Thoracic outlet syndrome: a review.

BACKGROUND: : Arterial and venous thoracic outlet syndrome (TOS) were recognized in the late 1800s and neurogenic TOS in the early 1900s. Diagnosis and treatment of the 2 vascular forms of TOS are generally accepted in all medical circles. On the other hand, neurogenic TOS is more difficult to diagnose because there is no standard objective test to confirm clinical impressions. REVIEW SUMMARY: : The clinical features of arterial, venous, and neurogenic TOS are described. Because neurogenic TOS is by far the most common type, the pathology, pathophysiology, diagnostic tests, differential and associate diagnoses, and treatment are detailed and discussed. The controversial area of objective and subjective diagnostic criteria is addressed. CONCLUSION: : Arterial and venous TOS are usually not difficult to recognize and the diagnosis can be confirmed by angiography. The diagnosis of neurogenic TOS is more challenging because its symptoms of nerve compression are not unique. The clinical diagnosis relies on documenting several positive findings on physical examination. To date there is still no reliable objective test to confirm the diagnosis, but measurements of the medial antebrachial cutaneous nerve appear promising.

Historical perspectives and anatomic considerations. Thoracic outlet syndrome.

The major developments in the evolution of understanding the thoracic outlet syndromes is presented in a chronologically historical record beginning with the first mention of a cervical rib by Galen in the second century A.D. Appreciation of the vascular and neurologic types of TOS progressed slowly through the centuries until detailed clinical studies were presented in the early 1900s. Interest in these syndromes increased steadily since then with description of the effectiveness of first rib resection by Murphy in 1910, and scalenotomy without cervical rib resection favored by Adson in 1927. The term "thoracic outlet syndrome" was coined by Peete et al in 1956 to encompass all the forms and causes of neurovascular compression in the base of the neck. Although rib resection may be considered the oldest operation on mankind, its application to treatment for TOS became popular only after Clagett's description of the posterior periscapular approach in 1962 and the transaxillary approach in 1966. The techniques of arteriography and venography were introduced in the 1960s and remain the hallmark for evaluation of the arterial and venous types of TOS. The neuroelectric studies introduced by Jebsen in 1968 have become popular, but offer little definitive diagnostic information for the neurogenic form of this syndrome. Recent histochemical studies of scalene muscles have shown important changes at the cellular level of the scalene muscles with trauma leading to TOS. The basic cause of the various neurovascular symptoms relates to anatomic abnormalities, either congenital or developmental, that cause abnormal compression and irritation of the major nerves and vessels in the thoracic outlet, causing certain people to have anatomic susceptibility to develop symptoms under certain conditions. These anomalies are described in some detail to facilitate the understanding, diagnosis, and surgical treatment of these special patients.

History of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS), a condition in which neurovascular structures in the thoracic outlet region are compressed, can be caused by anatomical abnormalities or acquired changes in the soft tissues and bony structures in the region. The brachial plexus is the most frequently affected structure. TOS is one of the most difficult neurovascular compressions in the upper extremity to manage because of the variability of complaints and the high risk associated with surgical treatment.

An historical look at the thoracic outlet compression syndrome.

The story of the thoracic outlet compression syndrome begins with the identification of the anatomical abnormality of the cervical rib, and the symptoms related to it. Resection of the cervical rib, however, was soon followed by the recognition that symptoms could occur in the absence of a cervical rib. The scalenus anticus was then held to be the culprit, although several different mechanisms were advanced to explain the development of symptoms. Subsets of the thoracic outlet compression syndrome were then codified; costoclavicular compression; compression under the coracoid process during hyperabduction; primary symptoms related to arterial compression; and the syndrome that appears when neural and arterial compression are absent but venous occlusion is present. The importance of the first rib as a common denominator has brought about the idea that first rib resection is the best method of extirpating this common anatomic factor. That thesis is not accepted universally, however.

The history of surgery for thoracic outlet syndrome.

The history of surgery for thoracic outlet syndrome (TOS) is examined, ranging from the earliest recorded reference of TOS in the anatomic recognition of cervical ribs by Galen and Vesalius, to the current research on the diagnosis and treatment of TOS. The author discusses various cases that helped advance the use of surgery in treating TOS, tracing the years of progress that led to the present day understanding of the disease.

Thoracic outlet syndromes: new concepts from a century of discovery.

From March of 1861 to the present day there has been a striking evolution in the understanding of the neurovascular compressive disorders arising at the thoracic outlet. In 1958, Rob and Standeven reported the clinical characteristics of a group of patients with upper-extremity arterial complications. They suggested the commonality of the various compressive abnormalities by introducing the term, 'Thoracic Outlet Compression Syndrome' to the surgical literature. The development of morphologic, embryologic, and histochemical concepts is outlined in the framework of the author's investigations.