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OBJECTIVEBoth clinical and radiological reports have suggested that the subclavius, a muscle in the costoclavicular space of the thoracic outlet, participates in neurogenic thoracic outlet syndrome (NTOS) in some instances, especially during movements narrowing the costoclavicular space. Magnetic resonance imaging can identify subclavius muscles with signs of nerve impingement, yet the impact of the subclavius in such situations remains unclear. Therefore, the authors investigated whether dividing or sparing the subclavius characterized by nerve impingement on MRI would affect surgical outcomes.METHODSIn this retrospective nonrandomized study, authors analyzed all NTOS patients with a subclavius muscle characterized by nerve impingement on MRI (loss of normal fat planes surrounding the brachial plexus) in the period between March 2010 and November 2016. Patients were divided into two groups: the sparing group, in which patients had undergone conventional supraclavicular scalenectomy and first rib resection (FRR), and the dividing group, in which patients had undergone scalenectomy, FRR, and subclavius dividing using a modified supraclavicular incision. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, a shoulder range of motion subscale (DASH items 6, 12–15, and 19) concerning overhead activities that can significantly narrow the costoclavicular space, postoperative MRI studies, and patient self-assessments were used to assess surgical outcomes. Univariate and multivariate analyses were conducted to identify independent factors associated with subscale scores.RESULTSFrom a total of 261 patients screened, 71 were eligible for study inclusion. Compared with the sparing group (33 patients), the dividing group (38 patients) had similar postoperative DASH scores and self-assessments but better subscale scores (9.50 ± 2.76 vs 11.94 ± 2.87, p = 0.0005). Postoperative MRI on hyperabduction showed that the brachial plexus became surrounded by normal fat tissue in the costoclavicular space in the diving group but still had signs of impingement from the untreated subclavius muscle in the sparing group. This observation agreed with a better functional recovery in terms of overhead activities in the dividing group, which was reflected by better subscale scores. Multivariate analyses indicated that the type of treatment and symptom duration prior to surgery influenced the subscale scores independently.CONCLUSIONSThis study revealed that an untreated radiological nerve-compressing subclavius muscle could lead to a relatively lower degree of recovery in the ability to perform overhead activities for NTOS patients postoperatively, suggesting that such subclavius muscles may participate in positional brachial plexus compression during movements narrowing the costoclavicular space. Dividing the muscles could decompress the costoclavicular space more effectively and may lead to better functional recovery.

Background Venous thoracic outlet syndrome (vTOS) is a rare disease with no defined guidelines regarding treatment. Patients with first rib resection with anterior scalenectomy (FRRS) often have residual subclavian vein stenosis. The aim of this study was to evaluate the use of intravascular ultrasound (IVUS) in the treatment of vTOS patients who have been surgically decompressed with FRRS. Methods Patients treated with venography after FRRS for vTOS during 2015–2017 were retrospectively reviewed. Patients were included if they received a venogram with IVUS after FRRS. The axillosubclavian vein at the site of the thoracic outlet was imaged using single-plane venography and IVUS. A greater than 50% diameter stenosis on venography or 50% cross-sectional area reduction on IVUS was considered significant and treated with balloon venoplasty. Results During the 2-year period, 14 patients underwent 24 upper extremity venograms performed after surgical decompression for vTOS, 18 of which included IVUS. Of the 18 cases with IVUS, 5 (27.8%) stenoses >50% were detected by IVUS, which were not apparent on venography, leading to intervention. IVUS detected a greater degree of stenosis than venography. Seven patients required repeat venograms. Overall, IVUS detected significant venous stenosis in 94.4% of patients compared with 66.7% of patients with venography after FRRS for vTOS. Conclusions These results suggest that IVUS detected greater levels of stenosis than venography, leading to more interventions. Just as IVUS being ideal for identifying occult iliac venous lesions, it may have a similar role in identifying venous lesions not evident on single-plane venography for postsurgical decompression in vTOS patients. Further studies may show this technique to increase the number of stenoses identified and improve long-term symptom relief.

The purposes of this study were to identify possible compression points along the transit route of the subclavian artery and to provide a detailed anatomical analysis of areas that are involved in the surgical management of the thoracic outlet syndrome (TOS). The results of the current study are based on measurements from cadavers, computed tomography (CT) scans and dry adult first ribs.The width and length of the interscalene space and the width of the costoclavicular passage were measured on 18 cervical dissections in 9 cadavers, on 50 dry first ribs and on CT angiography sections from 15 patients whose conditions were not related to TOS.The average width and length of the interscalene space in cadavers were 15.28 ± 1.94 mm and 15.98 ± 2.13 mm, respectively. The widths of the costoclavicular passage (12.42 ± 1.43 mm) were significantly narrower than the widths and lengths of the interscalene space in cadavers (P 0.05). The average width and length of the interscalene space (groove for the subclavian artery) in 50 dry ribs were 15.53 ± 2.12 mm and 16.12 ± 1.95 mm, respectively. In CT images, the widths of the costoclavicular passage were also significantly narrower than those of the interscalene space (P 0.05). The measurements from cadavers, dry first ribs and CT images were not significantly different (P 0.05).Our results showed that the costoclavicular width was the narrowest space along the passage route of the subclavian artery. When considering the surgical decompression of the subclavian artery for TOS, this narrowest area should always be kept in mind. Since measurements from CT images and cadavers were significantly similar, CT measurements may be used to evaluate the thoracic outlet region in patients with TOS.

Neurovascular compression at the thoracic outlet may give rise to one of the thoracic outlet compression syndromes. It is generally accepted that all these compression syndromes have one common problem: compression of the nervous or vascular structures, or both, as they pass from supraclavicular space to beyond the pectoralis minor tendon.

To accomplish decompression of the thoracic outlet, the first rib must be completely resected along with the tendons of the anterior and medial scalene muscle which can be safely done making two incisions as described.

The thoracic outlet syndrome [TOS] is most easily conceived as three conditions in which the elements of the neurovascular bundle, compressed at the thoracic outlet, produce a venous, an arterial and a neurogenic form of TOS. In the absence of hard diagnostic criteria and with the relative frequency of neurogenic TOS [NTOS], clinical skills remain important in the diagnosis and treatment of NTOS. The elevated arm stress test [EAST] is helpful as is the finding of brachial plexus tenderness behind the scalenus anterior muscle, and improved diagnostic accuracy can be gained from using a chemo denervation test with local anaesthetic or botox to identify and select patients with NTOS.

Effort-induced thrombosis of the upper extremity is a relatively rare condition and one aspect of thoracic outlet syndrome. It accounts for 10% of all deep venous thromboses. In the vast majority of cases the etiology is repetitive motion of the upper extremity resulting in trauma to the axillo-subclavian vein as it passes through the thoracic outlet resulting in injury to the venous intima and the surrounding supportive tissue. A secondary cause is catheter-induced injury from central venous instrumentation. Patients usually present with swelling of the affected upper extremity and complaints of heaviness and pain. Diagnosis is confirmed by duplex ultrasonography and/or contrast venography. Computed tomogram and magnetic resonance imaging are complimentary. Treatment usually involves a combination of anticoagulation, thrombolysis, and surgical decompression. Of the different techniques to surgically decompress the axillo-subclavian vein, robotic technology offers an opportunity to precisely resect the first rib and a portion of the anterior scalene muscle along with the division of the costoclavicular ligament and surrounding venous scar. The details of the technique are described with a description of the outcomes.

Objective The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. Methods We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. Results Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). Conclusions This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.

A young man presented with the severe right upper limb swelling following a heavy weight lifting that was thought to be caused by a biceps tendon rupture. However, subsequent investigations confirmed the diagnosis of Paget-Schroetter syndrome that was associated with an incidental pulmonary embolism. The patient underwent a successful thrombolysis followed by a surgical thoracic outlet decompression. Overall, the patient has made a good recovery.

Paget-Schroetter syndrome (PSS) is thrombosis of the deep veins draining the upper extremity due to anatomic abnormalities of the thoracic outlet that cause subclavian compression and subsequent thrombosis, leading to thrombus formation in the subclavian vein. Vigorous arm activity in sports is a known risk factor. Here, we report a case of Paget-Schroetter syndrome in a 31-year-old male non-professional baseball pitcher.

Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior scalene. This results in possible impingement of BP nerves within the muscle belly and, therefore, predisposition for nTOS. We hypothesized that some cases of disputed nTOS result from these BP branching variants. We tested the association between BP piercing and nTOS symptoms, and evaluated the capability of ultrasonographic identification of patients with clinically relevant variations. Eighty-two cadaveric necks were first dissected to assess BP variation frequency. In 62.1%, C5, superior trunk, or superior + middle trunks pierced the anterior scalene. Subsequently, 22 student subjects underwent screening with detailed questionnaires, provocative tests, and BP ultrasonography. Twenty-one percent demonstrated atypical BP branching anatomy on ultrasound; of these, 50% reported symptoms consistent with nTOS, significantly higher than subjects with classic BP anatomy (14%). This group, categorized as a typical TOS, would be missed by provocative testing alone. The addition of ultrasonography to nTOS diagnosis, especially for patients with BP branching variation, would allow clinicians to visualize and identify atypical patient anatomy.

Background Neurogenic thoracic outlet syndrome (NTOS) results from compression of the brachial plexus by the clavicle, first rib, and scalene muscles and may develop secondary to repetitive motion of the upper extremity. Athletes routinely perform repetitive motions, and sports requiring significant arm and shoulder use may put the participant at increased risk for NTOS. Competitive athletes who develop NTOS may require first rib resection and scalenectomy (FRRS) for symptomatic relief. However, the effectiveness of FRRS has not previously been studied in this vulnerable population. Methods This is a cross-sectional study of competitive athletes with NTOS who received FRRS by the senior author between 2009 and 2014. Eligible patients were contacted by phone and invited to complete a nine-item survey assessing the long-term effects of FRRS on pain medication use, postoperative physical therapy duration, patient satisfaction, symptom relief, activities of daily living, athletic performance, time to return of athletic performance, and need for other operations. Multivariate analyses of the following risk factors were performed: age, pectoralis minor release, preoperative narcotic use, athletic shutdown, and involvement in a throwing sport. Results There were 232 competitive athletes who met the inclusion criteria, and 67 of these (age, 14-48 years; 35 male; 99% white) responded to the survey. The average time between surgery and survey completion was 3.9 years (range, 2.2-7.0 years). The most frequent sports conducted by this group were baseball and softball (n = 44 [66%]), volleyball (n = 7 [10%]), and cheerleading and gymnastics (n = 5 [7%]), ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%. Multivariate regression analysis identified younger age as a predictor of the length of physical therapy and preoperative narcotics use as a predictor of symptom resolution. Conclusions At our center, >40% of patients requiring FRRS for NTOS are competitive athletes. The results of this study show that the majority of them are able to return to their precompetitive state after FRRS, and few experience limitations in their daily living activities. Half can return to competition at or exceeding their premorbid ability level within 6 months of surgery. The majority are pleased with their decision to undergo FRRS. Further investigation is needed to identify predictive factors for successful return to competitive athletics.

Background Neurogenic thoracic outlet syndrome (nTOS) is a relatively common disorder and often affects younger, physically active populations. The modern American military is a population at risk for the development of nTOS given the intense physical training requirements. The purpose of this study is to determine functional recovery in the active duty military population resulting in full, unrestricted return-to-duty status following supraclavicular thoracic outlet decompression with partial first rib resection, partial anterior scalenectomy, and brachial plexus neurolysis. Methods This retrospective study was approved by the Institutional Review Board at Walter Reed National Military Medical Center, Bethesda, Maryland to evaluate functional recovery following the surgery management of nTOS. In accordance with the Walter Reed National Military Medical Center Institutional Review Board, patient informed consent was obtained for this study. An institutional procedural database (Walter Reed National Military Medical Center Surgery Scheduling System) was queried for consecutive patients who underwent supraclavicular thoracic outlet decompression from January 2011 to May 2015. This study involved the completion of two survey instruments: the Disabilities of the Arm, Shoulder, and Hand survey and the Cervical Brachial Symptoms Questionnaire. Patients were asked to complete the preoperative surveys and the postoperative surveys. Results Twenty responses were obtained with a 57% (20/35) overall response rate. Due to the low sample size, results were reported as a median rather than a mean to reduce the bias of outliers. Of the 20 patients who underwent supraclavicular thoracic outlet decompression, 85% reported improved functional recovery, 10% demonstrated no improvement but maintained stable functional and symptomatic deficits, and 5% demonstrated worsening of their functional and symptomatic status. The median total preoperative Disabilities of the Arm, Shoulder, and Hand score was calculated at 112 (interquartile range [IQR] 94-122) with an overall score reduction demonstrated by the median total postoperative Disabilities of the Arm, Shoulder, and Hand score of 50 (IQR 40-71). The median total score reduction of 57 (IQR 28.5-72) represented improved clinical and functional recovery (p < 0.001). The median total preoperative Cervical Brachial Symptoms Questionnaire score was 96 (IQR 74-111) with an overall score reduction revealed by the median total postoperative Cervical Brachial Symptoms Questionnaire score of 28 (IQR 19-45). The median total score reduction of 60 (IQR 23-77) reflected significant functional recovery consistent with clinical improvement (p < 0.001). Around 89% of patients had a predecompression temporary profile secondary to physical debilitation directly related to nTOS. Following surgery, temporary profile status was reduced to 39%. Around 61% of patients were able to complete and pass their service-specific physical fitness testing. Around 56% of patients demonstrated a full return-to-duty status without limitations. Conclusion Supraclavicular partial first rib resection, partial anterior scalenectomy, and brachial plexus neurolysis results in significant improvement in functional recovery in the military active duty patient population. Prospective studies are warranted to further characterize and define nTOS functional recovery after surgery in this population.

Background Thoracic outlet syndrome is rare in children but may have serious consequences. Compression of the neurovascular structures at the thoracic outlet by anomalous soft tissues or cervical ribs may cause neurological deficits in the upper limb and venous or arterial insufficiency. Patients The symptoms and signs of this condition are well documented, but we describe two patients with an atypical presentation. We review similar published cases where delay in diagnosis resulted in cerebrovascular catastrophe. Our patients presented with relatively nonspecific central nervous system symptoms and were found to have thoracic outlet compression. Both were treated by surgical decompression of the thoracic outlet, and the symptoms completely resolved with no long-lasting neurological consequences. Conclusions We highlight the importance of these rare cases because of the risk of stroke and discuss the theory behind the pathological process.

The thoraco-cervico-axillary region is a complex structure consisting of three narrow passages. This region contains three important structures: the subclavian artery and vein and brachial plexus. By definition, Thoracic outlet syndrome (TOS) is hand and arm symptoms of pain, parasthesia and weakness due to compression of the neurovascular bundle in the thoracic outlet area. Three spaces that could be responsible for upper extremity neurovascular compression symptoms are; inter-scalene triangle, costo-clavicular space, retro-pectoralis minor space. Congenital variations in bony and fibro-muscular structures in these areas compounded with trauma, inflammation, wrong posture or dynamic demands of upper extremity predispose to the onset of TOS. Knowledge of anatomy is the key to understanding the pathophysiology of TOS.

Paget-Schroetter syndrome due to thoracic outlet syndrome is a rare but potentially disabling condition that generally affects young patients otherwise healthy. The prompt diagnosis and treatment of Paget-Schroetter syndrome is necessary to avoid major morbidity and long-term disability. The more modern treatment paradigm reported in the current literature consists of hybrid procedures with surgical decompression of the thoracic outlet and endovascular techniques to potentially improve long-term vein patency. However, there seems to be no consensus in the literature with regard to the timing and precise nature of active management, and there is presently no agreed protocol for the optimum management of Paget-Schroetter syndrome. Controversy exists partly because no randomised controlled studies are present in literature. We present a case of Paget-Schroetter syndrome due to thoracic outlet syndrome in a young male patient submitted to a multimodal procedure.

A 59-year-old woman was admitted three times over a six-month period with recurrent upper extremity deep venous thrombosis (UEDVT). It was determined that this patient was suffering from an unusual presentation of Paget-Schröetter syndrome secondary to a 20-year-old non-union of a midshaft clavicle fracture. Following thrombolysis the patient underwent resection and plate fixation of the clavicle fracture non-union. Despite the anatomic proximity of the subclavian vessels to the clavicle, vascular complications from fracture are rare. Treatment of midshaft clavicle fractures is often non-operative. Non-union rates are generally less than 10%, and easily treated secondarily without complication. Clavicular pseudo-arthroses from trauma have been implicated in the development of the thoracic outlet syndromes, however, onset 20 years after fracture has never before been reported.

Rare disease patients are the predominant group of patients who are now connecting online to patient support groups, yet research on their uses of support groups has received little attention. This is a content analysis of three vascular diseases of differing degrees of rarity. Wall posts from Facebook patient support groups for May Thurner syndrome, thoracic outlet syndrome, and superior mesenteric artery syndrome were analyzed over a period of two years. Using Uses and Gratifications as the theoretical framework, the study purpose was to assess how variations in health condition and rarity of condition affect online support group user needs. Results indicated common main cognitive and affective uses across conditions, indicating a consistent pattern of needs communicated by all patients. However, there were nuanced differences in subcategories of cognitive and affective uses between the most and least rare disorders, which inform areas for tailored support mechanisms. Additionally, these vascular patients used their respective support groups primarily for cognitive reasons, especially for the rarest conditions, which informs of basic medical informational needs these patients face related to tests, treatment, surgery, and diagnoses.

Background Thoracic outlet syndrome is an uncommon cause of upper extremity neuropathy resulting from either neurogenic or vascular compromise in the thoracic outlet. Congenital anomalies as the cause of this disease process represent a minority of cases, and the literature regarding their surgical management is still evolving. Case Report A 42-year-old female without any relevant history presented to a clinic for evaluation of worsening neuropathic symptoms in the upper left extremity. Initial physical exam was unremarkable, and MRI identified an anomalous first rib, but no abnormality of the brachial plexus. The patient was managed conservatively for almost 4 years before symptoms became debilitating. Physical exam at that time found atrophy and weakness in the muscles supplied by the upper trunk of the brachial plexus, and CT demonstrated anomalies of the bone and brachial plexus not apparent on previous MRI. Neurolysis with local resection of the abnormal bone led to successful resolution of the patient's symptoms. Conclusion Identification of a rare congenital anomaly allowed for a precise surgical treatment of the condition. The importance of careful selection of modality and review of imaging in diagnosis and operative planning is discussed.

Ultrasound examination of the brachial plexus, although at first sight difficult, is perfectly feasible with fairly rapid practical and theoretical training. The roots are accurately identified due to the shape (a single tubercle) of the transverse process of C7 in the paravertebral space, and the superficial position of C5 in the interscalene groove. The téléphérique technique allows the roots, trunks and cords to be followed easily into the supraclavicular fossa. In just a few years, ultrasound imaging of the plexus has become a routine anesthesia examination for guiding nerve blocks. In trained hands, it also provides information in thoracic outlet syndromes, traumatic conditions (particularly for postganglionic lesions) and tumoral diseases. Even if MRI remains the standard examination in these indications, ultrasound, with its higher definition and dynamic character, is an excellent additional method which is still under-exploited.

Key Clinical Message Transaxillary partial excision of the first rib is associated with minimal morbidity and excellent relief of symptoms of thoracic outlet syndrome due to instant and permanent obviation of the external arterial compression. Three‐dimensional imaging offers incremental value of the surgical outcome, highlighting the role of minimally invasive partial resection.

Objective: 5 year retrospective study of patients presenting to emergency departments at the four tertiary care hospitals in Calgary, Alberta with upper extremity (UE) deep vein thrombosis (DVT) to define the patient population, determine practice patterns and management of upper extremity clots. Methods: All adult patients with suspected upper extremity DVT presenting to any of the four tertiary care centers in the Calgary health region and who had undergone diagnostic imaging were included in the study. Ultrasounds and CT scans were obtained from the Diagnostic Imaging department from January 2014 to December 2018. Inclusion criteria included patients above 18 years of age and evidence of deep, superficial or catheter-associated upper extremity venous thrombosis on imaging. Exclusion criteria were any known cancer or life expectancy under 6 months. Basic demographic data were collected, in addition to disposition from emergency, choice of anticoagulant, duration of anticoagulation, history of thrombophilia and thoracic outlet obstruction (TOO) work-up. Results: 1236 patient records were reviewed, of which 151 (12.2%) were positive for UE deep venous thrombosis (DVT) and 114 (9.2%) for superficial vein thrombosis (SVT). Mean age was 47 years and 50.2% were males. Duration of treatment for both DVT and SVT ranged anywhere from no therapy to lifelong treatment, with an average of 5.01 months for DVT and 1.15 months for SVT. 22.5% of all DVTs were recommended lifelong therapy. 21 (18.4%) patients were treated for more than 45 days for SVT, of which only 9 had another indication for anticoagulation. Common risk factors identified for DVT included line associated thrombosis (17.2%), of which 38.5% were specifically PICC associated, trauma (2.6%) and intravenous drug use (2.0%). Anticoagulant agents for DVT included low molecular weight heparin (7.9%), direct oral anticoagulants (DOACs) (39.1%) and warfarin (42.4%). 8.6% of the DVTs received no treatment. Follow-up was variable from the emergency department ranging from following up with the patient's own family physician to sending an urgent referral to General Internal Medicine, Hematology or Vascular surgery. 30.5% of the patients with DVT were referred to General Internal Medicine (GIM) outpatient, compared to 24.5% to Hematology and 33.7% to their family doctor. 29.8% of the patients with SVT were referred to GIM, 7.9% to Hematology and 66.7% to their family doctor. 39.7% of the people with DVT were tested for thrombophilia, of which 10% tested positive for any type of thrombophilia. 29.8% were tested for TOO, of which 48.9% were found to have TOO and 11.1% received surgery for same. Conclusion: Our study demonstrates that there is significant variability in the management of upper extremity clots, highlighting the lack of literature in this field. Developing a structured, standardized approach along with ongoing provider education could help reduce this variability and optimize management of this patient population. Disclosures No relevant conflicts of interest to declare.

Objectives: Thoracic outlet syndrome represents a complex combination of symptoms in the upper extremity that occurs due to compression of the neurovascular structures of the thoracic outlet or subcoracoid space. It can be seen in overhead athletes and is commonly misdiagnosed as other shoulder pathology. This study seeks to highlight patient characteristics, intraoperative findings, and both short term and long term outcomes of thoracic outlet decompression in the adolescent population as well as a comparison of outcomes by mechanism of injury including athletes. Methods: A retrospective chart review was performed of patients between the ages of 13 and 21 with a clinical diagnosis of TOS that were treated surgically by a single surgeon between 2000 and 2015. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient reported outcome scores including quickDASH, CBSQ, VAS, and SANE were obtained for a cohort of patients with long-term follow up ranging from 2 to 15 years. Results: The study population consisted of 54 adolescents (61 extremities) aged 13-21 at the time of presentation. There was a 3:1 female to male ratio. Patients saw an average of 2.08 other healthcare providers before referral to our institution. The most common surgical procedures included neurolysis of the brachial plexus (60; 98.4%), anterior scalenectomy (59; 96.7%), middle scalenectomy (54; 88.5%), excision of the first rib (28; 45.9%), excision of cervical rib (5; 8.2%), and subclavian artery manipulation (50, 81.9%). A second incision in the subcoracoid space was utilized in 28 (45.9%) extremities for exploration of the infraclavicular brachial plexus with release of the coracocostal ligament in 26 of these 28 patients (92.9%). Long-term follow-up data, including patient reported outcomes, was collected for 24/54 patients (44%). In this patient subset, the average follow-up was 69.5 months and ranged from 24 months to 180 months. The average preoperative VAS was recorded at 8.2 with an average postoperative VAS of 2.0, showing an improvement of 6.2 points. The average preoperative SANE score was 28.9 and the average postoperative SANE score was 85.4 with an improvement in 56.5. The average postoperative quickDASH score was 11.4. The average postoperative CBSQ score was 27.4 . The average postoperative NTOS Index score was 17.2. Subgroup analysis was performed analyzing patients having a first rib excision versus patients where their first rib was left intact. There was no difference regarding clinical outcome measures in these groups including CBSQ, VAS, SANE score, quick DASH and NTOS index. An additional subgroup analysis was performed comparing mechanism of injury including overuse from sports, trauma, and idiopathic causes. There was also no difference regarding clinical outcome measures in these groups including CBSQ, VAS, SANE score, quick DASH and NTOS index. Conclusion: We found no difference in clinical outcome scores in patients treated with rib resection versus patients with the first rib left intact. We also found no difference in outcomes with respect to mechanism of injury including overhead sports athletes. Overall, patients did well long-term after decompression of the thoracic outlet. Thoracic outlet syndrome should be considered in the differential diagnosis of athletes with upper extremity pain especially if they have neurologic findings.

Aneurysmal bone cyst is a rare benign cystic bone lesion with an incidence of only 0.14 per 100,000 individuals and most commonly affects the metaphyses of long bones, spine, and pelvis. We present a very rare case of a 17-year-old boy with a rapidly expanding aneurysmal bone cyst arising from the first rib, resulting in neurogenic thoracic outlet syndrome secondary to its compression of the brachial plexus. The patient's symptoms resolved after en bloc resection. To our knowledge there have been no other reports in the literature of thoracic outlet syndrome due to aneurysmal bone cyst arising from the first rib.

Inferior vena cava (IVC) thrombosis is rare, but its incidence is increased in those with IVC filters or inflammatory bowel disease. Once the IVC is thrombosed, venous return is via collateral channels on the torso and retroperitoneum. Limitations in this collateral venous return can result in symptoms, usually in the lower extremities. Syncope and dyspnea are rare. We report a patient with a 1-year history of worsening syncope when working with his upper extremities. Iliocaval venous occlusion with lack of accommodation of venous return at the thoracic outlet was diagnosed. Treatment with iliocaval stenting resolved his symptoms.

Background Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery, resulting in neurogenic (NTOS), venous (VTOS), and arterial (ATOS) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of paraclavicular surgical decompression for TOS. Methods A prospective analysis of patients who underwent surgical decompression for TOS at a newly established center was performed. Diagnosis of TOS was based on clinical history, a physical examination, and additional diagnostic studies. The indication for surgery in patients diagnosed with NTOS was the presence of persistent symptoms after a trial of physical therapy. Primary outcomes were assessed according to Derkash's classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and duration of hospital stay. Results Between August 2004 and June 2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 men) with TOS. The mean age was 36.5 years (range: 15–68). Bilateral decompression was performed on 4 patients. The types were NTOS (n = 19; 48%), VTOS (n = 16; 40%), and ATOS (n = 5; 12%). In addition to pain, the most common presenting symptom was numbness in NTOS, swelling in VTOS, and coolness in ATOS. A history of trauma was present in 22.2%. Two patients suffered from recurrent symptoms after previous transaxillary first rib resection for VTOS at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and first rib resection. The first rib resection was partial, through a supraclavicular only approach in NTOS and ATOS patients (60%) or complete, through a supra- and infraclavicular approach for VTOS patients (40%). Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow-up. Two patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths. Complications included pleural effusion requiring evacuation (n = 4), neuropraxia (n = 1), and lymph leak (n = 1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean duration of hospital stay was 4.4 days. The mean follow-up was 10.3 months. Conclusions In our experience, surgical paraclavicular decompression can provide safe and effective relief of NTOS, VTOS, and ATOS symptoms. Functional outcomes were excellent or good in the majority of patients, with minimal complications.

Thoracic outlet syndrome (TOS) is a blanket term encapsulating many different clinical entities. Neurologic or neurogenic TOS (NTOS) is its main contributor, but it remains a complicated and sometimes controversial entity. NTOS incorporates numerous types, etiologies, clinical presentations, diagnostic findings, and therapeutic modalities. This article reviews the spectrum of disease within the thoracic outlet that affects the brachial plexus, with a special emphasis on the commonly afflicted sports medicine patient.

Neurogenic thoracic outlet syndrome (NTOS) is a neuromuscular condition affecting brachial plexus functionality. NTOS is characterized by paresthesia, pain, muscle fatigue, and restricted mobility in the upper extremity. This study quantified massage therapy's possible contribution to treatment of NTOS. A 24-year-old female with NTOS received eight treatments over 35 days. Treatment included myofascial release, trigger point therapy, cross fiber friction, muscle stripping, and gentle passive stretching. Abduction and lateral rotation at the glenohumeral (GH joint) assessments measured range of motion (ROM). A resisted muscle test evaluated upper extremity strength. The client rated symptoms daily via a visual analog scale (VAS). Findings showed improvement in ROM at the GH joint. VAS ratings revealed a reduction in muscle weakness, pain, numbness, and 'paresthesia'. Results suggest massage may be useful as part of a broad approach to managing NTOS symptoms and improving mobility.

Venous thoracic outlet syndrome is a relatively rare condition. One variety that is related to effort, often referred to as Paget-Schroetter syndrome, is seen more often in persons who are athletic or occupationally active. This condition can have significant morbidity if left untreated. Diagnosis is best undertaken with duplex ultrasound or venogram. The current standard for treatment includes catheter-directed thrombolysis with surgical correction of the thoracic outlet and subclavian vein with some variability of this depending upon the presentation. Some cases may require anticoagulation for approximately 12 wk. Return to play should be expected in successfully corrected cases that include a collaborative rehabilitation program.

We present the case of a 30-year-old female, complaining of thoracic outlet compression symptoms caused by a supernumerary muscle, the subclavius posticus, accompanied by a caudally inserted middle scalenus muscle on the second rib. This rare anatomic variant was clearly shown on CT angiography and MRI images and surgical treatment was successful. As first described by Rosenmuller in 1800, subclavius posticus is a supernumerary muscle originating from the cranial surface of the sternal end of the first rib, running laterodorsally beneath the clavicle, and inserting into the superior border of the scapula. Its role in thoracic outlet syndrome has been seldom demonstrated in living patients nor described in imaging, although it is theoretically easily recognizable on modern imaging modalities. It should be taken into account during workout of patients with thoracic outlet syndrome, since it can be potentially treated.

We report a case of a 45-year-old woman who underwent a complete resection of a liposarcoma using thoracoscopic and cervical approaches. General checkup and computed tomography revealed a large mediastinal tumor occupying the thoracic outlet, which had reached the posterior thyroid region, and another small tumor at a subcarina. A cervical method for evaluating a neck lesion and a thoracoscopic (video-assisted thoracic surgery) approach for assessing a mediastinal lesion were performed. This double approach provided excellent visualization and enabled us to perform fine manipulation even within the narrow thoracic outlet region. The patient was disease free at 11 months after surgery.

Axillosubclavian vein thrombosis, also referred to as effort thrombosis or Paget–Schroetter syndrome, is the most common presentation of the venous form of thoracic outlet syndrome. With timely diagnostic and therapeutic measures, thrombosis of the axillary or subclavian veins can be treated with minimal long-term morbidity. Case reports and single-center reviews have greatly contributed to our understanding of the pathophysiology, clinical presentation and most effective treatment modalities for venous thoracic outlet syndrome. This article provides an evidence-based review of the contemporary management of venous thoracic outlet syndrome, emphasizing the role of diagnostic venography, catheter-directed thrombolysis and prompt thoracic outlet decompression. In addition, controversies in current therapy and perspectives on future research will be addressed.

The purpose of this case report is to describe chiropractic management of a patient with arm and hand numbness and who was suspected to have ulnar nerve compression.A 41-year-old woman presented with hand weakness and numbness along the medial aspect of her right forearm and the 3 most medial fingers. The onset of symptoms presented suddenly, 3 weeks prior, when she woke up in the morning and assumed she had "slept wrong." The patient's posture showed protracted shoulders and moderate forward head carriage. Orthopedic assessment revealed symptomatic right elevated arm stress test, grip strength asymmetry, and a Tinel sign at the right cubital tunnel.The patient was treated using chiropractic care, which consisted of manipulative therapy, myofascial therapy, and elastic therapeutic taping. Active home care included performing postural exercises and education about workstation ergonomics. She demonstrated immediate subjective improvement of her numbness and weakness after the first treatment. Over a series of 11 treatments, her symptoms resolved completely; and she was able to perform work tasks without dysfunction.Chiropractic treatment consisting of manipulation, soft tissue mobilizations, exercise, and education of workstation ergonomics appeared to reduce the symptoms of ulnar nerve compression symptoms for this patient.

Thoracic outlet syndrome (TOS) is a condition arising from compression of the subclavian vessels and/or brachial plexus as the structures travel from the thoracic outlet to the axilla. Despite the significant pathology associated with TOS, there remains some general disagreement among experts on the specific anatomy, etiology, and pathophysiology of the condition, presumably because of the wide variation in symptoms that manifest in presenting patients, and because of lack of a definitive gold standard for diagnosis. Symptoms associated with TOS have traditionally been divided into vascular and neurogenic categories, a distinction based on the underlying structure(s) implicated. Of the two, neurogenic TOS (nTOS) is more common, and typically presents as compression of the brachial plexus; primarily, but not exclusively, involving its lower trunk. Vascular TOS (vTOS) usually involves compression of the vessel, most commonly the subclavian artery or vein, or is secondary to thrombus formation in the venous vasculature. Any anatomical anomaly in the thoracic outlet has the potential to predispose a patient to TOS. Common anomalies include variations in the insertion of the anterior scalene muscle (ASM) or scalenus minimus muscle, the presence of a cervical rib or of fibrous and muscular bands, variations in insertion of pectoralis minor, and the presence of neurovascular structures, which follow an atypical course. A common diagnostic technique for vTOS is duplex imaging, which has generally replaced more invasive angiographic techniques. In cases of suspected nTOS, electrophysiological nerve studies and ASM blocks provide guidance when screening for patients likely to benefit from surgical decompression of TOS. Surgeons generally agree that the transaxillary approach allows the greatest field of view for first rib excision to relieve compressed vessels. Alternatively, a supraclavicular approach is favored for scalenotomies when the ASM impinges on surrounding structures. A combined supraclavicular and infraclavicular approach is preferred when a larger field of view is required. The future of TOS management must emphasize the improvement of available diagnostic and treatment techniques, and the development of a consensus gold standard for diagnosis. Helical computed tomography offers a three-dimensional view of the thoracic outlet, and may be valuable in the detection of anatomical variations, which may predispose patients to TOS. This review summarizes the history of TOS, the pertinent clinical and anatomical presentations of TOS, and the commonly used diagnostic and treatment techniques for the condition.

Hintergrund Das neurogene Thoracic-outlet-Syndrom (nTOS), gilt im Hinblick auf Diagnose und Therapie unverandert als umstritten, ursachlich hierfur ist in erster Linie das Fehlen klar definierter Diagnosekriterien.

Brachial plexus compression (BPC) occurs above the clavicle as neurogenic thoracic outlet syndrome (NTOS) and below as neurogenic pectoralis minor syndrome (NPMS). It was recently noted that 75% of the adults seen for NTOS also had NPMS and in some this was the only diagnosis. This is also true in children but has not yet been reported. Because surgical treatment of NPMS is a minimum risk operation for pectoralis minor tenotomy (PMT), recognition of NPMS and distinguishing it from NTOS becomes important. In this study, 40 operations, 20 PMT and 20 NTOS procedures, were performed. Success rate for PMT was 85% and for thoracic outlet decompression was 70%. It was concluded that in children, as in adults, BPC is more often due to combined NTOS and NPMS. Surgical PMT should be considered first as the treatment of choice for children with NPMS. Thoracic outlet decompression is available if PMT is unsuccessful.

An interesting and rare case where a longstanding multinodular goitre causes sudden onset symptoms of superior vena cava obstruction. The symptoms were caused by bilateral brachiocephalic vein compression against the first rib. The patient's symptoms included upper limb and facial swelling, whereas her lower limbs were not oedematous (figure 1). The patient underwent CT imaging which showed a multinodular retrosternal thyroid filling the space created by the first rib, sometimes known as the thoracic outlet. The goitre expanded sufficiently to compress the brachiocephalic vein on both sides as shown in figures 2 and 3. This prevented venous drainage from the upper limbs and head. The goitre was also large enough to cause deviation of the trachea although there was no airway compromise. This case is interesting as it is very rare for a benign condition such as a multinodular goitre to cause symptoms of superior vena cava obstruction.

Always exclude injuries to the great thoracic aortic branches after injury to the cervical, clavicular, and thoracic regions. One-third of patients who survive a blunt thoracic vascular trauma has minor or lacks external signs of thoracic injury. A plain chest X-ray should be performed in all patients with thoracic injuries. Moderate restoration of BP to 100–120 mmHg is advisable to avoid rebleeding. Be liberal with insertion of a chest tube in patients with moderate or worsening hemothorax.

Thoracic outlet syndrome (TOS) is defined as compression of neural and vascular structures passing through the superior aperture of the chest ‘Thoracic Outlet’. The involved anatomical structures are brachial plexus, subclavian artery and vein, and they are at risk of compression on their course between neck and axilla.

Thoracic outlet syndrome may result from a posterior sternoclavicular (SC) joint subluxation, or an anterior SC joint subluxation after surgical fixation. This case report presents the physical therapy management of a patient with bilateral thoracic outlet syndrome (TOS) secondary to bilateral idiopathic anterior SC joint subluxation. A 16-year-old female presented with a 2-year history of numbness, tingling, and coldness in bilateral upper extremities, and intermittent headaches with occasional vision loss. Ipsilateral upper extremity symptoms were reproduced with cervical rotation and shoulder flexion and abduction from 90° to end of the range. All TOS tests were positive. Passive horizontal abduction, through the plane of scaption, produced anterior subluxation of the ipsilateral SC joint. Sustained posterior glides to the medial clavicle relieved all symptoms during shoulder flexion and the Adson's test. Interventions consisted of manual therapy, therapeutic exercise, and the trial of two orthoses. After 12 treatment sessions, the patient's symptoms resolved and she improved by 10 points on the Upper Extremity Functional Index. She had no reproduction of symptoms with the thoracic outlet special tests. She maintained a static hold for 90 sec at 90° shoulder flexion, 90° shoulder abduction, and full shoulder flexion without symptoms. The outcomes describe a successful intervention for a patient with bilateral TOS secondary to idiopathic bilateral anterior SC joint subluxation. This case suggests that SC joint dysfunction should be considered as a cause of TOS and should be screened during the initial examination.

The thoracic outlet syndromes (TOSs) are a group of etiologically and clinically distinct disorders with 1 feature in common: compression of 1 or more neurovascular elements as they traverse the thoracic outlet. The medical literature reflects 5 TOSs: arterial; venous; traumatic neurovascular; true neurogenic; and disputed. Of these, the first 4 demonstrate all of the features expected of a syndrome, whereas disputed TOS does not, causing many experts to doubt its existence altogether. Thus, some categorize disputed TOSs as cervicoscapular pain syndrome rather than as a type of TOS. To better understand these disorders, their distinctions, and the reasoning underlying the categorical change of disputed TOS from a form of TOS to a cervicoscapular pain syndrome, a thorough understanding of the pertinent anatomy, pathology, pathophysiology, and electrodiagnostic manifestations of these pathophysiologies is required. This review of the TOSs is provided in 2 parts. In part 1 we covered general information pertinent to all 5 TOSs and reviewed true neurogenic TOS in detail. In part 2, we review the arterial, venous, traumatic neurovascular, and disputed forms of TOS. Muscle Nerve 56: 663-673, 2017.

The thoracic outlet syndromes (TOSs) are a group of etiologically and clinically distinct disorders with 1 feature in common: compression of 1 or more neurovascular elements as they traverse the thoracic outlet. The medical literature reflects 5 TOSs: arterial; venous; traumatic neurovascular; true neurogenic; and disputed. Of these, the first 4 demonstrate all of the features expected of a syndrome, whereas disputed TOS does not, causing many experts to doubt its existence altogether. Thus, some categorize disputed TOS as a cervicoscapular pain syndrome rather than as a type of TOS. To better understand these disorders, their distinctions, and the reasoning underlying the categorical change of disputed TOS from a form of TOS to a cervicoscapular pain syndrome, a thorough understanding of the pertinent anatomy, pathology, pathophysiology, and the electrodiagnostic manifestations of their pathophysiologies is required. This review of the TOSs is provided in 2 parts. In this first part we address information pertinent to all 5 TOSs and reviews true neurogenic TOS. In part 2 we review the other 4 TOSs. Muscle Nerve 55: 782-793, 2017.

Thoracic outlet syndrome is caused by compression of the neurovascular bundle as it passes from the upper thorax to the axilla. The neurovascular bundle can be compressed by bony structures such as the first rib, cervical ribs or bone tubercles, or from soft-tissue abnormalities like a fibrous band, muscle hypertrophy or space-occupying lesion. Thoracic outlet syndrome commonly affects young adults but can be seen in the pediatric age group, especially in older children. Diagnosis is based on a holistic approach encompassing clinical features, physical examination findings including those triggered by various maneuvers, electromyography, nerve conduction studies and imaging. Imaging is performed to confirm the diagnosis, exclude mimics and classify thoracic outlet syndrome into neurogenic, arterial, venous or mixed causes. MRI and MR angiography are useful in this process. A complete MRI examination for suspected thoracic outlet syndrome should include the assessment of anatomy and any abnormalities using routine sequences, vessel assessment with the arms in adduction by MR angiography and assessment of dynamic compression of vessels with abduction of the arms. The purpose of this paper is to describe the anatomy of the thoracic outlet, causes of thoracic outlet syndrome, the MR imaging techniques used in its diagnosis and the principles of image interpretation.