Thoracic Outlet Syndrome



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Thoracic Outlet Syndrome


Wilbourn’s Classification



  1. Vascular

  1. Arterial – major and minor

  2. Venous

  1. Neurogenic

  1. True

  2. Disputed


Arterial


  • 1-2%

  • Acute events such as thrombosis easy to diagnose (pain, pallor, pulselessness and parasthesia)

  • May present with coolness of hand, claudication, unilateral Raynauds or fingertip ulcerations

  • Affected arm has a lower BP of >20mmHg difference (a reliable indicator of arterial involvement)

  • Full developed cervical rib seen in 50%

  • Other 50% thought to have some other type of bony anomaly

Venous


  • 2-3%

  • sudden effort induced thrombosis (Paget-Schroetter syndrome) or at rest with the extremity in a compromised position for a prolonged period

  • may develop large superficial collaterals with more chronic disease

  • Acute cases present with cyanosis, swelling and pain

  • Mostly seen in muscular young males after exercise

True Neurogenic



  • 1:1,000,000

  • A typical patient is a young, thin female with a long neck and dropping shoulders

  • usually C8-T1 distribution

  • Hypothenar atrophy, decreased grip and sensation

  • present as isolated hand intrinsic muscle atrophy without any pain (Gilliat-Sumner hand)

Disputed Neurogenic




Epidemiology


  • Overall F>M 3.5:1

  • Neurologic - Female-to-male ratio approximately 3.5:1

  • Venous - More common in males than in females

  • Arterial - No sexual predilection

  • Much more common in countries where TOCS is a legitimate work related condition

  • Some morphotypes predispose to the syndrome: poor muscular development, droop of scapula, obesity and breast hypertrophy.

  • Anomalous cervical ribs seen in 0.17-0.74%, with a higher percentage of cervical ribs in women






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