Proposed Pathogenesis for a Subgroup of Patients with Neurogenic Thoracic Outlet Syndrome (original) (raw)

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.

Difficult diagnosis of a neurogenic thoracic outlet syndrome and review of the current literature

International Journal of Research in Orthopaedics, 2020

Thoracic outlet syndrome (TOS) is an uncommon disorder, without a clear clinical presentation or a fully accepted definition. The patients usually present a set of symptoms arising from compression of the brachial plexus or subclavian vessels during their passage through the thorax, between the base of the cervical region and the axilla. The authors present a case of a 20 years old woman with sporadic paresthesia in the territory of C7-T1 nerve root. At the physical examination she had a positive Wright's test. The imaging studies revealed the presence of a right cervical rib. A partial rib resection was performed with exploration of the braquial plexus and at the current follow up; 24 months after the surgery, the patient is asymptomatic. Our objective is to present a case of TOS and to highlight the clinical-management and treatment challenges of this pathology.

Coexistence of arterial compression in patients with neurogenic thoracic outlet syndrome

JAMA surgery, 2014

Patients with neurogenic thoracic outlet syndrome (NTOS) may have signs and symptoms of arterial compromise without thrombosis or aneurysm. To evaluate these patients' presentation, duration of signs and symptoms, and outcomes of immediate surgical operation. Demographic and clinical data for patients with NTOS and signs and symptoms of arterial compromise without arterial thrombosis or aneurysm were extracted from a prospectively maintained, institutional review board-approved database and patient medical records between May 22, 2003, and October 16, 2012, in the Johns Hopkins Medical Institutions' Department of Vascular and Endovascular Surgery. All patients received immediate first rib resection and scalenectomy (FRRS) (n = 15), cervical rib resection and FRRS (n = 6), or FRRS and second rib resection due to fusion (n = 1). Further physical therapy or anterior scalene block was not considered owing to arterial compression. Surgical intervention relieved arterial and neuro...

Neurogenic thoracic outlet syndrome: Are anatomical anomalies significant?

South African Journal of Surgery, 2015

Thoracic outlet syndrome (TOS) is controversial in terms of definition, anatomy, aetiology and treatment. The definition of TOS is generally accepted as 'upper extremity symptoms due to compression of the neurovascular bundle in the area of the neck just above the first rib'. [1] The thoracic outlet, also known as the cervicothoracobrachial junction, consists of three important compartments through which vital structures such as nerves and blood vessels run. These compartments are the interscalene space, the costoclavicular space and the retropectoralis minor space. Neurogenic TOS, resulting from nerve compression, is the most common pathology, accounting for >95% of TOS cases. [1] The majority of cases result from anatomical distortion at the interscalene triangle. [2] For various reasons, the described anatomical spaces transform and evolve into 'entrapment spaces'. The aetiology of this is largely unclear, but it is thought that changes may be congenital or acquired, and that these alterations involve either the bony structures or the soft tissues. [1,2] The observation of anatomical anomalies, especially of the brachial plexus, initiated this study. The aetiology of neurogenic TOS is multifactorial, with bony tissue abnormalities and soft-tissue abnormalities described as definite contributors to the syndrome. These abnormalities contribute to the syndrome by altering the space within which the brachial plexus trunks run. Brachial plexus anomalies, however, have not classically been described in direct association with TOS. Recent interest in brachial plexus anomalies suggests them as a cause for various pathologies, including TOS. [3] We hypothesised that brachial plexus anomalies, alone or in conjunction with additional pathology, are almost always associated with neurogenic TOS. The objective of this study was to attempt to clearly define anatomical anomalies causing TOS. Methods The study design is a retrospective review from a prospectively maintained computer database of patients presenting with TOS, over a 10-year period. From the computer database, the records of all patients with TOS were scrutinised, and information regarding their preoperative symptoms, investigations, operative surgery and clinical outcomes documented. The neurological presentation of pain, paraesthesia, weakness, wasting of the hand muscles and the segmental distribution in conjunction with the clinical investigations (including the elevated arm stress test), investigations (a chest radiograph, magnetic

A rare cause of thoracic outlet syndrome

Archives of Orthopaedic and Trauma Surgery, 2007

First rib pathology can narrow the thoracic outlet thus producing compression of the brachial plexus and subclavian vessels. There have been only three case reports of neurogenic thoracic outlet syndrome (TOS) caused by a nonunion of the Wrst rib and there have been no reports of a Wrst rib malunion causing TOS. A rare case of TOS caused by a malunion of the Wrst rib is presented.