4/14/2016 1 Management of Chronic Thoracic Outlet Syndrome David Rigberg, MD Professor of Surgery Vascular Surgery Division UCLA School of Medicine Disclosures: Speaker honorarium for W.L. Gore and Associates, 9/2015. Outline Outline Outline Outline – – – 7 Minutes 7 Minutes 7 Minutes 7 Minutes Diagnosis of neurogenic TOS -vTOS and aTOS non controversial Anterior approach Trans-axillary approach BRACHIAL PLEXUS SUBCLAVIAN ARTERY SUBCLAVIAN VEIN Neuro Neuro Neuro Neuro- - -Vascular Structures Vascular Structures Vascular Structures Vascular Structures Crossing the Thoracic Outlet Crossing the Thoracic Outlet Crossing the Thoracic Outlet Crossing the Thoracic Outlet
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Management of Chronic Thoracic Outlet Syndrome€¦ · Management of Chronic Thoracic Outlet Syndrome David Rigberg, MD ... BRACHIAL PLEXUS SUBCLAVIAN ARTERY ... Anterior Scalene
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Management of Chronic Thoracic Outlet
SyndromeDavid Rigberg, MD
Professor of SurgeryVascular Surgery DivisionUCLA School of Medicine
� Disclosures: Speaker honorarium for W.L. Gore and Associates, 9/2015.
Thoracic Outlet: Assessment with MR Imaging in Thoracic Outlet: Assessment with MR Imaging in Thoracic Outlet: Assessment with MR Imaging in Thoracic Outlet: Assessment with MR Imaging in Asymptomatic and Symptomatic PopulationsAsymptomatic and Symptomatic PopulationsAsymptomatic and Symptomatic PopulationsAsymptomatic and Symptomatic Populations
35 healthy volunteers and 54 patients with clinical symptoms of thoracic outlet syndrome (TOS)
� Patients were included in the study when at least two provocative clinical tests reproduced the
���symptoms
Xavier Demondion, MD, et al . Université de Lille 2, France. Radiology, 2003
MRI Diagnosis of nTOS MRI Diagnosis of nTOSMRI Diagnosis of nTOSMRI Diagnosis of nTOSMRI Diagnosis of nTOS� 54 patients with TOS:� Smaller costoclavicular distance (P < .001), � Thicker subclavius muscle (P < .001), � Wider retropectoralis minor space (P < .001) than
did volunteers. � Vascular or nerve compression in 44 (81%).� Arterial compression in 72% of TOS patients. � Nerve compression in 7% of TOS patients.
� No arterial or nerve compression seen in volunteers. � No standardized criteria
Demondion X et al. Radiology 2003;227:461-468
Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOS
Defines “True Neurogenic” TOS – less than 5% of all.
SSEP Improved PostSSEP Improved PostSSEP Improved PostSSEP Improved Post----OpOpOpOpNeurogenic TOS
Of 80 TOS patients 59 (74%) with Abnormal SSEP51 (86%) improved with surgery 8 (14%) showed no improvement
Post-op SSEP correlated with outcome (pos or neg) in 92%
. Somatosensory Evoked Potentials (SSEP) in the Assessment of Thoracic Outlet Compression SyndromeMachleder HI, Moll F, Nuwer M, Jordan S. J Vasc Surg. 1987
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Anterior Scalene Muscle BlockAnterior Scalene Muscle BlockAnterior Scalene Muscle BlockAnterior Scalene Muscle Block� U/S-Guided Injection of Lidocaine into Anterior Scalene
muscle.
� Results in relaxation of anterior scalene muscle. � No anesthesia. � No paralysis. � (Not an inter-scalene block.)
� Positive: Greater than 50%reduction of symptoms.
Neurogenic TOSNeurogenic TOSNeurogenic TOSNeurogenic TOSDiagnosis of Thoracic Outlet Syndrome Using Diagnosis of Thoracic Outlet Syndrome Using Diagnosis of Thoracic Outlet Syndrome Using Diagnosis of Thoracic Outlet Syndrome Using Electrophysiologically Guided Anterior Scalene Electrophysiologically Guided Anterior Scalene Electrophysiologically Guided Anterior Scalene Electrophysiologically Guided Anterior Scalene
BlocksBlocksBlocksBlocks
� 122 Patients evaluated for TOS� 122 underwent ASMB
� 102 patients diagnosed with TOS� 20 patients diagnosed with other condition� 1 had Positive ASMB = 5% false negative
Jordan and Machleder. Annals of Vascular Surgery 1998
Supra-Clavicular Scalene Muscle and 1st Rib Resection Supra-Clavicular Scalene Muscle and Rib
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Supra-Clavicular Scalene Muscle and Rib Supra-Clavicular Scalene Muscle and Rib
Dorsal ScapularNerve
Long ThoracicNerve
Brachial PlexusC5, C6, C7
PhrenicNerve
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Supra-Clavicular Scalene Muscle and Rib Supra-Clavicular Scalene Muscle and Rib
Supra-ClavicularLimitations: The anterior portion of the first rib is not accessible.
This alone may be inadequate for decompression of v TOS.
Supra-ClavicularTraction and manipulation of neural structures is required.
Possibly increased risk of nerve injuries.
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Arterial TOSArterial TOSArterial TOSArterial TOS TransTransTransTrans----Axiallary First Rib ResectionAxiallary First Rib ResectionAxiallary First Rib ResectionAxiallary First Rib Resection
Advantage: working beneath nerves.
Division of Anterior ScaleneDivision of Anterior ScaleneDivision of Anterior ScaleneDivision of Anterior Scalene TransTransTransTrans----Axillary Rib ResectionAxillary Rib ResectionAxillary Rib ResectionAxillary Rib Resection
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Venous Channel
vTOS
nTOS
Surgical Complications686 operations in 491 patients