TOS

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THORACIC OUTLET SYNDROME

• Dr. Deborah Denno
• NMS 670

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THORACIC OUTLET SYNDROME

• AKA Neurovascular Compression Syndromes
• Classic Presentation Diffuse arm symptoms,
  numbness, tingling typically down medial arm to
  4th and 5th digits.
• Symptoms are worse with overhead activity.

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THORACIC OUTLET SYNDROME

• Generalized Symptoms Pain in the upper
  extremity, paraesthesia, numbness, weakness, skin
  discolorations, swelling, Raynauds Phenomenon.

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Anatomy of TOS

• The Neurovascular Bundle (NVB)
• Brachial Plexus
• Subclavian Artery/Vein
• Axillary Artery/Vein

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Causes of TOS

• Elongated C7 TVP
• Cervical Rib (or fibrous band)
• Trauma, exostosis
• Posture induced (Forward head/rounded shoulders)
• Pancoast Tumor
• Scalene Muscles (spastic, flaccid, or anomalous)
• Costoclavicular area
• Subcoracoid area (Pec minor/Coracoid Pr.)

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Cervical Ribs

• A congenital overdevelopment, bony or fibrous, of
  the C7 costal process. Can be unilateral or
  bilateral
• Usually asymptomatic.
• Occurs in 1 of the population and only 10 of
  those are symptomatic.
• Pain and paresthesias in the medial forearm and
  hand, usually relieved by changing position. Can
  have weakness and difficulty with fine motor
  control.

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Interscalene Triangle

• Anterior Scalene
• Middle Scalene
• T1 Rib
• Subclavian Artery
• Brachial Plexus
• Subclavian Vein passes anterior

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Interscalene Triangle
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Scalenus Anticus Syndrome

• Scalene muscles elevate the 1st Rib, lateral
  flexion and rotation. Also flexion.
• C8/T1 are at greatest risk.
• Symptoms pain, paresthesia, hyperesthesia and
  numbness. These can occur anywhere from the
  shoulder to the fingers.
• Ischemia numbness, cold, weakness, and skin
  color changes.
• Adsons Test is diagnostic

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Costoclavicular Syndrome

• NVB is compressed between the 1st Rib, Subclavius
  muscle and Clavicle.
• The Subclavian Vein is most susceptible.
• Sense of Fullness in the Hand and Fingers
• Cramping pain in the forearm and hand
• Vague shoulder pain
• Swollen and engorged veins-intermittent
• Symptoms dont follow dermatome or NR.
• Shoulder ROM is maintained.
• Costoclavicular Maneuver and Edens Test are
  diagnostic.

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Hyperabduction Syndrome

• Occurs with repetitive or prolonged
  hyperabduction of the arm.
• Involves the BP and Axillary Art/Vein
• Compressed by tendon during Abduction.
• Pain, paresthesia, and numbness occur first in
  the fingers, later in the hand.
• May resemble Raynauds Ds.
• Neurologic symptoms are usually absent.
• Wrights Test is diagnostic

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General Rules

• Symptoms depends on
• Frequency
• Duration
• Degree of Compression
• Perform Allens Test first to determine the
  patency of the Radial and Ulnar Arteries.

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Treatment of TOS

• Postural Correction
• Stretching tight muscles
• Strengthening weakened muscles
• Trigger Point Therapy
• Adjust the 1st Rib
• Adjust clavicle, shoulder, C and T spines

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Special Studies

• X-ray for fracture/dislocation, cervical ribs
• Arteriography for patency of vessels.

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Differential Diagnosis

• Central Lesions? Spinal Cord Tumors
• Plexus Lesions? Pancoast tumor
• Peripheral Nerve Lesions
• Carpal Tunnel Syndrome
• Cardiac Symptoms