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Musculoskeletal III > Thoracic Outlet Syndrome- Lecture > Flashcards

Thoracic Outlet Syndrome- Lecture Flashcards

1
Q

TOS

A
  • Frequently overlooked peripheral nerve compression or tension event
  • Originally coined in 1956 by Peet to indicate compression of the neurovascular structures in the INTERSCALENE TRIANGLE
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2
Q

Prevalence and types of TOS

A
  • It is estimated that over 90% of all TOS cases are of neurogenic origin (ulnar area symptoms), whereas less than 1% are arterial and approximately 3-5% are venous.
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3
Q

Pathoanatomical

A
  • 3 Compartments of the Thoracic Outlet:
    • (from C-spine & Mediastinum à lower border of pec minor)
  1. Interscalene triangle
  2. Costoclavicular space
  3. Thoraco-coraco-pectoral or retropectoralis minor space
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4
Q

Interscalene triangle

A
  • Borders:
    • Anterior scalene: anterior
    • Middle scalene: posterior
    • Medial surface of 1st rib: inferior
  • Contents:
    • Trunks of the brachial plexus
    • Subclavian ARTERY
    • Subcavian vein
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5
Q

Costoclavicular space

A
  • Borders:
    • Middle 1/3rd of the clavicle: anterior
    • 1st rib: posteromedial
    • Upper border of the scapula: posterolateral
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6
Q

Thoraco-coraco-pectoral space/
Retropectoralis minor space

A
  • Borders:
    • Coracoid process: superiorly
    • Pectoralis minor: anteriorly
    • Ribs 2-4: posteriorly
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7
Q

Scalene Anatomy/Implications

A
  • Anterior Scalene origin=TVPs of C3–C6
  • Middle Scalene origin= TVPs of C2–C7
  • Insertion= 1st rib
  • Action= Elevate rib 1 during inhalation, flex head and neck and ….According to Greys the anterior scalene rotates the neck to the opposite side??

“In the macaque and in the human, all 3 scalenes rotate the cervical spine toward the same side.”

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8
Q

Risk Factors – boney abnormalities

A
  • Cervical ribs=supranumerary ribs originating from C7 (<1% of population; and only 10% will experience symptoms)
  • Elongated C7 transverse process
  • Abnormal 1st rib or clavicle=exostosis, tumor, callus, fracture, irritating the brachial plexus (clavicular malunion, fragmentation, retrosternal dislocation etc
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9
Q

Risk Factors – soft tissue abnormalities

A
  • Scalene muscle variations=hypertrophy of the anterior scalene, broad/excessively anterior middle scalene insertion on 1st rib
  • Anomalous fibrous bands within the thoracic container àincreasing the stiffness and decreased compliance àincreasing neurovascular load. (Roos identified 10 different types of bands c MRI)
  • Clavicular movement = shoulder pain c altered clavicular rotation and elevation may increase tension to the neurovascular bundle (e.g. ACJ & SCJ structural & functional integrity)
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10
Q

Risk Factors – mechanical dysfunction

A
  • Clavicular movement = shoulder pain with altered clavicular rotation and elevation may increase tension to the neurovascular bundle (e.g. ACJ & SCJ structural & functional integrity)
  • Normal clavicle is expected to elevate, retract and spin backwards during upper extremity elevation
  • The integrity of the ACJ is indirectly controlled by the coracoclavicular ligament complex (trapezoid and conoid ligaments), which provides 75% of the constraint against axial compression of the clavicle toward the acromion.
  • The various ligament systems (costoclavicular and sternoclavicular) reinforce the capsule and limit anteroposterior movement of the medial end of the clavicle. The SCJ can be susceptible to anterior and posterior subluxations via direct and indirect trauma
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11
Q

Epidemiology

A
  • 20-50 years old
  • Neurogenic TOS=Women 3-4 times more likely to develop
  • Vascular TOS=to non athletic men and women, but > in competitive athletic men vs women
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12
Q

S/S- location

A
  • Vary according to location
  • Range from mild pain and sensory changes to limb-and/or life-threatening complications. Patients can present with multiple unilateral or bilateral S&S associated with both neurogenic and vascular components
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13
Q

S/S- Arterial TOS

A
  • Arterial TOS: can present with pain, numbness in a non-radicular distribution, coolness to touch and pale discoloration, all of which worsen with cold ambient temperatures
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14
Q

S/S- Venous TOS

A
  • Venous TOS: results in excruciating deep chest, shoulder and entire upper extremity pain, accompanied by a feeling of heaviness that occurs especially after activity
  • The patient will present with cyanotic discoloration and distended collateral veins, potentially accompanied by edematous increases in the volume of the extremity
  • Paget-Schroetter Syndrome (DVT
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15
Q

S/S- Neurogenic TOS

A
  • Neurogenic TOS:
  • Normally doesn’t follow dermatomal or myotomal distribution unless the root is compressed.
  • c/o pain, paresthesias, numbness or weakness
  • true vs disputed (see lecture)
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16
Q

General S/S

A
  • Symptom location most frequently reported in patients with TOS:
    • Paresthesia in the upper limb (98%)
    • Trapezius pain (92%)
    • Neck pain (88%)
    • Shoulder and/or arm pain (88%)
    • Supraclavicular pain (76%)
    • Occipital headache (76%)
    • Chest pain (72%)
    • Paresthesia in all 5 fingers (58%)
    • Fourth and fifth fingers only (26%)
    • First à third finger (14%)
17
Q

Timing of symptoms

A
  • Are the symptoms present during the day or night
  • Awaking at night c paresthesia in the upper limb (‘RELEASE PHENOMENON’) – suggests release of the perineural blood supply to the brachial plexus and signals a return of normal sensation
    • Prognostic indicator of favorable outcome
    • Pts categorized as ‘releasers’
18
Q

Compressors

A
  • Patients who experience symptoms throughout the day while using prolonged postures (such as shoulder girdles protracted, and depressed and the head forward) or activities (such as working over head with elevated arms)
  • Increase in tension or compression of the neurovascular bundle
19
Q

General Examination

A
  • Observe posture (seated/standing)
  • Round sh, fwd head, thor kyphosis-,
  • Post tilt, downward rot, depression of scapulae
  • Supraclavicular fullness (a 1st rib prominence or cervical rib presence vs soft tissue swelling)
  • Inspect: edema, cyanosis, paleness, atrophy
  • SUPRACLAVICULAR FOSSA
    • Palpated for pain (brachial plexus) scalene triangle
20
Q

Disputed TOS

A
  • Supported by systematic assessment

*No valid standard diagnostic test available*

1 .Presence of non-radicular sx in neck-sh-arm worse/relieved c mov’t or position of neck-arm-sh girdle accompanied by cluster of TOS provocation tests

  1. Postural dysfunctions and container mobility (1st rib, thoracic, mm length of scalenes, esp c WT LIFTERS, COPD, p WHIPLASH)
  2. r/o double crush = PN entrapement
21
Q

Management

A
  • SURGICAL:
  • NEUROGENIC: surgical decompression (w/mm wasting, NCV<60m/sec (85m/sec=normal), failed therapy
    • Resection of the 1st rib
    • Scalenectomies (ant/middle)
  • ARTERIAL: decompress compressing SC artery, restore blood flow
  • VENOUS: Thrombolytic therapy
  • Post OP PT: shoulder, cervical, and thoracic areas, avoid lifting 2-4 weeks, correct muscle imbalance
22
Q

Conservative measures

A

General RULE in prognostication

  • Recent review of evidence: Disputed Neurogenic TOS
    • Found good to very good results, 76-100% for disputed TOS (short term in a mo); 59-88% long term f/u in a year)
    • Poor outcome: obesity, workers comp, double crush pathology involving carpal and cubital tunnel
    • Good prognosis w/NCV>60m/sec
    • **must attempt to correct postural, biomechanical, or habitual position prior to efforts at pain relief – may escalate symptoms initially educate and make pt aware/cautiously initial treatment stages
23
Q

Cyriax thoracic release

A
  • The goal of this technique is to fully unload the neurovascular structures in the thoracic outlet prior to going to sleep at night.
  • Remain in this position as long as can be tolerated
24
Q

Costoclavicular space treatment

A
  • 1st Rib mobility
  • Encouraging diaphragmatic breathing reducing scalene accessory recruitment
  • Sternoclavicular and Acromioclavicular joint mobilizations
  • Glenohumeral joint mobilizations
  • Dynamic scapular stabilizer (enhancing proper lower trap recruitment & reducing influence of upper trap)
25
Q

Posterior scalene triangle tx

A
  • Mobilizing 1st rib in the direction of expiration
  • Stretching the scalene muscles
26
Q

Thoraco-coraco-pectoral space tx

A
  • Stretching of pectoralis major minor and major muscles
  • Emphasize proper posture + Taping tactile cueing
  • Shoulder retraction
  • Dynamic scapular stabilizer (enhancing proper lower trap recruitment & reducing influence of upper trap)
  • Neural mobilization techniques

Musculoskeletal III (18 decks)

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