This group of patients suffers from compression of the axillosubclavian vein which ultimately results in thrombosis. Venous thoracic outlet syndrome (vTOS) makes up an additional 3–5% of patients. Furthermore, they may directly impinge on the nerves or vessels. Tissue contraction from scar or adhesions can certainly affect the dynamics of the already small thoracic outlet. It is suspected that the formation of scar tissue and adhesions may play a likely role in this relationship. In our practice, 50% of patients present with a history of either trauma or chronic repetitive motion. Patients seem to additionally describe a history vigorous repetitive activity, likely related to their profession or lifestyle. Many of these patients have experienced some type of trauma, typically motor vehicle accidents or falls. Patients can present with vague symptomatology but most often complain of pain and numbness in their fingers, hands, or arms on the affected side. Neurogenic thoracic outlet syndrome (nTOS) makes up approximately 95% of all patients suffering from this syndrome. What is not so understood is why neurogenic is much more common than either the venous or arterial thoracic outlet syndrome. As these structures travel together while exiting the thorax and entering the axilla, it can be understood why any of the three can be affected. There are three types of TOS: neurogenic, venous, and arterial. Simultaneously, fibrosis and scarring may occur, which can then cause encroachment or inflammation.ģ. As the space continuously contracts and expands, there may be impingement of the brachial plexus or subclavian vessels by the osseous structures. Additionally, cervical ribs or anomalous first ribs, which tend to be more cephalad or fused with the second rib, can further affect the dimensions of the thoracic outlet. The thoracic outlet is also dynamic the volume changes with respiration and any activity of the neck, thorax, or arm. It is a very small space, already occupied by the anterior scalene, the subclavius, and prevertebral muscles. The brachial plexus travels posterior and laterally to the artery and is accompanied by the middle scalene muscle ( Figure 1). Next, the scalene separates the subclavian vein from the subclavian artery. Anteriorly, the subclavius tendon lies next to the subclavian vein. The thoracic outlet is anatomically defined by the space between the first thoracic vertebra, first rib, and manubrium of the sternum.
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