Thoracic Outlet Obstruction Workup

  • Author: Mark K Eskandari, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Mar 12, 2012
 

Laboratory Studies

  • No laboratory studies are required for the workup of thoracic outlet syndrome (TOS) because no laboratory study aids in the diagnosis of this condition.
  • Laboratory studies are useful to rule out other diseases, such as a hypercoagulable state in venous thrombosis, and they also may be useful to prepare a patient for general anesthesia.
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Imaging Studies

  • Chest radiography may be helpful when evaluating patients with neurogenic or arterial TOS. Cervical ribs or rudimentary first ribs often can be identified on chest radiography.
  • Standard CT scanning may help to rule out other pathologies that might cause symptoms mimicking TOS. For example, a herniated cervical disc or spinal stenosis is diagnosed by CT scanning.
    • CT scanning with 3-dimensional reconstruction have become popular for evaluating the thoracic outlet. With the use of 3-dimensional CT scanning, compression of the structures at the thoracic outlet can be demonstrated clearly using dynamic positioning, as depicted in the images below. Thoracic outlet obstruction. Three-dimensional CT Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery at the thoracic outlet. Thoracic outlet obstruction. Three-dimensional CT Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery with the arm abducted.
    • CT scan angiography, as depicted in the first 2 images below, and venography, as depicted in the last 2 images below, can produce excellent images using maximal intensity projection (MIP). Thoracic outlet obstruction. CT scan, maximal inteThoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery in the neutral position. Thoracic outlet obstruction. CT scan, maximal inteThoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery when arm is abducted. Thoracic outlet obstruction. CT scan, maximal inteThoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in neutral position. Thoracic outlet obstruction. CT scan, maximal inteThoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in abducted position.
  • Standard MRI also can be used to rule out alternative diagnoses. Dynamic MRI with gadolinium infusion provides detail of the thoracic outlet and may be helpful when evaluating for compression. Gadolinium-enhanced magnetic resonance angiography is thought to hold significant potential for imaging the thoracic outlet.
  • Angiography with dynamic positioning is used to demonstrate compression of the subclavian artery. Angiography may identify axillary-subclavian aneurysm,, as depicted in the image below, and if an aneurysm is present, it is useful in planning surgery. Arterial stenosis with poststenotic dilatation also may be identified angiographically. Thoracic outlet obstruction. Angiogram showing subThoracic outlet obstruction. Angiogram showing subclavian artery aneurysm in abduction/external rotation (AER).
  • Venography with dynamic positioning demonstrates abnormalities of the subclavian vein in patients with Paget-Schroetter syndrome, as depicted in the image below. Interestingly, venography of the contralateral arm of patients with venous TOS identifies compression with dynamic positioning in as many as 80% of patients. Despite the compression that occurs in the contralateral extremity, the incidence of contralateral DVT is only 15%. During venography, abduct patients' arms to only 30° to avoid an erroneous diagnosis of complete vein occlusion. Always perform provocative maneuvers under fluoroscopy to document venous compression in patients with presumed Paget-Schroetter syndrome. If compression of the vein is not identified at 30 degrees of abduction, then rotation of the neck, flexion or extension of the neck, or further abduction may be useful. Thoracic outlet obstruction. Venogram showing venoThoracic outlet obstruction. Venogram showing venous stenosis.
  • In venous TOS, ultrasonography is useful as a noninvasive test to search for collateral circulation and evaluate the extent of thrombosis. Identification of significant collaterals may help with operative planning, and may determine the type of exposure used in order to limit damage to these collaterals. In arterial TOS, ultrasonography can document stenosis, poststenotic dilatation or aneurysm of the subclavian artery, and mural thrombus.
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Other Tests

  • Electromyography (EMG) and nerve conduction studies are useful in the workup of patients suspected of having neurogenic TOS. Findings on EMG usually are normal in patients with TOS, but it is helpful in ruling out other neuromuscular problems. Nerve conduction velocity studies usually are more helpful than EMG studies. A reduction in nerve conduction velocity of less than 85 m/s of either ulnar or median nerves across the thoracic outlet corroborates the diagnosis of neurogenic TOS. These studies also can be used as baseline values prior to treatment.
  • Carefully examine the scalene muscles and supraclavicular fossa when evaluating a patient with neurogenic TOS. Scalene muscle block with local anesthetic has a 94% correlation with good early results of surgery.
  • The Adson sign is the loss of the radial pulse by rotating the head to the ipsilateral side and inspiring. A positive test result was considered pathonomic for TOS, but the Adson test no longer is considered reliable because these findings occur in as many as 53% of subjects without TOS.
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Histologic Findings

Muscle biopsy specimens show that type I fibers predominate and type II fibers atrophy in patients with neurogenic thoracic outlet syndrome (TOS). Increased fibrosis also has been noted in the scalene muscles of these patients. These findings suggest that repetitive trauma may have a role in the development of neurogenic symptoms.

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Contributor Information and Disclosures
Author

Mark K Eskandari, MD  the James T Yao Professor of Education in Vascular Surgery, Chief, Division of Surgery-Vascular, Associate Professor, Division of Surgery-Vascular and Medicine-Cardiology and Cardiology, Northwestern University, The Feinberg School of Medicine; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Lake Forest Hospital

Mark K Eskandari, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Cardiovascular and Interventional Radiological Society of Europe, Central Surgical Association, International Society of Endovascular Specialists, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Interventional Radiology, Society of University Surgeons, Southern Association for Vascular Surgery, and Western Surgical Association

Disclosure: Harvard Clinical Research Honoraria Consulting; Medtronic Honoraria Consulting; Abbott Vascular Honoraria Consulting

Coauthor(s)

Nicholas D Garcia, MD  Chief of Surgery, Exeter Hospital; Director, Board of Directors, Core Physician Services; Associate Medical Director, Core Physicians, LLC

Nicholas D Garcia, MD is a member of the following medical societies: American College of Surgeons, New Hampshire Medical Society, and Society for Vascular Surgery

Disclosure: Nothing to disclose.

Mark D Morasch, MD  Professor of Surgery, Division of Vascular Surgery, John Marquardt Clinical Research Professor in Vascular Surgery, Northwestern University, The Feinberg School of Medicine

Mark D Morasch, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Medical Association, American Venous Forum, Central Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Surgical Association

Disclosure: W.L. Gore & Associates Honoraria Speaking and teaching

Specialty Editor Board

Jeffrey Lawrence Kaufman, MD  Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine

Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, and Society for Vascular Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center Program Director, Vascular Surgery Residency

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center Program Director, Vascular Surgery Residency

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Hassan Tehrani, MB, BCh, to the development and writing of this article.

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Thoracic outlet obstruction. Scalene triangle.
Thoracic outlet obstruction. Costoclavicular space.
Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery at the thoracic outlet.
Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery with the arm abducted.
Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery in the neutral position.
Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery when arm is abducted.
Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in neutral position.
Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in abducted position.
Thoracic outlet obstruction. Angiogram showing subclavian artery aneurysm in abduction/external rotation (AER).
Thoracic outlet obstruction. Venogram showing venous stenosis.
 
 
 
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