Review Article of American Journal of Surgical Research and Reviews
Modern Diagnosis and Surgical Management of Thoracic Outlet Syndrome: A Comprehensive Review
Farid Gharagozloo*, M.D., Nabhan Atiquzzaman, Mark Meyer, M.D., Scott Werden M.D.
Center for Advanced Thoracic Surgery. Global Robotics Institute. Advent health Celebration. University of Central Florida.
Conventionally TOS has been thought to represent a group of diverse disorders that result in compression of the neurovascular bundle exiting the thoracic outlet. Until recently, TOS classification has been based on symptoms, rather than the underlying pathology, with the subgroups consisting of neurogenic (NTOS), venous (VTOS or PSS), and arterial (ATOS). Neurogenic TOS accounts for over 95% of the cases, followed by venous (3–5%) and arterial (1–2%). Neurogenic TOS (NTOS) has been further divided into True NTOS (TNTOS) and Disputed NTOS (DNTOS), with DNTOS reportedly representing 95–99% of all neurogenic cases. In order to decrease confusion and to improve therapeutic results with TOS, the disease should be classified based on the underlying pathologic entity. Acquired and traumatic abnormalities of the clavicle and first rib should be classified separately. Clearly after the more common and objectively supported diagnoses of conditions that result in neurovascular symptoms of the upper extremity, such as cervical spine disease, carpal tunnel disease, and nerve entrapment syndromes, have been ruled out, there remains a group of patients who are suspected of having TOS. In these patients, rather than the more usual classification such as arterial, venous, or neurogenic, the more accurate approach from a diagnostic and therapeutic approach is to classify them as: Cervical Rib Disease: Patients with cervical rib syndrome (CRS) can have complications relating to compression of the subclavian artery (previously referred to as ATOS) and the brachial plexus(previously referred to as True NTOS) secondary to a well-formed cervical rib, or to an incompletely formed first rib, fibrous band associated with a rudimentary cervical rib, or a giant transverse process of C7. Thoracic Outlet Disease or “Subclavian Vein Compression Syndrome”: In these patients an abnormal first rib at its junction with the sternum results in compression of the subclavian vein at the subclavian-innominate junction. Compression of the vein results in venous hypertension in the upper extremity and resultant neurologic symptoms. With prolonged compression of the subclavian-innominate junction, the vein clots giving rise to Paget–Schroetter syndrome. Therefore, patients who have been previously classified as Disputed Neurogenic and Venous TOS represent a variable symptomatic presentation of the same pathologic entity, which affects the subclavian vein. Presently MRA of the thoracic outlet with arm maneuvers is the test of choice in patients suspected of having TOS. This test shows the abnormal bony tubercle on the first rib with extrinsic compression of the subclavian innominate junction, which is exacerbated with elevation of the arm above the shoulder. Robotic resection of the medial aspect of the first rib along with disarticulation of the costo-sternal joint has the best reported results to date.
Keywords: Thoracic Outlet Syndrome, TOS, Neurogenic, Venous TOS, Arterial TOS, Paget Schroetter Syndrome
How to cite this article:
Farid Gharagozloo, Nabhan Atiquzzaman, Mark Meyer, Scott Werden. Modern Diagnosis and Surgical Management of Thoracic Outlet Syndrome: A Comprehensive Review. American Journal of Surgical Research and Reviews, 2021; 4:27. DOI:10.28933/ajsrr-2021-06-0606
1. Peet RM. Thoracic-outlet syndrome: evaluation of a therapeutic exercise program. Proc Staff Meet Mayo Clinic. 1956;31:281.
2. Rob CG, Standeven A. Arterial occlusion complicating thoracic outlet compression syndrome. Br Med J. 1958;2:709–12.
3. Werden S. Radiologic imaging in diagnosis and assessment of NTOS. In: Illig KA, Thompson RW, Freischlag J, Donohue DM, Edgelow PI, Jordan SE, eds. Thoracic outlet syndrome.1st edn. New York: Springer. pp.111–25.
4. Stopford JSB, Telford ED. Compression of the lower trunk of the brachial plexus by a first dorsal rib. Brit J Surg. 1919;7:168.
5. Adson WA. Surgical treatment for symptoms produced by cervical ribs and the scalenus anticus muscle. Surg Gynecol Obstet. 1947;85:687–700.
6. Ochsner A, Gage M, Debakey M. Scalenus anticus syndrome. Am J Surg. 1935;28:669–95.
7. Eden KC. The vascular complications of cervical ribs and frst thoracic rib abnormalities. Br J Surg. 1939;27:111–39
8. Falconer MA, Weddell G. Costoclavicular compression of the subclavian artery and vein. Lancet. 1943;2:539–43.
9. Falconer MA, Li FW. Resection of the first rib in costoclavicular compression of the brachial plexus. Lancet. 1962 Jan 13;1:59–63.
10. Bramwell E, Dykes HB. Rib pressure and the brachial plexus. Edinburgh Med J. 1927;27:65.
11. Beyer JA. The hyperabduction syndrome, with special reference to its relationship to Raynaud’s syndrome. Circulation. 1951;4:161–72
12. De Villiers JC. A brachiocephalic vascular syndrome associated with cervical rib. Br Med J. 1966;2:140–3.
13. Wartenberg R. Brachialgia Statica Paresthetica. J Nerv Ment Dis. 1944;5:877.
14. Hughes ES. Venous obstruction in the upper extremity; PagetSchroetter’s syndrome; a review of 320 cases. Surg Gynecol Obstet. 1949;88:89–127.
15. Swartley WB, Weeder SD, McLaughlin EF. Thrombosis and gangrene of the right arm associated with polycythemia vera: its relation to effort thrombosis. Ann Surg. 1942;116:184–93
16. Aynesworth KH. The Cervicobrachial syndrome. Ann of Surg. 1940;5:724–42.
17. Hanson KG. The Cervicobrachial syndrome. Arch Phys Ther. 1941;22:662–6
18. Lang EK. Scalinus anticus and pectoris minor syndrome. J Indiana Med Assoc. 1967;80:440.
19. Lord JR, Stone PW. Pectoralis minor Tenotomy and anterior Scalenotomy with special reference to the Hyperabduction syndrome and “effort thrombosis” of the subclavian vein. Circulation. 1956;13:537–42.
20. Nelson PA. Treatment of patients with cervicodorsal outlet syndrome. J Am Med Assoc. 1957;163:1570–6.
21. Ranney D. Thoracic outlet: an anatomical redefnition that makes clinical sense. Clin Anatomy. 1996;9:50–2.
22. Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A. Thoracic outlet syndrome: defnition, aetiological factors, diagnosis, management and occupational impact. J Occup Rehabil. 2011;21(3):366–73.
23. Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB, Brunk AJ, Eng MR, Orhurhu V, Cornett EM, Kaye AD. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain Ther. 2019;8:5–18
24. Freischlag J, Orion K. Understanding thoracic outlet syndrome. Scientifca (Cairo). 2014;2014:1–6
25. Stewman C, Vitanzo PC, Harwood MI. Neurologic thoracic outlet syndrome: summarizing a complex history and evolution. Curr Sports Med Rep. 2014;13(2):100–6.
26. Ferrante MA, Ferrante ND. The thoracic outlet syndromes: part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017;56(4):663–73.
27. Brooke BS, Freischlag JA. Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol. 2010;25(6):535–40
28. Raptis CA, Sridhar S, Thompson RW, Fowler KJ, Bhalla S. Imaging of the patient with thoracic outlet syndrome. Radiographics. 2016;36(4):984–1000.
29. Ferrante MA. The thoracic outlet syndromes. Muscle Nerve. 2012;45(6):780–95.
30. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007;46(3):601–4.
31. Davis GA, Knight SR. Pancoast tumors. Neurosurg Clin N Am. 2008;19(4):545–57.
32. Abdolrazaghi H, Riyahi A, Taghavi M, Farshidmehr P, Mohammadbeigi A. Concomitant neurogenic and vascular thoracic outlet syndrome due to multiple exostoses. Ann Card Anaesth. 2018;21(1):71–3.
33. Gharagozloo F, Meyer M, Tempesta B, et al. Proposed pathogenesis of Paget-Shroetter disease: impingement of the subclavian vein by a congenitally malformed boney tubercle on the first rib. J Clin Pathol. 2012;65:262–6
34. Gharagozloo F, Meyer M, Tempesta B, et al. Robotic en bloc frst-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results. Innovations. 2012;7(1):39–44.
35. Gharagozloo F, Meyer M, Tempesta B, et al. Robotic transthoracic first rib resection for Paget-Schroetter syndrome. Eur J Cardiothorac Surg. 2019;55:434–9
36. Gharagozloo F, Meyer M, Tempesta B, Werden S. Robotic First Rib Resection.
37. Gharagozloo F, Atiquzzaman N, Meyer M, Tempesta B, Werden S. Robotic first rib resection for thoracic outlet syndrome. J Thorac Dis 2020 | http://dx.doi.org/10.21037/jtd-2019-rts-04.
38. Gharagozloo F, Tempest ab, Weden S, Meyer M. Robotic First Rib Resection for Thoracic Outlet Syndrome. Surg Tech Int. 2020; 36:1228.
39. Kobayashi S, Takeno K, Miyazaki T, et al. Effects of arterial ischemia and venous congestion on the lumbar nerve root in dogs. J Orthop Res. 2008;26(11):1533–40
40. Murphy T. Brachial plexus neuritis caused by pressure of the first rib. Aust Med J. 1910;15:582–5.
41. Clagett OT. Presidential address, American Association of Thoracic Surgery Research and Prosearch. J Thorac Cardiovasc Surg. 1962;44:153–66.
42. Roos DB. Transaxillary approach for frst rib resection to relieve thoracic outlet syndrome. Ann Surg. 1966;163:354–8.
43. Urschel HC. Management of the thoracic-outlet syndrome. N Engl J Med. 1972;286:1140–3.
44. Sanders RJ, Monsour JW, Baer SB. Transaxillary first rib resection for the thoracic outlet syndrome. Arch Surg. 1968;97(6):1014–23.
45. Vemuri C, Wittenberg AM, Caputo FJ, Earley JA, Driskill MR, Rastogi R, Emery VB, Thompson RW. Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2013;57:1345–52.
46. Silver D. Thoracic outlet syndrome. In: Textbook of Surgery (Davis: Christopher). 10th ed. Philadelphia: W. B. Saunders Co; 1972. p. 1858.
47. Lord JR, Stone PW. Pectoralis minor Tenotomy and anterior Scalenotomy with special reference to the Hyperabduction syndrome and “effort thrombosis” of the subclavian vein. Circulation. 1956;13:537–42
48. Sanders RJ, Monsour JW, Gerber WF, Adams WR, Thompson N. Scalenectomy versus first rib resection for treatment of the thoracic outlet syndrome. Surgery. 1979;85:109–21
49. Peek J, Vos CG, Ünlü Ç, et al. Long-term functional outcome of surgical treatment for thoracic outlet syndrome. Diagnostics (Basel). 2018;8(1):12.
50. Peek J, Vos CG, Ünlü Ç, et al. Outcome of surgical treatment for thoracic outlet syndrome: systematic review and meta-analysis. Ann Vasc Surg 2017;40:303–326.
51. Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. 2004;55(4):897–902.
52. Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of botulinum toxin in the treatment of this syndrome. Toxins (Basel). 2012;4(11):1223–35.
53. Finlayson HC, O’Connor RJ, Brasher PMA, Travlos A. Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial. Pain. 2011;152(9):2023–8
54. Weaver M, Lum Y. New diagnostic and treatment modalities for neurogenic thoracic outlet syndrome. Diagnostics. 2017;7(2):28.
55. Hwang J, Min BJ, Jo W-M, Shin JS. Video-assisted thoracoscopic surgery for intrathoracic frst rib resection in thoracic outlet syndrome. J Thorac Dis. 2017;9(7):2022–8.
56. George RS, Milton R, Chaudhuri N, et al. Totally endoscopic (VATS) frst rib resection for thoracic outlet syndrome. Ann Thorac Surg. 2017;103:241–5
57. Ohtsuka T, Wolf RK, Dunsker SB. Port-access first-rib resection. Surg Endosc. 1999;13:940–2.
58. Chang DC, Lidor AO, Matsen SL, Freischlag JA. Reported inihospital complications following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg. 2007;21(5):564–70.
59. Hosseinian MA, Loron AG, Soleimanifard Y. Evaluation of complications after surgical treatment of thoracic outlet syndrome. Korean J Thorac Cardiovasc Surg. 2017;50(1):36–40.