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Thoracic Outlet Syndrome Prof . T. Vidyasagaran
HOD, Dept of Vascular Surgery Vascular Surgeon, Chennai.
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Thoracic Outlet Area Definition Upper extremity symptoms
TOS Definition Upper extremity symptoms due to compression of the neuro vascular bundle in the Thoracic Outlet Area
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TOS 95 % Neurogenic 1 % Arterial 2 - 4 % Venous Vasculogenic
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TOS
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Three Spaces Scalene Triangle Costoclavicular space
TOS Three Spaces Scalene Triangle Costoclavicular space Pectoralis minor space
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TOS
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Neurogenic TOS Predisposing Anatomic Factors Neurogenic TOS Bony
Congenital narrowing - Cervical 4.5 % Rudimentary rib Long C7 transverse process Acquired narrowing - Malunion Callus Exostosis or tumors
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Scalene Muscle TOS Neck trauma - Primary cause
Anatomy of muscle - Predisposing factor for nerve compression Splitting of SA Scalene minimus Interdigitation Middle scalene 58 % SM SA SM SA V V BP A BP A Rib Rib cms
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Neck Trauma Neurogenic TOS Automobile accidents
Hyperextension neck injuries Repetitive stress injuries Keyboard Jobs Arm Neck stretching
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Symptoms Neurogenic TOS Young 20 - 45 years 70 % Women Paresthesia
All nerves Commonest Ulnar Lower chord Median Upper chord Pain Headaches occipital Scapular pain Trapezius Dorsal scapular nerve Rhomboids Weakness Vascular - sympathetic response
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Clinical Diagnosis Neurogenic TOS Supraclavicular muscle tenderness
Tinel’s signs - specific signs AER - EAST Decreased sensation to light touch Adson’s 50 % normal individuals % of TOS Positional Maneuvers Pulse deficit
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3 cms lateral to the midline
Neurogenic TOS Diagnostic Tests Scalene muscle block ml 1 % lignocaine ASM - Tender area cephalad 94 % - with surgical decompression 2 cms above clavical 3 cms lateral to the midline
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X ray chest (upper thoracic) X Ray neck - AP - oblique cervical spine
Neurogenic TOS X ray chest (upper thoracic) X Ray neck - AP - oblique cervical spine MRI
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DD Neurogenic TOS Neurological diseases Shoulder disorders
Spinal cord tumor Multiple sclerosis Shoulder disorders Shoulder tendinitis Myositis Nerve compression syndrome Carpal tunnel guyen tunnel Cuboid tunnel epicondylitis Cervical spine pathology Cervical spine injury Disc herniation Spinal stenosis Sympathetic diseases Raynaud’s Reflex sympathetic dystrophy
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Strengthening Exercise Worsens
Neurogenic TOS Treatment Non operative modalities Neck stretching Abdominal breathing Posture exercise Shoulder shrugs Lifting light weight Neck traction Ineffective Strengthening Exercise Worsens
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Surgery Failure of Conservative
Neurogenic TOS Surgery Failure of Conservative Disabling symptoms Work Recreation Daily living Symptoms more than a year
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Principles Decompression of brachial plexus Rib excision Scalenectomy
Neurogenic TOS Principles Decompression of brachial plexus Rib excision Scalenectomy
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Complications Nerve Injuries Bleeding Lymph leakage Less than 1 %
Neurogenic TOS Complications Nerve Injuries Bleeding Lymph leakage Less than 1 %
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Post stenotic dilatation
Arterial TOS Post stenotic dilatation Aneurysmal dilatation Thromboembolic complications
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Pathophysiology Significant Permanent Long standing
Arterial TOS Pathophysiology Significant Permanent Long standing Congenital or acquired bony abnormality 10 years older than neurogenic TOS
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Diagnostic Arterial TOS History
Examination - Pulsatile SC mass - bruit Radiological - Cervical spine Upper thoracic Duplex Arteriography DSA Dynamic views Helical CT MRA Surgical exploration
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Surgery Management Principles Compression
Arterial TOS Management Principles Surgery Compression Subclavian axillary artery lesions Distal tree status
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Reconstruction Arterial TOS
PSD with no intramural thrombosis - No intervention Tailoring subclavian artery Intimectomy with tailoring subclavian artery Vein patch closure Resection Primary repair Graft interposition
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Distal Embolism Multiple & diffuse Various ages
Arterial TOS Distal Embolism Multiple & diffuse Various ages Recent - Thromboembolectomy Old - Bypass Distal tree choked - Dorsal sympathectomy
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Paget Schroetter Syndrome Primary Subclavian Axillary Thrombosis
Venous TOS Subclavian Axillary Vein Thrombosis Paget Schroetter Syndrome Primary Subclavian Axillary Thrombosis
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Venous TOS Incidence 1.4 % of all DVT 25 % of all upper DVT
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Clinical Presentation
Venous TOS Clinical Presentation Young males 2 : 1 Age 30 years Strenuous exercise % Dominant extremity % Associated neurogenic %
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Diagnosis Venous TOS Clinical swelling Venous engorgement Sudden onset
Duplex Venography MRV Radionuclide venography
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Treatment Rest & Elevation Long Term Morbidity
Venous TOS Treatment Rest & Elevation Systemic anticoagulation Long Term Morbidity
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Restore luminal patency Remove extrinsic compression
Venous TOS Restore luminal patency Remove extrinsic compression Intrinsic stenosis
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Thrombectomy - with decompression
Venous TOS Thrombectomy - with decompression Thrombolytic
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Thrombolytic Venous TOS Systemic
Catheter directed - Venographic evaluation possible Assess extrinsic compression immediately - Oral anticoagulation 3 months / 1 month - Decompression Balloon angioplasty & stenting
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Algorithm Venous TOS Presentation Duplex confirm Appropriate candidate
Venography Complete lysis Positional venography CD Thrombolysis Incomplete lysis EC No EC Intrinsic stenosis TOD Anticoagulation TOD + Vein patch angioplasty or balloon angioplasty stent
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Algorithm Venous TOS Incomplete Lysis Short occlusion Long occlusion
Operative thrombectomy or Balloon AP Stent Anticoagulation Failure Persistent symptoms Surgery
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Trinity Oration
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THANK YOU
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Scalene Triangle Commonest site of Nerve compression Brachial plexus
TOS Scalene Triangle Commonest site of Nerve compression Brachial plexus Subclavian artery
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TOS Costoclavicular Artery Vein Nerve
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Pectoralis Minor Space
TOS TOS Pectoralis Minor Space Seldom involved in TOS
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