thopaedic Science Diagnosis and treatment of thoracic outlet syndrome* Instructional lecture

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J Orthop Sci (1997) 2:119-127 ~ Journal of thopaedic Science The Japanese Orthopaedic Association Instructional lecture Diagnosis and treatment of thoracic outlet syndrome* MASATAKA ABE, TADASHI

1 J Orthop Sci (1997) 2: ~ Journal of thopaedic Science The Japanese Orthopaedic Association Instructional lecture Diagnosis and treatment of thoracic outlet syndrome* MASATAKA ABE, TADASHI SHIMAMURA, JUN NISHIDA, and KATSUAKI ICHINOHE Department of Orthopaedic Surgery. Iwate Medical University, 19-1 Uchimaru, Morioka 020, Japan Abstract: Patients who develop symptoms of thoracic outlet syndrome (TOS) have a predisposing anatomic abnormality. In most patients with TOS, the symptoms are caused by entrapment of the brachial plexus and they do not arise from compression of the subclavian artery, as was previously thought. The tests advocated for diagnosing this common syndrome (i.e., evaluating the positional compression of the artery when the arms are raised, the neck is turned, or the shoulders are braced) cannot accurately diagnose this syndrome. There are two reasons for this. The symptoms of TOS are not related to the compression of the artery in the outlet in 98% of patients, and 75 % of normal individuals without symptoms show diminished radial pulse on various provocation tests. We employed four timed provocation tests (minute tests) to diagnose TOS: the timed Morley test, timed Wright test; timed Eden test, and elevated arm stress exercise, all of which are very sensitive. In normal individuals without symptoms, 20% experience transitional symptoms such as slight pain and tiredness, on these tests indicating a subclinical state. TOS is treated by keeping the thoracic outlet wide, this being done either conservatively or surgically. In 1993 and 1994, we conservatively treated 418 of 422 patients with TOS by means of active exercise, a brace, and by block therapy. These measures did not reduce the symptoms in 23 of these patients, so surgical treatment was indicated. In the remaining 4 of the 422 patients, conservative treatment was not indicated and surgery was performed directly. All the patients showed significant clinical improvement of varying degree. Key words: thoracic outlet syndrome, diagnostic provocation tests, revised treatment protocol Offprint requests to: M. Abe Received for publication On Aug. 15, 1996; accepted on Sept. 27, 1996 * Presented at the 69th Annual Meeting of the Japanese Orthopaedic Association, Tokyo, April 12, 1996 Introduction Patients who develop thoracic outlet syndrome (TOS) have a predisposing anatomic abnormality. 12 TOS is associated with musculo-skeletal anomalies and/or poor posture, which includes drooping shoulder, upper thoracic kyphosis, and costo-clavicular narrowing (wing scapula). Posture is an important factor in the symptomatology, and we noted exacerbating and relieving symptoms associated with posture in many patients. In most patients, the symptoms are caused by entrapment of the brachial plexus; they do not arise from compression of the subclarian artery, as was previously thought?,4 Most patients have a history of trauma in the anatomical background. Two types of traumas cause TOS: (1) cumulative trauma disorders, for example, those in individuals who work with key punchers or those who use vibrating tools, and (2) acute trauma, such as cervical sprain. 4 As most cases of TOS are caused by entrapment of the brachial plexus, diagnosis and treatment are focused mainly on entrapment neuropathy of the brachial plexus. We discuss diagnostic provocation tests for TOS, the protocol for conservative treatment, a revised surgical procedure, and the outcome in patients treated by our regimens. Patients In 1993 and 1994, we treated 422 patients with TOS -- diagnosis and treatment procedures are described below. Three hundred and twenty patients had a history of cumulative trauma, while 47 had a history of acute trauma. The other 55 patients had no history of trauma. Other entrapment neuropathies were associated with TOS (Table 1).

2 120 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome Table 1. Double crush syndrome associated with thoracic outlet syndrome Number of patients Cervical radiculopathy 11 Carpal tunnel syndrome 13 Cubital tunnel syndrome 7 Radial tunnel syndrome 1 Table 2. Positive rates for provocation tests Percentage Timed Morley test ~~ 79.3% Timed Wright test % Timed Eden test % EASE test (Roos) j3 72.6% EASE, Elvated arm stress exercise Diagnosis A detailed history and appropriate physical examination are essential for the accurate diagnosis of TOS. Acute trauma, such as a cervical sprain, can cause TOS (scalenus syndrome). Cumulative trauma, due to strenuous work with the arms elevated, and lengthy use of vibrating tools (such as chain saws or key punchers) can also cause TOS. Laboratory and radiological studies proposed for diagnosing TOS have generally proven inaccurate. The information obtained by electromyography, nerve conduction velocities, and arteriography is generally unreliable and offers little that cannot be obtained less expensively and non-invasively by careful clinical evaluation of the patient. 13 Complete clinical evaluation has led us to suspect the presence of other conditions that may simulate or coexist with TOS, such as carpal tunnel syndrome, cubital tunnel syndrome, and cervical radiculopathy. These entrapment neuropathies often coexist with TOS, causing double crush syndrome. When TOS is diagnosed, the coexistence of other entrapment neuropathies should be investigated, and vice versa. To diagnose entrapment neuropathy, provocation tests must be timed (minute tests). 8 In normal individuals without symptoms, 20% experience transitional symptoms, such as slight pain and tiredness, on these tests. 9 We employed the following four tests. 1 Test I Timed Morley test: 1~ Light compression (50mmHg) of the supraclavicular fossa with the cushion of the thumb for no longer than l min (Fig. 1). The test should be discontinued soon after the neurological symptoms are provoked. Test 2 Timed Wright test: TM Upper extremities are held passively in a position of hyper-abduction for no longer than 1 min (Fig. 2). Test 3 Timed Eden test: ~ With bilateral shoulder girdles extended, shoulder joints are slightly extended for no longer than 1 min (Fig. 3). Test 4 Elevated arm stress exercise (EASE; Roos test): 13 With arms in a surrender position, the fingers are slowly flexed and extended (Fig. 4). The test should be stopped soon after neurological symptoms are provoked, otherwise the condition may be exacerbated. These provocation tests are highly sensitive and specific for TOS. In most patients with TOS, more than two tests were positive; positive rates for provocation tests are shown in Table 2. However, tests 2 and 4 are not suitable for patients with limited ability to elevate the shoulder joints. Patients sometimes present with frozen shoulder coexistent with TOS, although the causal relationship is obscure (Fig. 5). We speculate that attempting to hypermobilize the scapulo-thoracic articulation in patients with frozen shoulder injures the brachial plexus, including the dorsal scapular nerve. For accurate diagnosis, mobility of the cervical spine, tenderness with radiation pain of the lateral region of the neck, cervical radiculopathy, and other entrapment neuropathies should be examined. Most entrapment neuropathies can be diagnosed in the outpatient clinic, by for example, employing the elbow flexion test and Tinel's sign of cubital tunnel syndrome, the Phalen test with Tinel's sign of carpal tunnel syndrome, 11 the Spurling test, and the Jackson test for cervical radiculopathy. 7 Conservative treatment The posture that induces the symptoms should initially be defined. Most patients with TOS, except for those with pure scalenus syndrome, feel relief when the back is straight and the shoulder girdles are flexed and elevated (Fig. 6). Postures that provoke symptoms should be avoided. Whenever symptoms appear or become exacerbated, we recommend that the patient rests in a comfortable posture and carries out an exercise program. This program was designed to be simple enough to be performed at home or during work, after minimal training.

3 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome 121 Fig. 1. Timed Morley ~~ test Fig. 3. Timed Eden 5 test Fig. 2. Timed Wright 14 test Fig. 4. Elevated arm stress exercise test (Roos) 13

rib and resection of anomalous muscle. This combined procedure offers several advantages.

4 122 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome The most effective operation for relief of severe outlet syndrome is surgical decompression of the neurovascular bundle by resection of the first rib and resection of anomalous muscle. This combined procedure offers several advantages. Costoclavicular scissoring of the neurovascular bundle is eliminated by removing one blade of the scissors; the anterior and middle scalene muscles are permanently detached and therefore relaxed; anomalous fibromuscular bands are permanently removed; and there are no visible or mechanical deficits when the procedure is performed properly. 13 Prior to surgery, brachial plexography 6 must be performed to determine the entrapment point and assess adhesion. We adopted the approach established by Roos. 13 This procedure employs the axillary approach, in which a low transverse incision is made below the axillary hairline, overlying the third rib (Figs ). We use custom-made safety retractors to avoid injury to the vessels and pleura (Fig. 19). Attachments of anterior and medial scalene muscles to the first rib are cut off, after which abnormal bands are resected, the periosteum of the first rib is then split, and finally the first rib is partially resected from the osteochondral junction to the juxta posterior tubercle of the rib. The posterior rib stump is covered by free fat grafting, avoiding adhesion of the T1 nerve to the rib Fig. 5. Thoracic outlet syndrome combined with wing scapula related to frozen shoulder To correct a drooping shoulder, wing scapula, and rounded back, isometric exercises of the serratus anterior, levator scapulae, and elector spinae muscles are indicated. These are performed with mild effort, for 10s for each exercise, several times per day (Figs. 7-11). We advise patients that anything they can do comfortably is acceptable, but anything that hurts should be avoided. For patients with moderate or severe symptoms, a custom-made brace that keeps the thoracic outlet wide is also prescribed (Figs ). A plaster bed or pillow, to keep the thoracic outlet wide, is also prescribed to control night pain (Fig. 15). Patients with pure scalenus syndrome are treated with blocks of the scalenus muscle, stellate ganglion, and brachial plexus; relief is usually only transient and the procedure is not curactive. Surgery When patients with TOS have severe symptoms and conservative treatment is insufficient, surgical decompression is indicated. Fig. 6. Assisted thoracic outlet-enlarging posture, symptomreducing posture corrects wing scapula and drooping shoulder

M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome 123 10 11 Fig. 7.

Push fists against each other with 1 or 2kg pressure for 10s.

Push one fist anteriorly with 1 or 2kg pressure, blocked by the opposite finger, for 10s, with back straight, and

5 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome Fig. 7. Isometric exercises for the serratus anterior, levator scapulae, and erector spinae muscles. Exercise 1. Push fists against each other with 1 or 2kg pressure for 10s. There is a distinct hollow in the supraclavicular region Fig. 8. Exercise 2. Push one fist anteriorly with 1 or 2kg pressure, blocked by the opposite finger, for 10s, with back straight, and elevated and flexed scapular girdles. Then change sides Fig. 9. Correct form. Flexed and elevated positions of scapular gurdle are held during exercise Fig. 10. Incorrect form. Drooping shoulder is not corrected Fig. 11. Incorrect form. Drooping shoulder and wing scapulae remain

6 124 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome Fig. 12. Molding of the thoracic outlet brace Fig. 13. Custom-made brace Fig. 14. Brace to keep the thoracic outlet wide

7 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome 125 Fig. 17. Arm holder designed by Roos 12 is helpful,9 Fig. 15. Plaster bed molding to keep the thoracic outlet wide Fig. 16. Posture at surgery. Restrained by a "magic bed" on the table

126 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome Fig. 18.

Custom-made retractors with rounded tip protect vessels and pleural membranes stump.

8 126 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome Fig. 18. Endoscopic tools (light, bipolar coagulator, scissors) are useful Fig. 19. Custom-made retractors with rounded tip protect vessels and pleural membranes stump. In patients with severe sympathetic dysfunction, resection of the T2 stellate ganglion was performed at the time of rib resection. The upper plexus type of TOS is caused by friction neuritis and traction injury in and around the scalene muscles. We partially resect the anterior scalene muscle and perform neurolysis, through the supraclavicular approach, as a two-stage operation secondary to transaxillar rib resection (Fig. 20). Fig. 20. Partial resection of anterior scalene muscle and neurolysis through the supraclavicular approach. This patient had a congenital rib anomaly, vascular anomaly, and scalenus syndrome

M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome 127 Postoperative rehabilitation is important to minimize postoperative pain and to promote recovery.

9 M. Abe et al.: Diagnosis and treatment of thoracic outlet syndrome 127 Postoperative rehabilitation is important to minimize postoperative pain and to promote recovery. Anything that the patient can do comfortably is permitted, but anything that causes discomfort cannot be attempted until 3 months after surgery. Other conservative procedures, such as physiotherapy, the administration of nonsteroidal antiinflammatory drugs, and block therapy may be necessary. Three months after surgery, patients may resume their normal activities. Criteria for evaluation of response to treatment for TOS were: Excellent, no pain or limitation of movement during and after work, or any negative results on provocation tests; good, slight pain or limitation of movement during work, with some positive results (e.g., prolonged provocation time, or diminished positive tests) on provocation tests; fair, slight pain or limitation of movement during and after work, or positive results on provocation tests, but at a level lower than before treatment. Poor, no change on provocation tests or feeling worse subjectively. Length of follow-up was 4-48 months. Results Positive rates for the provocation tests are shown in Table 1. Conservative treatment was successful (i.e., the response was good or excellent) in 395 (94.5%) of 418 patients. In the 23 patients (32 thoracic outlets) who failed to respond to conservative treatment, surgery was performed. Four of the 422 patients with TOS did not meet the indications for our conservative therapy protocol, and underwent surgery directly. Rib resection was associated with transient wing scapula in one patient, in whom a branch of the long thoracic nerve, which passes through the belly of the scalenus medius muscle, could have been entrapped by muscle contraction after detachment. Five of the 27 operated patients had the twostage operation. Success of this treatment was defined as an "excellent" or "good" response after treatment. Surgery was successful in 25 of these 27 patients. Results in the remaining 2 were rated as fair, as they did not persevere with the rehabilitation program. Comment The results obtained from applying these newer concepts of the etiology, diagnosis, and treatment of TOS were superior to the outcomes when the older, more traditional, and now obsolete modalities were employed. 2 References ]. Abe M, Saitoh M, Kaneko H, et al. New employment of four diagnostic provocation tests of thoracic outlet syndrome (in Japanese). East Jpn J Clin Orthop 1989;1: Abe M, Nishida J, Furumachi K, et al. Transaxillary resection of the 1st rib in thoracic outlet syndrome: 8 year experience and revision of the technique. European Medical Bibliography for Hand Surgery 1991; Suppl 1: Abe M, Nishida J. Ichinohe K, et al. Cervico-brachial syndrome (in Japanese). MB Orthop 1993;6: Abe M, Nishida J, Tajima K, et al. Treatment of thoracic outlet syndrome: A revised protocol. 6th congress of IFSSH, 1995; Eden KC. The vascular complications of cervical ribs in first thoracic rib abnormalities. Br J Surg ;27: Kataoka Y, Yamaga M, Takagi K, et al. Pathogenesis of thoracic outlet syndrome -- brachial plexus graphy (in Japanese). J Jpn Orthop Assoc 1994;68:357~i5. 7. Kawai S, Cervical spine. In: Koshino T, Shirai y, Ikuta Y, editors. Essentials of orthopaedic surgery, lshiyaku Shuppan: Tokyo, 1989: Lister G. The Hand. 3rd ed. Edinburgh: Churchill Livingstone, 1993: Nishida J, Abe M, Provocation test of thoracic outlet syndrome (in Japanese). J Jpn Orthop Assoc 1993;67:674. I0. Ohshima Y. Examination of brachial plexus and thoracic outlet. In: Tsuji H, Takahashi H, editors. Diagnosis of orthopaedic diseases. 2nd ed. Tokyo: Kanehara, 1988: Phalen G, Gardner W, LaLonde A. Neuropathy of the median nerve due to compression beneath the transverse carpal ligament. J Bone Joint Surg (Am) 1950;32: Roos DB. Congenital anomalies associated with thoracic outlet syndrome. Am J Surg 1976;132: Roos DB. New concepts of thoracic outlet syndrome that explain etiology, symptoms, diagnosis, and treatment. J Vasc Surg 1979;13: Wright IS. The neurovascular syndrome produced by hyperabduction of the arms. Am Heart J 1945;29:1-19.

THORACIC OUTLET SYNDROME: A FREQUENT CAUSE OF NON-DISCOGENIC BRACHIALGIA

THORACIC OUTLET SYNDROME: A FREQUENT CAUSE OF NON-DISCOGENIC BRACHIALGIA Debora Garozzo Brachial Plexus and Peripheral Nerve Surgery Unit Neurospinal Hospital Dubai, United Arab Emirates THE THORACIC OUTLET