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Thoracic outlet syndrome 

Thoracic outlet syndrome
Chapter:
Thoracic outlet syndrome
Author(s):

Ali Azizzadeh

, Sapan Desai

, Kristofer M. Charlton-Ouw

, and Hazim J. Safi

DOI:
10.1093/med/9780199658220.003.0034
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date: 18 October 2019

Thoracic outlet syndrome (TOS) results from compression of the brachial plexus, subclavian vein, or the subclavian artery in the anatomical space formed by the scalene muscles, the first rib, and the clavicle. Depending on the specific structure being compressed, TOS is classified into neurogenic (NTOS), venous (VTOS), and arterial (ATOS) thoracic outlet syndromes. NTOS is the most common variant, and leads to hand pain, numbness, or weakness. The diagnosis is primarily based on history and physical examination. Physical therapy is considered the first line of treatment. Surgical decompression is effective in selected patients who continue to have persistent symptoms after physical therapy. VTOS is caused by chronic compression and scarring of the subclavian vein, which leads to arm oedema. Effort thrombosis or Paget–Schroetter syndrome, results from acute subclavian vein thrombosis. The diagnosis is confirmed by ultrasound or venogram. Thrombolysis is considered the first line therapy followed by surgical decompression to treat the extrinsic compression. ATOS is typically caused by osseous anomalies that cause subclavian artery compression, aneurysmal degeneration, thrombus formation, and distal embolization to the arm and/or hand. Plain X-rays can often diagnose a bony anomaly. Ultrasound and vascular imaging techniques can diagnose a subclavian artery aneurysm. Treatment involves surgical decompression with arterial reconstruction. The management of TOS requires a multi-specialty team that is capable of comprehensive diagnosis and treatment of this rare and challenging clinical condition.

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