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Thoracic Outlet Obstruction Workup

  • Author: Mark K Eskandari, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Nov 25, 2014
 

Imaging Studies

Chest radiography

Chest radiography may be helpful in evaluating patients with neurogenic or arterial TOS. Cervical ribs or rudimentary first ribs often can be identified on chest radiography.

Computed tomography

Standard computed tomography (CT) may help to rule out other pathologic conditions that might cause symptoms mimicking TOS. For example, a herniated cervical disc or spinal stenosis is diagnosed by means of CT.

CT with three-dimensional (3D) reconstruction has become popular for evaluating the thoracic outlet. With the use of 3D CT scanning, compression of the structures at the thoracic outlet can be demonstrated clearly by using dynamic positioning (see 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 arteriography (see the first and second images below) and venography (see the third and fourth images below) can produce excellent images by using maximal intensity projection (MIP).

Thoracic outlet obstruction. CT scan, maximal inte Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery in the neutral position.
Thoracic outlet obstruction. CT scan, maximal inte Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery when arm is abducted.
Thoracic outlet obstruction. CT scan, maximal inte Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in neutral position.
Thoracic outlet obstruction. CT scan, maximal inte Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in abducted position.

Magnetic resonance imaging

Standard magnetic resonance imaging (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 (MRA) is thought to hold significant potential for imaging the thoracic outlet.

Poretti et al described an MRA protocol for evaluation of TOS that permits separate assessment of veins and arteries through the use of a single, simultaneous and bilateral (SB-MRA) contrast injection that is valid for both abduction and adduction.[5] The investigators found this protocol to be safe and reliable protocol and to be helpful for the diagnosis of TOS of arterial or venous origin.

Arteriography and venography

Arteriography with dynamic positioning is used to demonstrate compression of the subclavian artery. Angiography may identify axillary-subclavian aneurysm (see 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 sub Thoracic 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 (see 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%.

Thoracic outlet obstruction. Venogram showing veno Thoracic outlet obstruction. Venogram showing venous stenosis.

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 30º of abduction, then rotation of the neck, flexion or extension of the neck, or further abduction may be useful.

Ultrasonography

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. EMG usually yields normal findings in patients with TOS, but it is helpful in ruling out other neuromuscular problems. Nerve conduction velocity studies usually are more helpful than EMG is. 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 before 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 upon rotation of the head to the ipsilateral side and inspiration. 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 from patients with neurogenic TOS show that type I fibers predominate and type II fibers atrophy. 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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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. However, laboratory studies are useful for ruling out other diseases, such as a hypercoagulable state in venous thrombosis, and they also may be useful in preparing a patient for general anesthesia.

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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), 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: Central Surgical Association, Society for Vascular Surgery, Society of University Surgeons, Western Surgical Association, Society of Interventional Radiology, Southern Association for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, International Society of Endovascular Specialists, Cardiovascular and Interventional Radiological Society of Europe, American College of Surgeons, American Medical Association, Association for Academic Surgery

Disclosure: Received honoraria from Harvard Clinical Research for consulting; Received honoraria from Medtronic for consulting; Received honoraria from Abbott Vascular for consulting.

Coauthor(s)

Mark D Morasch, MD, RPVI Vascular Surgeon, Section Head of Vascular and Endovascular Services, Billings Clinic; John Marquardt Clinical Research Professor in Vascular Surgery, Division of Vascular Surgery, Northwestern University, The Feinberg School of Medicine

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

Disclosure: Nothing to disclose.

Nicholas D Garcia, MD Chief of Surgery, Exeter Hospital; Chair, Board of Directors, Core Physicians, LLC

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

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

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

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

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases 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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