We have tried to provide information that we hope will be helpful to our patients in order to better understand the diagnosis, nonsurgical management, and surgical treatment of all types of tos, including. As previously mentioned, patients may present with symptoms similar to other commonly seen musculoskeletal disorders. Thoracic outlet syndrome information page national. The cause is pressure in the neck against the nerves and blood vessels that go to the arm. The place for scalenectomy and firstrib resection in thoracic outlet syndrome. All of these symptoms are due to pressure or compression against the nerves called the brachial plexus or blood vessels within the scalene triangle at the thoracic outlet. Thoracic outlet syndrome radiology reference article. Since tos is rare, the diagnosis can be easily missed, and it is common for patients to have seen multiple specialists without a clear diagnosis or understanding of the cause of their symptoms. Neurogenic thoracic outlet syndrome involves compression of the brachial plexus. Etiology of neurogenic thoracic outlet syndrome peet et al. Jun 17, 2019 neurogenic thoracic outlet syndrome history. Patients with disabling neurogenic or arterial tos may present with symptoms characteristic of sympathetic overactivity. The least common, but most serious, type of tos is caused by congenital present at birth bony abnormalities in the lower neck and upper chest. Historically, several names have been coined to describe pathology involving the thoracic outlet, including.
Most often, the general term thoracic outlet syndrome refers to neurogenic thoracic outlet syndrome, a condition which is caused by a compression of nerves called the brachial plexus. Repetitive upper extremity use in highperformance athletes is associated with the development of neurogenic and vascular thoracic outlet syndrome tos. Ultrasound, angiogram, ct or mri can find critical blood clots. Surgery for thoracic outlet syndrome nyu langone health.
Longterm functional outcome of surgical treatment for. A multicenter retrospective cohort study including all patients who underwent operations for tos from january 2005 until december 2016. Mr imaging findings in brachial plexopathy with thoracic. She also experiences left upper extremity numbness and tingling that are aggravated by use, especially with the arm elevated, as well as occipital headaches. Thoracic outlet syndromespecialized tos mri diagnosis. Nov 01, 2006 the term thoracic outlet syndrome was coined by peet et al, 11 in 1956 to indicate compression of one or several of the neurovascular structures crossing the thoracic outlet. Imaging findings of thoracic outlet syndrome include 10.
Updated perspectives on neurogenic thoracic outlet syndrome. Venous thoracic outlet syndrome vtos results from subclavian vein. True neurogenic thoracic outlet syndrome is diagnosed when actual nerve compression is found on a diagnostic test. Thoracic outlet syndrome nord national organization for. Thompson and chandu vemuri presentation a 28yearold female postal clerk presents to your office with a 3year history of left hand, arm, and neck pain. In general, there are many modalities used for imaging, ranging from xrays to mri.
Computed tomographyguided reoperation for neurogenic. From 8595% of all patients with thoracic outlet syndrome are affected by neurogenic tos. Other underlying medical conditions that may be confused with thoracic outlet syndrome and must be considered in the differential diagnosis of thoracic outlet syndrome. Tos is an umbrella term that encompasses three related syndromes that involve compression of the nerves, arteries, and veins in the lower neck and upper chest area. Thoracic outlet syndrome in highperformance athletes. Libby weaver 1 and ying wei lum 2, 1 department of surgery, johns hopkins hospital, baltimore, md 21287, usa.
The most common age range for this syndrome is 2040 years, with a femaletomale ratio of 4. However, longterm functional outcomes are still insufficiently known. The accurate and timely diagnosis of thoracic outlet syndrome makes a critical difference in treatment outcomes. Diagnosis and treatment of thoracic outlet syndrome. Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Tos is divided into two broad categories, the neurogenic type and the vascular type, each of which has two subtypes. Sep 30, 20 thoracic outlet syndrome tos is a frequently overlooked and misunderstood syndrome which is most often of neurogenic origin. Doctors should diagnose patients with arterial or venous thoracic outlet syndrome urgently. Initial imaging and followup imaging after surgery or intervention.
Mr imaging is useful in patients with neurogenic thoracic outlet syndrome particularly in evaluating the brachial plexus and surrounding structures. Fortunately for patients with neurogenic tos, we are living in the golden age of medical imaging. Protocol design and diagnostic value of contrastenhanced 3d mr angiography and equilibrium phase imaging on 1. Electrodiagnostic studies were characteristic of true neurogenic thoracic outlet syndrome,1 and a chest xray showed bilateral elongated c7 transverse processes. The classic patient with neurogenic tos has shoulder, neck, head, chest, or arm pain or. Procedure appropriateness category relative radiation level. Neurogenic thoracic outlet syndrome caused by compression of the nerves to the arm.
How thoracic outlet syndrome is diagnosed based on factors such as signssymptoms, patient history, physical examination, provocative compression maneuvers, and imaging studies. Thoracic outlet syndrome medical treatment guidelines. Neurogenic thoracic outlet syndrome ntos is an oftoverlooked and obscure cause of shoulder pain that regularly presents to the office of shoulder surgeons and pain specialists. Imaging assessment of thoracic outlet syndrome radiographics. Doctors usually recommend nerve conduction studies, electromyography, or imaging studies to confirm or rule out a diagnosis of tos. Imaging of the patient with thoracic outlet syndrome radiographics. The diagnosis of thoracic outlet syndrome mark lewis,1 akash prashar,1 andoni p toms,1 matthew p armon,2 paul n malcolm1 1department of radiology, 2department of vascular surgery, norfolk and norwich university hospital, norwich, uk abstract. The clinical examination of neurogenic thoracic outlet syndrome has limited. Thoracic neurogenic neoplasms may be a diagnostic challenge both clinically and radiologically, ranging from benign, incidentally discovered tumors to aggressive, symptomatic malignancies.
Acr appropriateness criteria thoracic outlet syndrome. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Electrodiagnostic features of true neurogenic thoracic. In this article, we describe the imaging features of thoracic outlet syndrome. The mechanical etiology patterns at reoperation include 1 inadequate previous rib resection, 2 rib regrowth, 3 scar tissue formation, or 4 intact scalene muscle.
Neurogenic tosnerve compression comprises 95% of all. Imaging assessment of thoracic outlet syndrome1 scottalexander. While thoracic outlet syndromes as a group are not rare, individual. Thoracic outlet syndromes toss are a group of disorders with one common feature. Thoracic outlet syndrome tos refers to a constellation of signs and symptoms that arise from compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle, within the confined space of the thoracic outlet. And, while imaging of neurogenic tos has lagged behind other imaging tests, imaging of tos is now excellent and available. New perspectives on neurogenic thoracic outlet syndrome. Imaging of the patient with thoracic outlet syndrome. Frequency of neurogenic thoracic outlet syndrome in patients with definite carpal tunnel syndrome. The term thoracic outlet syndrome doesnt refer to a specific injury. Thoracic outlet syndrome tos is a condition presenting with arm complaints of pain, numbness, tingling and weakness. Surgical therapy in appropriately selected patients can provide relief of symptoms and protection from future disability. Thoracic outlet syndrome holly grunebach, margaret w. Imaging in the diagnosis of thoracic outlet syndrome.
Thoracic outlet syndrome occurs when there is pressure against the blood vessels or nerves in your thoracic outlet area that causes you to experience symptoms in your arms and hands. Thoracic outlet syndrome is a term that covers a range of conditions and abnormalities causing a variety of presentations and symptoms. The symptoms may be intermittent and positional or involve the upper upper tos or lower trunk. Neurogenic thoracic outlet syndrome ntos has been found to be the most common form of thoracic outlet syndrome tos, consisting of 9095% of clinical cases. Neurogenic thoracic outlet syndrome is a widely recognized, yet controversial, syndrome. Ultrasound imaging may be able to visualize these brachial plexus. Neurogenic tos ntos is the most common and reported as about 90% of all tos cases. The lack of specific objective diagnostic modalities makes diagnosis difficult. The causes of ntos include anatomic variations anomalous scalene musculature, aberrant fibrofascial bands, andor cervical ribs and previous neck or upper extremity injury, which promotes scalenepectoralis muscle spasm, fibrosis, and other pathologic changes. The washington university thoracic outlet syndrome center describes the causes, symptoms and treatment of neurogenic tos.
Physical therapy management, surgical treatment, and. Ultrasound of thoracic outlet syndrome paranormal zone. However, if clinical findings of neurogenic thoracic outlet syndrome are found, this is referred to as true neurogenic thoracic outlet syndrome. Neurogenic thoracic outlet syndrome ntos is caused by dynamic compression of the brachial plexus at the level of the supraclavicular scalene triangle or the subcoracoid pectoralis minor space, or both. These tumors may originate from any nervous structure within the chest and are derived from cells of the nerve sheath, autonomic ganglia, or paraganglia.
Surgery is usually the only option for treating this type of thoracic outlet syndrome. Mr imaging remains the method of choice when searching for neurologic compression. Clinicians should be aware of thoracic outlet syndrome as a differential diagnosis when treating string instrumentalists with upper extremity musculoskeletal ailments. Senol american journal of neuroradiology mar 2010, 31 3 410417. Full text the diagnosis of thoracic outlet syndrome jvd. Thoracic outlet syndrome i ohio state medical center. Thoracic outlet syndromes genetic and rare diseases. There are 4 recognized subtypes of tos, each with a distinct cause and pattern of symptoms. Aug 07, 2016 the causes of ntos include anatomic variations anomalous scalene musculature, aberrant fibrofascial bands, andor cervical ribs and previous neck or upper extremity injury, which promotes scalenepectoralis muscle spasm, fibrosis, and other pathologic changes. Imaging diagnosis of neurogenic tos modern imaging provides essential information in patients with neurogenic tos. This completes the surgery for neurogenic thoracic outlet syndrome.
The primary purpose of the washington university center for thoracic outlet syndrome at barnesjewish hospital is to better treat patients. Persistent or recurrent symptoms after surgical treatment for neurogenic thoracic outlet syndrome ntos is a problem commonly encountered by highvolume referral centers. Patients with symptoms from compression of the neurovascular bundle in the thoracic outlet are described as having thoracic outlet syndrome tos, which is best thought of as three conditions classified according to which structures are involved. Acr appropriateness criteria 1 thoracic outlet syndrome. Symptoms include cold sensitivity in the hands and fingers, numbness, pain or sores of the fingers and poor blood circulation to the arms, hands and fingers. Firstly, imaging tests can directly or indirectly demonstrate compression of veins, arteries or nerves. This helps to reduce pain and prevent blood clots in people with neurogenic thoracic outlet syndrome. Thoracic outlet syndrome tos is the presence of a mixture of hand, arm, shoulder and neck symptoms. Thoracic outlet syndrome tos is a frequently overlooked and misunderstood syndrome which is most often of neurogenic origin. Jul 14, 2016 neurogenic thoracic outlet syndrome robert w. Physical therapy management, surgical treatment, and patientreported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.
Diagnosis of neurogenic tos thoracic outlet syndrome. In a scalenectomy, the scalene muscleswhich pass through the thoracic outletare removed to reduce compression on the nerves, arteries, and veins in the area. New diagnostic and treatment modalities for neurogenic. Longterm functional outcome was assessed using a validated questionnaire. The term thoracic outlet syndrome was coined by peet et al, 11 in 1956 to indicate compression of one or several of the neurovascular structures crossing the thoracic outlet. Jan 10, 2019 neurogenic thoracic outlet syndrome involves compression of the brachial plexus. Originally coined in 1956, the term tos indicated a compression of the neurovascular structures in the interscalene triangle corresponding to the possible etiology of the symptoms.
Jun 12, 2017 thoracic outlet syndromes toss are a group of disorders with one common feature. The procedure may be performed in conjunction with surgery to remove an extra rib. Similar to vascular thoracic outlet syndrome, a pure neurogenic presentation is also rare. The definition, incidence, diagnosis, and treatment of thoracic outlet syndrome tos are somewhat controversial. Imaging is performed with the patients arms both in the raised abducted and neutral adducted positions for comparison. Pdf imaging assessment of thoracic outlet syndrome1. Sonographically guided anesthetic injection of anterior scalene muscle for investigation of neurogenic thoracic outlet syndrome. Patients present with painless atrophy of the intrinsic muscles of the hand, and athletes may report difficulty grasping a racket or ball as a result of intrinsic muscle. There are vascular and neurogenic forms of thoracic outlet syndrome tos. The thoracic outlet includes three compartments the interscalene triangle, costoclavicular space, and retropectoralis minor space, which extend from the cervical spine and mediastinum to the lower border of the pectoralis minor muscle. First rib resection for thoracic outlet syndrome tos is clinically successful and safe in most patients. Surgery then continues with repair of the subclavian artery, in which the aneurysm is removed and a. The middle scalene muscle and its contribution to the thoracic outlet syndrome. Involvement of the retropectoral space is common in neurogenic tos, with a recent study.
Thoracic outlet syndrome tos is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit. If the patient has arterial thoracic outlet syndrome, the procedure usually includes removal of an extra cervical rib. Thoracic outlet syndrome affecting highperformance. Mr imaging findings in brachial plexopathy with thoracic outlet syndrome a. Presented at the fortysecond annual meeting of the midwestern vascular surgical society, st. There are three types of tos depending on which structure is being compressed. The neurogenic type is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb. A thorough clinical examination is essential in properly diagnosing tos, differentiating neurogenic tos from vascular arterial or venous tos, and effectively managing patients suffering from this condition. Aug 14, 2016 how thoracic outlet syndrome is diagnosed based on factors such as signssymptoms, patient history, physical examination, provocative compression maneuvers, and imaging studies. Thoracic outlet syndrome is diagnosed through a combination of patient history, physical examination findings, and imaging studies.
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