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Vascular Surgery > Chap 125-128 Thoracic Outlet Syndrome > Flashcards

Chap 125-128 Thoracic Outlet Syndrome Flashcards

1
Q

What is TOS?

A

Constellation of symptoms that occur from compression of the neurovascular bundle

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2
Q

What is usual age of onset?

A

20-50

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3
Q

Is there a sex predominance? Why?

A

70% are female

likely because 70% of cervical rib happen in women

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4
Q

Which form of TOS is most common? Least common?

A

nTOS 95%

aTOS <1%

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5
Q

What injuries cause nTOS?

A

hyperextension injury, whiplash, repetitive stress injury, falls

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6
Q

What are anatomical predisposing factors for nTOS? (3)

A

Cervical rib
Congenital band
Scalene triangle muscle variations

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7
Q

What are the histopathological findings in nTOS? (4)

A

Predominance of Type I muscle fibers (slow twitch)
Endomysial fibrosis (thickened tissue around individual muscle finer)
2fold increase in CT
Mitochondrial abnormalities

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8
Q

What is the usual composition of type I and II muscle fibbers?

A

usually 50% each but become 80% in nTOS

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9
Q

What are symptoms of nTOS? (5)

A 
Extremity pain 
paresthesia
weakness + neck pain and occipital headache
raynaud's
CP for pec minor syndrome
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10
Q

Why remove the first rib in nTOS?

A

Prevents lower trunk of plexus from getting fixed to the rib with scarring

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11
Q

How does a neck injury cause nTOS?

A

Underlying narrowed scalene triangle
Asympto until neck trauma tears scalene muscle
Swelling and bleeding result in swelling, scarring and compression

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12
Q

How many patients with nTOS have a predisposing neck injury?

A

> 80%

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13
Q

What is the double crush syndrome?

A

get distal neurapathy from proximal axonal injury

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14
Q

What is the treatment for nTOS?

A

Conservative therapy is physical therapy for 4-6weeks

If fails then surgical approach

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15
Q

What are findings of nTOS on CT/MRI?

A

negative findings support diagnosis of nTOS

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16
Q

What can findings be on EMG for nTOS?

A

usually negative

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17
Q

What is necessary for diagnosis of nTOS?

A

Physical findings

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18
Q

What is the path of the phrenic nerve?

A

lateral border of scalene, passes lateral to medial as it descends along anterior surface of the scalene, then passes behind the subclavian into the mediastinum

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19
Q

What is the path of the long thoracic nerve?

A

passes through the belly of the middle scalene where the components form a single nerve

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20
Q

what does the long thoracic nerve supply? what happens if you injure the nerve?

A

serratus anterior, winged scapula

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21
Q

what proportion of patients have abnormal scalene anatomy?

A

2/3

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22
Q

What syndrome can develop in long-standing severe nTOS?

A

complex regional pain syndrome type I

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23
Q

What are symptoms of CRPS-I

A

persistent vasospasm, disuse edema, extreme hypersensitivity

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24
Q

What investigations to do for nTOS?

A

CXR, CT/MRI, EMG

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25
Q

What can you do to see if patient will respond to surgical decompression?

A

Scalene muscle block

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26
Q

What are some differential diagnoses for nTOS?

A

Carpel tunnel syndrome, ulnar nerver compression, rotator cuff tendonitis, cervical spine strain, fibromyositis, cervical disk disease, cervical arthritis, brachial plexus injury

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27
Q

What are advantages/disadvantages for transaxillary approach for nTOS?

A

cosmetic incision, adequate to remove first rib

incomplete exposure of scalene triangle, limited for vascular reconstruction

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28
Q

What are advantages/disadvantage of supraclavicular approach?

A

wider exposure, compete resection of scalene muscles, direct visualization of nerve roots, vascular reconstruction
first rib resection may need additional incision

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29
Q

What are complications after decompression for nTOS?

A

pneumothorax 10%
phrenic 10% (usually asymptote)
other nerve injuries
lymph leak

similar for either approach

30
Q

What is the adson test for aTOS?

A

Adson’s sign is the loss of the radial pulse in the arm by rotating head to the ipsilateral side with extended neck following deep inspiration. for nTOS
Many false positives

90 degree abduction in external rotation hold for 3 mins. This will elicit symptoms usually within 60s

31
Q

What is the elveys test for nTOS?

A

for nTOS
Arms out then flex hand then tilt head contra to illicit symptoms.. negative test usually can rule out nTOS and a positive usually indicates compression along the nerve

32
Q

how many patients have cervical rib in nTOS?

A

5%, gen pop 1.5%

33
Q

What bony abnormalities does aTOS have?

A

cervical ribs 63%, anomalous 1st rib?, fibrocart band 10%

34
Q

What segment of the subcalvian is usually compressed?

A

thrid segment and get post-stenotic dilation

35
Q

What are the symptoms in aTOS?

A

hand schema from micro emboli most common manifestation

exertional pain, raynauds, retrograde extension of thrombus rare but can cause stroke

36
Q

what is the pe in aTOS?

A

Bilateral BP, bruits in supraclavicular fossa, bruit with shoulder abduction or overhead, papable cervical rib, pulsatile supraclavicular mass, splinter hemorrages, digital ischemia

37
Q

What maneuvers to diagnose aTOS?

A

adson Take long deep breath elevate chin and trun head to affected side with patient seated upright with arms resting on knees. Positive result occurs with ablation of radial pulse

Abduction-external rotation (elevated arm stress)
Externally rotates and abducts arms greater then 90 degrees
Devel of hand pain or paresthesias within 60 is positive result
This is diagnostic for nTOS

38
Q

What will NIVS show in aTOS?

A

Duplex
High peak velocities, aneuryms, intimal disruption
Clavicle may interfer
Arm abduction to 130 while imaging costoclavicular space is most discriminating technique

39
Q

what is the rate of bilat aTOS?

A

10-25%

40
Q

what is treatment for aTOS?

A

no role for medical

anticoag role unknown

41
Q

What are the three components of surgical treatment in aTOS?

A

relieve arterial compression
remove cervical rib, first rib and scalene to avoid recurrence

Remove source of emboli
aneurysm, thrombus

restore distal circulation

42
Q

what is the classification for anatomical findings of aTOS?

A

Scher
0 asympto no tx
I stenosis with mini post stenotic dilations. no intimal disruptio. needs decompression of TO
II aneurysm with intimal damage and mural thrombus. decompression of TO with subclavian artery reconstruction
III distal embolization from subclavian pathology. needs thrombolysis or thrombectomy, decompression, vascular reconstruction`

43
Q

Why do we remove first rib in a TOS?

A

allows neruvasc bundle to relax downward

common insertion fro fibromuscula structures

44
Q

What surgical approaches for aTOS?

A

transax not adequate for vascular reconstruction

supraclavicular

45
Q

what are outcomes of surgical repair of aTOS?

A

90% symptom relief
bypass patency 90-100%
no mortality

46
Q

What are complications for aTOS?

A

pneumo, hem, chylous leak, brachial plexopathy, vascular injury, injury to phrenic or long thoracic
cervical sympathetic chain injury uncommon but can give horners

47
Q

What is vTOS?

A

thrombosis or severe narrowing of subclav-ax vein secondary to extrinsic compression
effort thromosis as usually young healthy individiauls who engage in repetitive shoulder motion

48
Q

What elements contribute to vTOS compression?

A

first rib, clavicle with associated subclavius muscle and fibrous costocoracoid ligament , anterior scalene and tubercle
alternating inflammation, perivenous fibrosis, endothelial injury, stasis, thrombosis

may have no abnormality of structure or may have anomalies of ant scalene, subclavius, pec minor, scalenus minimus, bony abnormalities of clavicle, rib and ligementous abnorm of costocoracoid ligament

49
Q

what is mean ge of onset for vTOS?

A

32

50
Q

What is the order of common to least common TOS?

A

n
v
a

51
Q

What are the clinical features of vTOS?

A

Upper arm edema hallmark (93%)with subclavian vein thrombosis
Can be accompanied by pain and cyanosis (77%)
Edema usually involves shoulrder and is non pitting
Dilated superficial veins neck chest wal
Pain described as aching, stabbing or tight
Worse with exertion
Ahing with exeriese 66%
Venous hypertension and worsening of smptoms

52
Q

What are rare but bad complications of vTOS?

A

Bad complications include PE <12% and phlegmasia cerulea dolens

53
Q

What investigations for vTOS?

A

B mode Low sensitivity high specificity for thrombosus
Color flow increased sensitivy 80-100% and specificity 80-100%
Venography

54
Q

how do you perform venography?

A

Gold standard
Puncture basilic vein
Cephalic may not be adequate as it often drains directly into the subclavian
Full addcution then in 90degree of abduction with external rotation (hand on head)
Collaterization can mean that it is chronic situation

55
Q

What are tx strategies for vTOS?

A

classic rest/elevation and antocoag. 40% persia symptoms with morbidity
thrombi therapy. 82-100% success. need within 14 d
surgical decompression

56
Q

how do you do thrombi therapy in vTOS?

A

tpa, trellis peripheral infusion system, anjiojet
Angiojet high-pressure injection with simultaneous aspiration eddy creation aids in clot maceration
Trellis multilumen catherter with two compliant balloons and distal end and infusion holes b/w balloons. Oscillating wire macerates the clot then it is aspirated through the catherter lumen

57
Q

if thrombolysis unsuccessful, then what?

A

warfarin for 3-6 months if no compression

if compression then surgery or 3-6 months anticoagulation

58
Q

what are role of stents in vTOS?

A

no role radial force inadequate to overcome compression

59
Q

what surgical approaches for vTOS?

A

paraclavicular
infraclavicular
transaxillary

60
Q

What are the border of the scalene triangle?

A 
anterior scalene (ant)
middle scalene (post)
first rib (inf)
61
Q

What are the borders of the costoclavicular border and why is this space important?

A

subclavius muscle and clavicle (ant)
first rib (post)
scapula (post)

site of compression of subclavian vein

62
Q

What is the third space near the TO? What are the borders?
What passes in this location?
What can narrow this space?

A

the subcoracoid space
coracoid process and pec minor
the neruovascular bundle b/w them
tight band of clavipec fascia or costocoracoid ligament or hypertrophy of the pec min can narrow this space

63
Q

What are four anatomical disadvantages to axillary approach?

A

T1 prone to injury
subclavian vein prone to injury
congenital fibromuscular bands are medial to first rib and hidden by neurovasc trunk
can correct arterial pathology

64
Q

What are important nerves that relate to TOS?

A

brachial plexus (C5-T1 become 3 trunks in scalene triangle)
Phrenic nerve (C3-5)
Long thoracic nerve (C5-7, muscel belly of middle scalene)
Dorsal scapular nerve (C5, cephalic portion of middle scalene)
Cervical sympathetic chain (usually not inoperative field, near origin of ant/mid scalene, cautery can injure)

65
Q

Name 7 abnormalities of the scalene triangle.

A

splitting of the anterior scalene (C5-C6)
scalene minimus muscle
interdigitating muscel fibers (b/w AS and MS)
narrow triangle
congenital bands
phrenic nerve runs anterior to vein
vein lies more medial and compressed by costoclav ligament

66
Q

Where is the compression in pec minor syndrome?

A

subcoracoid space

67
Q

What is the aetiology of pec minor syndrome?

A

activities they hyperabduct the shoulder and stretch PM muscle
PM attached to coracoid process
tight PM comporesees the branches of BP and axillary vessels

68
Q

What are symptoms of pec minor?

A

pain neck, trap, shoulder
ant portion of chest
tenderness of PM insertion

69
Q

What is PM syndrome diagnosis?

A

PM muscle block
may co-exist with nTOS
if PM block insufficient, then Scalene block.

70
Q

What is PMS treatment?

A

physio, avoid hyperabd exercises
surgical treatment
divide PM at coracoid process and excise 2-3 cm of muscle

Vascular Surgery (53 decks)

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