Surgical solutions for patients

with Thoracic Outlet Syndrom

P. Dahl - Leipzig

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 Thoracic Outlet Syndrom
The Thoracic Outlet Syndrom (TOS) is defined as
sum of all symptoms caused by compression of

•
the brachial plexus

•
the subclavian artery and
•
the subclavian vein

when passing the thoracic outlet to the arm.

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 Thoracic Outlet Syndrom

Various names:

Cervical rib syndrome, Scalenus-anticus-syndrome,

Costclavicularsyndrome, Scalenus-minimus-
syndrome,
Pectoralis-minor-syndrome, Hyperabduktion-
syndrome Paget-von-Schroetter-Syndrom, Thoracic
inlet – syndrome, Compression Syndrome of the
neurovascular bundle,
Neck-Rip-Syndrom…

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 Thoracic Outlet Syndrom

Praevalence:

Rarely: In average 6,5 Doctors are needed for the

right diagnosis at the end of a 40 months – period.


In Germany: 100 up to 150 patients in one year !


Male-female ratio of 1 : 2,5

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 Thoracic Outlet Syndrom

Aetiology:

We see four factors playing a role in the aetiology of

TOS:

Postural anomalies

Osseous and fibromuscular anomalies

The physiological lowering of the shoulder girdle

Traumata

Gruss JD. Das Thoracic outlet Syndrom. Gefäßchirurgie 2006; 5: 371-380.

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Osseous and fibromuscular
anomalies

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Scalenus muscles and anomalies

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 Diagnostic Techniques and
provocative manoeuvres:


Special Arteriography: following Saalströmen.

Angiography in provocation positioning
while the patient is sitting


MRI in provocation positioning


Helical CT – angiography in provocation positioning


conventional radiography of the cervical spine to detect

cervical ribs
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 Cervical rips

Todd TW. Posture and the cervical rib syndrome. Ann Surg 1922; 75: 105-109.

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 The Roos “elevated arm stress test”

Provocational test for the diagnosis of TOS:

Both arms are held in 90 degree abduction,

right angled elbow joints and outside
directed hands.
Moving the hands strongly to fists, a TOS will
cause pain and paleness and no periferal
pulses are to be felt.
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Some Angiographies:

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 The presented case:

46 year old female

Finger tip necrosis D2 right hand

Paraesthesia right hand on radial side

Severe rest pain right arm

Angiography: provocated occlusion of the subclavian
artery,

Proximal subclavian aneurysm with periferal
embolism

occlusion of the radial artery, closed Arcus palmaris

Additional risk factor: smoking

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Supraaortal, abductional position

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Supraaortal, EAS-position

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Right subclavian artery

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Right subclavian artery

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Right axillary and brachial
artery

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Right lower arm

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Right hand: digital arteries
occluded

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 Surgical solution:

Transaxillar Resection of the first rib


Thoracal sympathectomy within the procedure

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Special instruments

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Anatomy of the transaxillary approach:

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 The surgical solution:

transaxillary exarticulation of the

first rib
and thoracal sympathectomy

…we recorded the following surgical procedure

on the 2 nd of December 2008.

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Dorsal Ventral

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First step: positioning, transaxillary approach,
preparation on the upper chest wall.
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2nd step: preparating the anterior skalenus gap,
the subclavian vein and cutting the tendon of the M.
subclavius.
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3rd step: after cutting the scalenus muscle: preparation
of the first rib und cutting the intercostal muscles.
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4rth step: perforating the fascia of Sibson.
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5th step: cutting the anterior and dorsal part of the first rib,
anterior exarticulation and preparation of the dorsal rest.
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6th step: exarticulation of caput costae, preparation
endothoracal and sympathectomy, pleura-control and
closing.
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 Our own results:
2007 2008
No symptoms, 7 19
Good results
Small symptoms, 1 2
Acceptible results
No improvement 1 0

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 REFERENCES:
1.
Roos DB. Thoracic outlet syndromes. In Vascular Disorders of the Upper Extremity.
Machleder HJ (ed). New York: Futura Publishing Company, 1983: 91-106.
2.
Roos DB. Thoracic outlet syndromes: Update 1987. Am J Surg 1987; 154: 568-573.
3.
Gruss JD, Hiemer W, Bartels D. Klinik, Diagnostik und Therapie des Thoracic outlet
Syndromes. VASA 1987; 16: 337-344.
4.
Roos DB. Historical perspectives and anatomic considerations . Semin Thorac Cardiovasc
Surg 1996; 8: 183-189.
5.
Gruss JD, Geissler C, Hanschke D, Prescher H. First rib excision is seldom required -
Against the motion. In The Evidence for Vascular or Endovascular Reconstruction.
Greenhalgh RM (ed). WB Saunders, 2002: 85 -99.
6.
Gruss JD. Das Thoracic outlet Syndrom. Gefäßchirurgie 2006; 5: 371-380.
7.
Peet RM, Hendriksen JD, Andersen TP, Martin GM. Thoracic outlet syndrome: Evaluation
of a therapeutic exercise program. Proc Mayo Clin 1956; 31: 281-287.
8.
Gruss JD. Schultergürtelenge-Syndrom (Thoracic outlet Syndrome). Acta Chir Austriaca
2000; 32: 15-19.
9.
Roos DB. New concepts in the etiology, diagnosis and surgical treatment of the thoracic
outlet syndrome. In: Greep JM, Lemmens HAJ, Roos DB, Urschel HC (eds) Pain in
shoulder and arm. Nijhoff, Dordrecht 1979; 201-214.
10.
Roos DB. Pathophysiology of congenital anomalies in thoracic outlet syndrome. Acta Chir
Belg 1980; 79: 353-361.

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 REFERENCES:

11.
Todd TW. The descent of shoulder after birth, its significance in the production of pressure
symptoms on the lower brachial trunk. Anat Anz 1912; 41: 385-392.
12.
Todd TW. Posture and the cervical rib syndrome. Ann Surg 1922; 75: 105-109.
13.
Dunant JH. Trauma als ätiologischer Faktor beim Schultergürtelsyndrom. VASA 1980; 9:
74-75.
14.
Martinez NS. Traumatic thoracic outlet syndrome. Contemp Surg 1982; 21: 1-3.
15.
Machleder HI. Vascular disorders of the upper extremity. Futura Publishing Company Inc,
New York 1998.
16.
Schulze-Bergmann G. Das Paget-von-Schroetter-Syndrom. In: Hach W (ed) Die venöse
Thrombose. Schattauer, Stuttgart, New York 1976; 79-87.
17.
Urschel HC, Razzuk MA. The failed operation for thoracic outlet syndrome: the difficulty of
diagnosis and management. Ann Thorac Surg 1986; 42: 523-528.
18.
Machleder HI, Moll F, Nuwer M, Jordan SJ. Somatosensory evoked potentials in the
assessment of thoracic outlet compression syndrome. J Vasc Surg 1987; 6: 177-184.
19.
Dongen van RJAM. Behandlung des neurovaskulären Kompressionssyndroms des
Schultergürtels - Transaxilläre Resektion der ersten Rippe und einer Halsrippe. In
Neurovaskuläre Kompressionssyndrome. Hepp W (ed). Oxford, London: Blackwell, 1996;
37-45.
20.
Gruss JD. Zweiteingriffe bei Kompressionssyndromen an der oberen Thoraxapertur. In
Neurovaskuläre Kompressionssyndrome. Hepp W (ed). Oxford, London: Blackwell, 1996;
55-64.

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 Thank you very much for
paying attention!

peter.dahl@parkkrankenhaus-leipzig.de

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