An Interesting Case of Thoracic Outlet Syndrome

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An Interesting Case of Thoracic Outlet Syndrome

• Laurel Romer, M.D.
• Primary Care Conference
• May 14, 2008

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Financial Disclosure

• I have received no outside financial support for
  this presentation.

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Learning Objectives

• Understand the pathophysiology of TOS
• Learn the provocative maneuvers to diagnose TOS
• Understand treatment options for TOS

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Outline

• Case Presentation
• Definition
• Anatomy
• Epidemiology
• Differential Diagnosis
• Symptoms
• Physical Exam
• Diagnostic Testing
• Treatment
• Case Presentation

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Case Presentation

• EB is a 30 year old white female who presents
  with left upper extremity swelling and pain,
  which began while she was watching a movie in a
  theater. She says that when she left the movie, a
  couple of hours after the symptoms initially
  began, she noted that the swelling of her left
  arm was worse and there was pain in her shoulder
  region. She also could not get her ring off of
  her finger and her left hand was dusky. She did
  not have any shortness of breath or pleuritic
  chest pain. A few days before that the patient
  had been shoveling snow during a heavy snow storm
  and the day after that developed upper
  respiratory symptoms including sore throat, sharp
  chest pain, a sensation of her ears being plugged
  and swollen glands in her neck.

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Case Presentation

• The patient had a Doppler evaluation which
  revealed clot in the subclavian and axillary
  veins. A CT scan of the chest revealed no
  evidence of pulmonary embolism. She had a
  hypercoagulable workup which was negative. She
  was treated with heparin and then started on
  Coumadin and consideration was given a couple of
  times to giving thrombolytics but this was not
  done. She was taken off her OCP.

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Case Presentation

• Ultrasound of the left upper extremity was
  performed about 15 days after the onset of
  symptoms and revealed interval partial
  recanalization of the left subclavian vein and
  slight increase in flow within the left axillary
  vein in a patient with previous occlusive
  thrombus in these vessels.
• MRI of the left upper extremity was performed to
  look for a compressive component to her
  vasculature in the left upper extremity as a
  cause for the DVT.

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TOS - Definition

• Adson first described his maneuver in 1927
• Thoracic Outlet Syndrome first coined in 1956
• Upper extremity symptoms due to compression of
  the neurovascular bundle by various structures in
  the area just above the first rib and behind the
  clavicle
• Etiologies include congenital bony structures,
  fibromuscular abnormalities, posture, certain
  movements, trauma

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TOS - Anatomy
Google Images
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TOS - Epidemiology

• 3 to 80 cases per 1000
• Ages 20-40
• Women gt Men (41)
• Neurogenic TOS (90) gt Venous TOS gt Arterial TOS
  (lt1)
• Cervical ribs occur in lt 1 of population
• 70 women

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TOS Differential Diagnosis

• Cervical disc disease
• Cervical facet disease
• Malignancies (Pancoast/local tumors, spinal cord
  tumors)
• Peripheral nerve entrapments (ulnar or median
  nerve)
• Brachial plexitis
• Rotator cuff injuries
• Fibromyalgia, muscle spasm
• Neurologic disorders (MS)
• Chest pain, angina
• Vasculitis
• Vasospastic disorder (Raynauds)
• Neuropathic syndromes of upper extremity

Talu, GK Agri 17 (2005), 5-9.
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TOS - Symptoms

• Neurogenic TOS
• Pain, paresthesia, and weakness in the hand, arm
  and shoulder, plus neck pain and occipital
  headaches
• Raynauds phenomenon, hand coldness and color
  changes are also seen frequently in NTOS

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
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TOS - Symptoms

• Venous TOS
• Swelling of the arm, plus cyanosis is strong
  evidence of subclavian vein obstruction
• Pain often present, but may be absent
• Arm swelling distinguishes VTOS from ATOS and NTOS

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
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TOS - Symptoms

• Arterial TOS
• Digital ischemia, claudication, pallor, coldness,
  paresthesia and pain in the hand (but rarely in
  the shoulder/neck)
• Symptoms are a result of arterial emboli from a
  mural thrombus in a subclavian artery aneurysm or
  from thrombus forming distal to subclavian artery
  stenosis

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
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TOS Physical Exam

• VTOS
• arm swelling
• cyanosis
• distended superficial veins over the shoulder and
  chest wall
• NTOS
• Tenderness over scalene muscles
• Positive provocative tests

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
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TOS Physical Exam

• Provocative tests
• Adson test
• Neck rotation and head tilting (ear to shoulder)
  eliciting pain and paresthesia down the
  contralateral side
• 90AER - Abducting arms to 90 degrees in external
  rotation, brings on symptoms within 60 seconds
• Upper Limb Tension Test

Sanders RJ, et al. J Vasc Surg, 46(3), 2007,
601-604.
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Fig. Upper Limb Tension Test (ULTT). Position 1
Arms abducted to 90 with elbows
extended. Position 2 Dorsiflex wrists. Position
3 Tilt head to side, ear to shoulder. Each
maneuver progressively increases stretch on the
brachial plexus.
                                               
    
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TOS Diagnostic Testing

• Neck or chest xray
• Detects cervical rib or elongated C7 transverse
  process
• EMG/NCS
• Normal in large majority of clinically NTOS
• Most common finding in NTOS is ulnar neuropathy
• Recent study suggests NCV abnormalities of the
  sensory medial antebrachial cutaneous nerve are
  seen in NTOS
• MRI/CT
• Venography/venous duplex
• VTOS
• Arteriography
• Only indicated in ATOS

Seror, O. Clin Neurophysiol 115 (2004),
2316-2322.
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TOS Treatment

• Conservative Management
• Massage, hydrotherapy and PT
• Behavioral modification/avoidance of provocative
  activities
• PT to strengthen muscles of the pectoral girdle
  and restore normal posture
• Improvement 50-90

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TOS Treatment

• Definitive management
• Surgical decompression of the neurovascular
  bundle
• First rib resection
• Scalenectomy
• Subclavian artery reconstruction
• Cervical sympathectomy

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Case Presentation

• A few months later, venous duplex ultrasound
  appears normal. There is no evidence of
  impingement on either side. Both veins are
  patent by duplex but there is bilateral
  impingement in multiple stress positions on both
  the right and left side.

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Case Presentation

• EB met with a vascular surgeon who felt that she
  was at high risk for recurrence of BUE DVT (off
  anticoagulants) without definitive treatment
• A left 1st rib resection was performed
• A few months later a right 1st rib resection was
  performed
• She was taken off anticoagulants
• She was restarted on her OCP along with Aspirin
  81mg qd
• She was strongly advised to continue longterm
  with a shoulder girdle strengthening exercise
  program

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References

• Barkhordarian, S. J Hand Surg 32 (4/2007),
  565-570.
• Demondion, X, et al. Radiographics 26 (2006),
  1735-1750.
• Sanders RJ, et al. J Vasc Surg, 46 (2007),
  601-604.
• Seror, O. Clin Neurophysiol 115 (2004),
  2316-2322.
• Talu, GK Agri 17 (2005), 5-9.
• Vanti C, et al. Eura Medicophys 43 (2007), 55-70.