Jodi Gerdes, MD Assistant Professor of Clinical Surgery Louisiana State University Health Science...
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Transcript of Jodi Gerdes, MD Assistant Professor of Clinical Surgery Louisiana State University Health Science...
Jodi Gerdes, MDAssistant Professor of Clinical Surgery
Louisiana State University Health Science Center
October 11, 2012
Thoracic Outlet Syndrome
LSU School of Medicine-New Orleans (LSUSOM-NO) is the provider of Continuing Medical Education for this activity. The planning and presentation of all LSUSOM-NO activities ensure balance, independence, objectivity and scientific rigor.
The LSU School of Medicine-New Orleans designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Dr. Jodi Gerdes
I do not have any commercial interests.
A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
History Galen – 2nd century – first description of
cervical ribs in medical literature Vesalius – 1543 – Belgian anatomist
described cervical ribs Gruber – 1842 – 4 types of cervical ribs
Sir Astley Cooper (1768-1841) “Prince of Surgery” Guy’s Hospital in London President of the Royal College of
Surgeons Suspensory ligaments of Cooper
Sir Astley Cooper (1768-1841) Many contributions to vascular surgery
Pathophysiology of cerebral circulationProximal ligation of carotid and external
iliac aneurysms 1821 – woman with pulseless, cold arm
and gangrenous changes to fingersCompression and thrombosis of subclavian
artery by a cervical rib
History William Halsted – 1916 - described how
cervical ribs cause subclavian artery post-stenotic dilatation
History Law – 1920 – described congenital
bands and ligaments that compressed the lower brachial plexus
Murphy – 1910 – excised normal first rib Adson and Coffey – 1927 – division of
anterior scalene muscle without cervical rib resection
Ochsner, Gage, DeBakey – 1935 – scalene anticus syndrome (Naffziger’s syndrome) – scalenotomy in the absence of cervical rib
History Peet – 1956 – “thoracic outlet
syndrome” Clagett – 1962 – posterior approach to
first rib resection Roos – 1966 – transaxillary first rib
resection Gol – 1968 – infraclavicular approach
History Arteriography and venography
introduced in the 1960s for diagnostic purposes
Jebsen – 1968 – nerve conduction studies
Urschel applied to TOS patients Princeton football player with nTOS
TOS Combination of anatomic anomalies,
physical activities, and life events Constellation of upper extremity
symptoms Compression of neurovascular bundle at
thoracic outletBrachial plexus (C5-T1)Subclavian veinSubclavian artery
Scalene MusclesWide vs narrow triangleCongenital bands/ligaments
Cervical ribs Incidence 0.74%Female:male ratio 7:3Complete vs incompleteMore common on left
Anomalous 1st ribs Incidence 0.76%Equal occurrence in men and women
Anatomic Variations
Epidemiology 20-50yo
<5% teenagers10% over 50Rarely >65
70% female70% cervical ribs occur in females
Neurogenic TOS Etiology
Hyperextension neck injury (whiplash)Repetitive stress injuries (typing, assembly
lines)Falls on slippery floors/ice
Neurogenic TOS Predisposing Factors
Scalene muscle anomaliesNarrow scalene trianglesCongenital ligaments/bandsHigh plexus rootsCervical ribs
Neurogenic TOS Classification of Congenital Bands and Ligaments within the Scalene Triangle 1 - Extends from the anterior tip of an incomplete cervical rib to the middle of the first thoracic
rib; inserts just posterior to the scalene tubercle on the upper rib surface 2 - Arises from an elongated C7 transverse process in the absence of a cervical rib and attaches
to the first rib just behind the scalene tubercle; associated with extension of the transverse process of C7 beyond the transverse process of T1 on anteroposterior spine radiographs
3 - Both originates and inserts on the first rib; starts posteriorly near the neck of the rib and inserts anteriorly just behind the scalene tubercle
4 - Originates from a transverse process along with the middle scalene muscle and runs on the anterior edge of the middle scalene muscle to insert on the first rib; the lower nerve roots of the brachial plexus lie against this band
5 - Scalene minimus muscle arises with the lower fibers of the anterior scalene muscle, runs parallel to this muscle but passes deep to it to cross behind the subclavian artery and in front of or between the nerve roots, and inserts on the first rib; any fibers passing anterior to or between the plexus but posterior to the artery
6 - Scalene minimus muscle inserting onto Sibson's fascia over the cupula of the pleura instead of onto the first rib; labeled separately to distinguish its point of insertion
7 - Fibrous cord running on the anterior surface of the anterior scalene muscle down to the first rib and attaching to the costochondral junction or sternum; lies immediately behind the subclavian vein, where it may be a cause of partial venous obstruction
8 - Arises from the middle scalene muscle and runs under the subclavian artery and vein to attach to the costochondral junction
9 - Web of muscle and fascia filling the inside posterior curve of the first rib and compressing the origin of the T1 nerve root
Adapted from Roos, Am J Surg
Neurogenic TOS Pathophysiology
Neck trauma stretches and tears scalene muscle fibers
Swelling of muscle belly pain, parathesias, numbness, weakness
Scarring/fibrosis of muscle belly occipital headaches, muscle spasms
Neurogenic TOS Machleder et al 1986 (UCLA)
Type 1 slow twitch muscle fibers convert to Type II fast twitch fibers following stretch injury in scalene muscles
Convert back after severing the muscle Sanders et al 1990
>2x more connective tissue cells in anterior scalene after trauma
Neurogenic TOS Symptoms
Pain, parathesias, numbness, weaknessThroughout affected hand/arm
Not necessarily localized to peripheral nerve distribution
Extension to shoulder, neck, upper back not infrequently
“Upper plexus” disorders – radial and musculocutaneous nerve distributions
“Lower plexus” disorders – median and ulnar nerve distributions
Neurogenic TOS Symptoms
Occipital headachesPerceived muscle weakness
Actual weakness and atrophy are rareVasomotor symptoms
Vasospasm, edema, hypersensitivity (CRPS)
Neurogenic TOS Pectoralis minor syndrome
Compression of neurovascular bundle under the pec minor
Pain over anterior chest and axillaFewer head/neck symptomsConsider pec minor tenotomy with thoracic
outlet decompression
Venous TOS Etiology
Developmental anomalies of costoclavicular space
Repetitive arm activities – throwing, swimming, overhead activities
Venous TOS Predisposing Factors
Relationship of vein to subclavius tendon and costoclavicular ligament
Dimensions of costoclavicular space Repetitive trauma to vein causing
fibrosis, stenosis, thrombosis
Paget-Schroetter syndrome Effort thrombosis of axillary-subclavian
vein Associated with TOS in some cases
Acute occlusionPainTightnessDiscomfort during exerciseEdemaCyanosis Increased venous patternTenderness over the axillary veinGangrene (1/23 patients)
Physical activitiesLifting or pulling heavy objects, basketball,
baseball, painting, tennis, raquetball, football, golf, wrestling, weightlifting, scrubbing, shoveling snow, swinging rifle
Up to 40% had residual symptoms after treatment
Arterial TOS Pathophysiology
Arterial compression resulting in post-stenotic dilatation or aneurysm
Distal embolization of thrombus
Arterial TOS Symptoms
Digital or hand ischemiaCutaneous ulcerationsForearm pain with usePulsatile supraclavicular mass/bruit
Diagnosis “the most accurate diagnosis of TOS…
must rely on a careful history and thorough, appropriate physical examination”
David B Roos, MD
No single diagnostic test has sufficient specificity to prove or exclude the diagnosis
Neck trauma preceding onset of symptoms
Repetitive stress injury Occipital headaches Pain over trapezius, neck, shoulder,
chest Specific disabilities regarding work and
daily activities Exertional arm pain Other specialists seen and
tests/procedures performed
History
Differential Diagnosis nTOS Carpal tunnel syndrome Ulnar nerve compression Rotator cuff tendinitis Cervical spine strain/sprain Fibromyositis Cervical disk disease Cervical arthritis Brachial plexus injury
Differential Diagnosis aTOS Other sources of emboli
Cardiac, aortic arch, hypothenar hammer syndrome, coagulopathies
Vasculitis Radiation-induced arteritis Connective tissue disorders Arterial dissection Atherosclerotic disease Traumatic
Pulse exam Listen for bruits Edema/cyanosis/collateral veins Tenderness over scalene muscles
(trigger points) or pectoralis minor Reduced sensation to very light touch in
fingers Provocative maneuvers
Physical Exam
With the patient seated, arms at the sides, the radial pulse is palpated and the examiner listens for bruits above the clavicle
Elevate arm and turn the chin both toward and away from the involved side
A positive test results in diminished radial pulse, bruit, and numbness and tingling
Up to 50% of healthy volunteers have a positive test – unreliable for diagnosis of TOS
Adson Test
Elevated arm stress test Most accurate clinical test (Roos) Hold “surrender” position for 3 minutes
while opening/closing hands
EAST
EAST nTOS
Heaviness, progressive weakness, numbness
Tingling in fingers, progressing up arm vTOS
Cyanotic arm with distended forearm veins aTOS
Ischemic, cramping pain
Positive response indicates compression of cervical roots or brachial plexus
Negative response is usually adequate to rule out nTOS
Upper Limb Tension Test
Imaging Xrays
Cervical ribElongated C7 transverse processHypoplastic 1st ribCallous formation from clavicle or 1st rib
fracturePseudoarthrosis of 1st rib
Unable to image soft tissue anomalies and fibromuscular bands – seen only at time of surgery
CT/MRI usually negative but can rule out other pathologies
MR neurography – newer technology to detect localized nerve function abnormality
Imaging
Imaging aTOS
Segmental arterial pressuresAngiography
vTOSDuplex U/SVenography
Use positional maneuvers during the studies
Consider bilateral studies
EMG/NCS Reduction in NCV to <85m/s Positive results
Aid in evaluation of other conditionsPoor prognostic factor if truly nTOS –
indicate advanced neural damage Negative results
Exclude other conditionsMay still be nTOS
Electrophysiology Testing Medial antebrachial cutaneous nerve
(MAC) Lowest branch of inferior trunk of brachial
plexusMore sensitive to compression than other
branches Higher sensitivity and specificity than
EMG/NCS
Most useful when diagnosis is unclear Correlation between relief of symptoms
after block and successful outcome after surgical decompression
Scalene muscle block
Physical therapy Physical therapy Physical therapy
Therapist must have experience in evaluation and treatment of nTOS
20-30% of patients respond, do not require surgical treatment
Treatment nTOS
Treatment nTOS Neck stretching Posture correction Avoid neck traction, weights, resistance
exercises, strengthening exercises
Treatment vTOS Catheter-directed thrombolysis Anticoagulation Surgical decompression with
intraoperative venography and subclavian vein PTA
Transaxillary approachAdvantages
Limited field of operative dissection Cosmetically placed incision Sufficient exposure (for 1 person) Achieve 1st rib resection and anterior
scalenectomy Removal of anomalous ligaments and fibrous
bandsDisadvantages
Incomplete exposure of entire scalene triangle Difficulty achieving brachial plexus neurolysis Limited if vascular reconstruction is needed
Surgical Treatment
Supraclavicular approachAdvantages
Wide exposure of all anatomic structures Permits complete resection of anterior and
middle scalenes as well as brachial plexus neurolysis
Allows resection of cervical ribs and anomalous 1st ribs
Vascular reconstruction is possible
Surgical Treatment
Complications Injury to
Subclavian artery/veinBrachial plexusPhrenic nerveLong thoracic nerveThoracic ductSympathetic chain Intercostal brachial cutaneous nerve
(axillary) Pneumothorax Lymph leakage
Transaxillary 1st rib resectionGood – 80%Fair – 6%Poor – 15%
Supraclavicular approachGood – 77%Fair – 15%Poor – 8%
Outcomes
No difference in long term results between the 2 approaches
No difference in outcome based onPresence of any particular provocative test
resultsExperience of operating surgeon
Predictors of ongoing disabilityAmount of work disability preopLonger intervals between injury and
diagnosisOlder age at time of surgery
Outcomes
Associations between preexisting psychological factors and socioeconomic characteristics have been examined
Independent risk factors associated with persistent disabilityMajor depressionSingleLess than a high school education
Outcomes
Results vary by etiology of symptomsFailure in 42% with symptoms after a work-
related injury or repetitive stressFailure in 26% with symptoms after auto
accidentFailure in 18% with nonspecific etiology
Outcomes
Postoperative scarring most common cause
Seprafilm – no change in recurrence rates but made plexus easier to find at reoperationWrap nerve roots prior to wound closure
Surgiwrap – only 8 recurrences in 175 patients in early studies
Recurrent nTOS
JVS Oct 2012 Retrospective review of 161 patients
with nTOS following first rib resection and scalenectomy (FRRS)
Unresolved, recurrent, and/or contralateral symptoms
JVS Oct 2012 161 patients, 182 FRRS
21 had bilateral procedures 121 females, 40 males Mean age 38.8yrs Mean f/u 12.8 +/- 12 months 128 patients (142 FRRS) reported
resolved symptoms – 78%
JVS Oct 2012 23 patients (24 FRRS) reported
unresolved symptomsOlderActive smokersLonger length of symptoms at initial
presentationHigher incidence of comorbid conditions
Chronic pain syndromes Neck/shoulder disease Etiology – trauma Opioid use and Botox injections more common
JVS Oct 2012 Unresolved symptoms
Physical therapyAnesthetic or steroid injectionsCT-guided Botox injectionsShoulder arthroplastyNeuroplasty of brachial plexus
6/23 patients - freedom from opioids
JVS Oct 2012 16 patients (16 FRRS) reported
recurrent symptoms at 12.1 +/- 9.7 monthsChronic pain syndromesNeck/shoulder diseaseReinjury – 31.3%
JVS Oct 2012 Recurrent symptoms
Physical therapyCT-guided Botox injectionsAnesthetic/steroid injectionsBiceps tendonesis, acromioplasty,
discectomy 13/16 patients - freedom from opioids
JVS Oct 2012 Patient demographics and clinical
variables play a role in successful vs failed surgical outcomesOlderLonger duration of symptomsChronic pain syndromes (fibromyalgia)Neck/shoulder disease (DJD, rotator cuff
tear)Opioid usePrevious surgeryActive smokers
JVS Oct 2012 Improper diagnosis vs complicated
recovery due to comorbid conditions Other studies discuss reoperation for
residual rib or incomplete scalenectomy
45 yo female with 10yr history of L arm pain and hand numbness
Exacerbated by external rotation and abduction of shoulder
2 L shoulder surgeries, carpel tunnel release
Extensive PT
History
Past Medical/Surgical HistoryGERDHypothyroidismRaynaud’s phenomenon2 L shoulder surgeries (2005, 2008)L wrist carpel tunnel release (Sept 2010)
History
Physical ExamP 80, R 16, BP 116/72, equal BPs in UEsNeck: no carotid bruits, no
supra/infraclavicular bruitsExt: absent L radial pulse with LUE
externally rotated and abducted and head turned away, develops harsh bruit over L clavicle with this maneuver as well
Neuro: CNs intact, motor/sensory intact
History
NCV and EMG – June 2010Mild thoracic outlet on LMild denervation L tricepsPossible mild L C7 radiculopathy
Non-invasive Studies
Positional PVRsRUE
Occlusive with arm at 180 degrees and head turned away
LUE Occlusive with arm in military position and at
180 degrees with head turned away
Non-invasive Studies
L transaxillary first rib resection Follow-up
L hand numbness resolved Post-op pain in neck/shoulder slowly
improving
Treatment
Conclusions nTOS most common nTOS most difficult to diagnose Treatment
Physical therapyAnterior scalene block Informed consent prior to surgery
Conclusion “A surgeon recognizing nTOS should not
be dissuaded by the impression that these problems are frequently associated with psychiatric overtones, dependency on pain medications, and ongoing litigation”
Rutherford’s Vascular Surgery 7th Edition