traverse the thoracic outlet. Accordingly, TOS has been divided into 3 subtypes, Neurogenic (NTOS), Arterial (ATOS) and Venous (VTOS) which are thought to be the result of the compression of the brachial plexus, subclavian artery, or subclavian vein, respectively. However, in the six decades since Peet's publication, TOS have been associated with the confusion among medical practitioners, difficulty in making the diagnosis, and poor results with surgical intervention. In the past decade, a number of observations, have resulted in reevaluation of the pathogenesis, diagnosis, and treatment of TOS. This communication outlines these observations which provide the evidence for the hypothesis that perhaps in the majority of patients, the complex upper extremity symptoms in TOS may be the result of the compression of the Subclavian Vein(SV) by a congenitally malformed medial aspect of the first rib and the resultant venous congestion of the tissues that are fed by the subclavian vessels, as opposed to direct compression of structures in the thoracic outlet.
Vascular thoracic outlet syndrome staging and treatment
Acta Neurochirurgica
Thoracic Outlet Syndrome (TOS) is a well known lesion. Sophisticated imaging techniques can clearly highlight any anatomical damage and a wide range of therapeutic choices are available. It would seem obvious that any given patient should obtain the same treatment irrespective of the medical institution he contacts, but this is not the case. Instead each specialist may recommend different treatments: physiatrist, neurologist, surgeons (thoracic, vascular, neuro, orthopedic). Everyone preserves his specific language and there is no univocal treatment plan consensus for this complex syndrome. Evidently, the correct staging of TOS is still an unresolved question. In order to solve this problem, we collected all clinical and instrumental aspects of the syndrome into a clear, precise classification. Similar to TNM staging of malignant diseases, we used a grouping model based on the three mainly involved anatomical structures: N (¼ Nerves; brachial plexus and sympathetic fibers), A (¼ Artery; subclavian-axillary), V (¼ Vein; subclavian-axillary). We named it the NAV staging of TOS. A retrospective examination of our case records confirmed a valid and useful correlation between the proposed NAV staging and the therapeutic procedures that were actually applied. It is now essential to perform a multi-centre study to extend the validity of our staging.
Surgical Updates on Thoracic Outlet Syndrome
Current Surgery Reports, 2016
Purpose of Review Thoracic outlet syndrome is a widely recognized, yet highly disputed, syndrome mostly affecting structures of the thoracic outlet, including the brachial plexus, subclavian artery, and subclavian vein. Surgical decompression in the form of first rib resection with scalenectomy remains the mainstay of treatment particularly for venous and arterial thoracic outlet syndrome. This review serves as an update of recent publications/updates in the literature. Recent Findings Approaches to operative management continue to evolve as minimally invasive techniques have increased in popularity. Diagnostic techniques continue to evolve, particularly with regard to neurogenic thoracic outlet syndrome, to allow for more timely and accurate diagnosis. Conservative management strategies, such as anterior scalene muscle blocks, are utilized with increasing frequency, although their long-term outcomes remain unclear. Summary The aim of the present work is to review updates in the diagnosis and management of thoracic outlet syndrome over the last decade, and discuss utility and outcomes of various strategies.
Journal of Brachial Plexus and Peripheral Nerve Injury
Thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus and/or subclavian vessels as they pass through the cervicothoracobrachial region, exiting the chest. There are three main types of TOS: neurogenic TOS, arterial TOS, and venous TOS. Neurogenic TOS accounts for approximately 95% of all cases, and it is usually caused by physical trauma (posttraumatic etiology), chronic repetitive motion (functional etiology), or bone or muscle anomalies (congenital etiology). We present two cases in which neurogenic TOS was elicited by vascular compression of the inferior portion of the brachial plexus.
Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet
Manual Therapy, 2010
Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement. Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques. The rehabilitation outlined in this paper also serves as a model for the management of any shoulder condition where scapula dysfunction is a major contributing factor.
Surgical treatment of thoracic outlet syndrome : immediate and mid-term results
2008
Introduction: We report the results from a consecutive series of patients treated by scalenectomy or cervical rib resection for clearly symptomatic or paucisymptomatic thoracic outlet syndrome (TOS) over a 6-year period. Material and methods: From September 1999 to August 2005, 14 surgical decompressions were performed in 12 patients with unremitting signs and symptoms of nerve or vascular compression at the thoracic outlet. The symptoms of TOS were due to involvement of the brachial plexus in 8 cases (57.1%). A sign of vascular obstruction could be detected in 10 cases (71.4%): in 6 cases (42.8%) the presentation was predominantly arterial (arm claudication, coldness, Raynaud’s phenomenon and distal embolisation) and in 4 cases (28.5%) was related to vein compression with congestion and swelling of the affected arm or vein thrombosis. Two patients presented as emergencies with critical upper limb ischaemia or distal vessel embolisation. Results: The median follow-up period was 28.2...