Upper Plexus Thoracic Outlet Syndrome. Case Report.

Matsuyama, Tomohiro; Okuchi, Kazuo; Goda, Kazuo

doi:10.2176/nmc.42.237

Cited by 10 publications

(6 citation statements)

References 18 publications

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“…The ASM is also implicated in the distribution of nerves comprising the brachial plexus. As previously mentioned (Roos, ; Wood and Ellison, ; Urschel and Razzuk, ; Matsuyama et al, ), upper plexus TOS is seen in 3–12% of nTOS cases. This is likely a result of the multitude of variations seen between C5/C6 and the ASM.…”

Section: Anatomy and Embryologymentioning

confidence: 63%

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Thoracic outlet syndrome: A neurological and vascular disorder

et al. 2013

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Thoracic outlet syndrome (TOS) is a condition arising from compression of the subclavian vessels and/or brachial plexus as the structures travel from the thoracic outlet to the axilla. Despite the significant pathology associated with TOS, there remains some general disagreement among experts on the specific anatomy, etiology, and pathophysiology of the condition, presumably because of the wide variation in symptoms that manifest in presenting patients, and because of lack of a definitive gold standard for diagnosis. Symptoms associated with TOS have traditionally been divided into vascular and neurogenic categories, a distinction based on the underlying structure(s) implicated. Of the two, neurogenic TOS (nTOS) is more common, and typically presents as compression of the brachial plexus; primarily, but not exclusively, involving its lower trunk. Vascular TOS (vTOS) usually involves compression of the vessel, most commonly the subclavian artery or vein, or is secondary to thrombus formation in the venous vasculature. Any anatomical anomaly in the thoracic outlet has the potential to predispose a patient to TOS. Common anomalies include variations in the insertion of the anterior scalene muscle (ASM) or scalenus minimus muscle, the presence of a cervical rib or of fibrous and muscular bands, variations in insertion of pectoralis minor, and the presence of neurovascular structures, which follow an atypical course. A common diagnostic technique for vTOS is duplex imaging, which has generally replaced more invasive angiographic techniques. In cases of suspected nTOS, electrophysiological nerve studies and ASM blocks provide guidance when screening for patients likely to benefit from surgical decompression of TOS. Surgeons generally agree that the transaxillary approach allows the greatest field of view for first rib excision to relieve compressed vessels. Alternatively, a supraclavicular approach is favored for scalenotomies when the ASM impinges on surrounding structures. A combined supraclavicular and infraclavicular approach is preferred when a larger field of view is required. The future of TOS management must emphasize the improvement of available diagnostic and treatment techniques, and the development of a consensus gold standard for diagnosis. Helical computed tomography offers a three-dimensional view of the thoracic outlet, and may be valuable in the detection of anatomical variations, which may predispose patients to TOS. This review summarizes the history of TOS, the pertinent clinical and anatomical presentations of TOS, and the commonly used diagnostic and treatment techniques for the condition.

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Section: Anatomy and Embryologymentioning

confidence: 63%

“…Two recent case reports are of clinical relevance to TOS. Matsuyama et al () reported a patient with atrophy of the right biceps muscle, as well as weakness in the deltoid, triceps, supraspinatus, and infraspinatus muscles. The case was diagnosed as upper plexus TOS because of C5–C7 nerve root compression.…”

Section: Clinical Presentationmentioning

confidence: 99%

Thoracic outlet syndrome: A neurological and vascular disorder

et al. 2013

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“…Rapid improvement in functional parameters after neurolysis has been described in humans and experimental animals [7,8], including anecdotal case reports involving the long thoracic nerve [4], and ulnar nerve [9]. It is difficult to measure the outcome of surgical procedures when relying on the patients' subjective reports or on postoperative electrical testing, which does not always correlate Abduction improvements one day post surgery with function [10,11].…”

Section: Discussionmentioning

confidence: 99%

Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury

Nath

Melcher

2014

J Brachial Plex Peripher Nerve Inj

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BackgroundInjury to the long thoracic nerve is a common cause of winging scapula. When the serratus anterior muscle is unable to function, patients often lose the ability to raise their arm overhead on the affected side.MethodsSerratus anterior function was restored through decompression, neurolysis, and tetanic electrical stimulation of the long thoracic nerve. This included partial release of constricting middle scalene fibers and microneurolysis of epineurium and perineurium of the long thoracic nerve under magnification. Abduction angle was measured on the day before and the day following surgery.ResultsIn this retrospective study of 13 neurolysis procedures of the long thoracic nerve, abduction is improved by 10% or greater within one day of surgery. The average improvement was 59° (p < 0.00005). Patients had been suffering from winging scapula for 2 months to 12 years. The improvement in abduction is maintained at last follow-up, and winging is also reduced.ConclusionIn a notable number of cases, decompression and neurolysis of the long thoracic nerve leads to rapid improvements in winging scapula and the associated limitations on shoulder movement. The duration of the injury and the speed of improvement lead us to conclude that axonal channel defects can potentially exist that do not lead to Wallerian degeneration and yet cause a clear decrease in function.

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“…Clinically, the superior piercing variant would cause neurologic symptoms in the C5 and C6 dermatomal distribution of the lateral arm, thumb, and second digit. Specifically, weakness and sensory deficits in the first two digits, and diminished reflexes of the biceps brachii and brachioradialis muscles [25,26,27,28]. The multiple piercing variant (Figure 2C) would result in more extensive neurogenic issues, corresponding with symptoms along the C5, C6, and C7 dermatomes, affecting the first through third digits of the hand.…”

Section: Discussionmentioning

confidence: 99%

“…The multiple piercing variant (Figure 2C) would result in more extensive neurogenic issues, corresponding with symptoms along the C5, C6, and C7 dermatomes, affecting the first through third digits of the hand. The clinical consequences could also include additional muscle weakness or decreased reflexes in the triceps brachii muscle [26,27,28]. …”

Section: Discussionmentioning

confidence: 99%

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation

et al. 2017

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Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior scalene. This results in possible impingement of BP nerves within the muscle belly and, therefore, predisposition for nTOS. We hypothesized that some cases of disputed nTOS result from these BP branching variants. We tested the association between BP piercing and nTOS symptoms, and evaluated the capability of ultrasonographic identification of patients with clinically relevant variations. Eighty-two cadaveric necks were first dissected to assess BP variation frequency. In 62.1%, C5, superior trunk, or superior + middle trunks pierced the anterior scalene. Subsequently, 22 student subjects underwent screening with detailed questionnaires, provocative tests, and BP ultrasonography. Twenty-one percent demonstrated atypical BP branching anatomy on ultrasound; of these, 50% reported symptoms consistent with nTOS, significantly higher than subjects with classic BP anatomy (14%). This group, categorized as a typical TOS, would be missed by provocative testing alone. The addition of ultrasonography to nTOS diagnosis, especially for patients with BP branching variation, would allow clinicians to visualize and identify atypical patient anatomy.

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Upper Plexus Thoracic Outlet Syndrome. Case Report.

Cited by 10 publications

References 18 publications

Thoracic outlet syndrome: A neurological and vascular disorder

Thoracic outlet syndrome: A neurological and vascular disorder

Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation

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