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Understanding thoracic outlet syndrome.

Freischlag J, Orion K - Scientifica (Cairo) (2014)

Bottom Line: Each type is in distinction to the others when considering patient presentation and diagnosis.Remarkable advances have been made in surgical approach, physical therapy, and rehabilitation of these patients.Dedicated centers of excellence with multidisciplinary teams have been developed and continue to lead the way in future research.

View Article: PubMed Central - PubMed

Affiliation: Division of Vascular Surgery, Department of Surgery, The Johns Hopkins Hospital, 720 Rutland Avenue, Ross 759, Baltimore, MD 21205, USA.

ABSTRACT
The diagnosis of thoracic outlet syndrome was once debated in the world of vascular surgery. Today, it is more understood and surprisingly less infrequent than once thought. Thoracic outlet syndrome (TOS) is composed of three types: neurogenic, venous, and arterial. Each type is in distinction to the others when considering patient presentation and diagnosis. Remarkable advances have been made in surgical approach, physical therapy, and rehabilitation of these patients. Dedicated centers of excellence with multidisciplinary teams have been developed and continue to lead the way in future research.

No MeSH data available.


Related in: MedlinePlus

Transection of the anterior scalene muscle with a right angle clamp and scissors (reprinted with permission of Elsevier; see [8]).
© Copyright Policy - open-access
Related In: Results  -  Collection


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fig5: Transection of the anterior scalene muscle with a right angle clamp and scissors (reprinted with permission of Elsevier; see [8]).

Mentions: FRRS has been performed via a supraclavicular incision; however, we favor the exposure of a transaxillary approach and use this technique for all our patients regardless of size. FRRS is performed under general anesthesia with avoidance of any long-acting paralytics for intraoperative nerve identification and monitoring. Positioning and retraction are the most important aspects of obtaining an adequate surgical field of view [13]. The patient is placed on a bean bag in the lateral position with the operative side up. Ample padding with foam or pillows should be used in order to protect pressure points as the bean bag is inflated. The axilla and arm are prepped circumferentially to the wrist and a Machleder retractor is utilized. This retractor allows excellent exposure of the thoracic outlet without the laborious need for an assistant to extend the arm throughout the surgery. The borders of the latissimus dorsi muscle and pectoralis major muscle are marked, and the incision is made between the two just below the axillary hair line (Figure 3). Dissection is taken down directly to the chest wall in order to avoid disturbing the axillary lymphatic bed. Gentle blunt dissection is then performed towards the apex of the axilla and first rib. Lighted hand-held retractors are used to provide illumination deep into the operative field. The anatomy is identified; the vein will be fluttering with respiration; the artery will be pulsatile (in vTOS, the vein can be fibrotic and more difficult to detect). The first rib is identified as the scalene muscle will insert on its most cephalad edge. Sharp periosteal elevators are used to clear intercostals and mobilize the first rib (Figure 4). Inferiorly, the pleura is gently peeled off the rib, but pneumothorax can be encountered in patients with significant scarring. Next, the subclavius muscle is divided sharply, which is followed by high division of the anterior scalene muscle (Figure 5). Great care must be taken to avoid injury to the artery during this step. Once the rib is completely mobilized, a rib cutter is used anteriorly first, next to the subclavian vein. Finally, the rib is then transected posteriorly at the level of or just anterior to the brachial plexus. Frequently a second transection is performed just behind the brachial plexus to assure that no scarring will occur between the nerves and the rib in the postoperative period causing recurrent symptoms 20% of the time. The rib is removed (Figure 6) and the space is inspected for hemostasis. If a pneumothorax has occurred, a small 12-French chest tube is placed prior to closing the incision in two or three layers.


Understanding thoracic outlet syndrome.

Freischlag J, Orion K - Scientifica (Cairo) (2014)

Transection of the anterior scalene muscle with a right angle clamp and scissors (reprinted with permission of Elsevier; see [8]).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4129179&req=5

fig5: Transection of the anterior scalene muscle with a right angle clamp and scissors (reprinted with permission of Elsevier; see [8]).
Mentions: FRRS has been performed via a supraclavicular incision; however, we favor the exposure of a transaxillary approach and use this technique for all our patients regardless of size. FRRS is performed under general anesthesia with avoidance of any long-acting paralytics for intraoperative nerve identification and monitoring. Positioning and retraction are the most important aspects of obtaining an adequate surgical field of view [13]. The patient is placed on a bean bag in the lateral position with the operative side up. Ample padding with foam or pillows should be used in order to protect pressure points as the bean bag is inflated. The axilla and arm are prepped circumferentially to the wrist and a Machleder retractor is utilized. This retractor allows excellent exposure of the thoracic outlet without the laborious need for an assistant to extend the arm throughout the surgery. The borders of the latissimus dorsi muscle and pectoralis major muscle are marked, and the incision is made between the two just below the axillary hair line (Figure 3). Dissection is taken down directly to the chest wall in order to avoid disturbing the axillary lymphatic bed. Gentle blunt dissection is then performed towards the apex of the axilla and first rib. Lighted hand-held retractors are used to provide illumination deep into the operative field. The anatomy is identified; the vein will be fluttering with respiration; the artery will be pulsatile (in vTOS, the vein can be fibrotic and more difficult to detect). The first rib is identified as the scalene muscle will insert on its most cephalad edge. Sharp periosteal elevators are used to clear intercostals and mobilize the first rib (Figure 4). Inferiorly, the pleura is gently peeled off the rib, but pneumothorax can be encountered in patients with significant scarring. Next, the subclavius muscle is divided sharply, which is followed by high division of the anterior scalene muscle (Figure 5). Great care must be taken to avoid injury to the artery during this step. Once the rib is completely mobilized, a rib cutter is used anteriorly first, next to the subclavian vein. Finally, the rib is then transected posteriorly at the level of or just anterior to the brachial plexus. Frequently a second transection is performed just behind the brachial plexus to assure that no scarring will occur between the nerves and the rib in the postoperative period causing recurrent symptoms 20% of the time. The rib is removed (Figure 6) and the space is inspected for hemostasis. If a pneumothorax has occurred, a small 12-French chest tube is placed prior to closing the incision in two or three layers.

Bottom Line: Each type is in distinction to the others when considering patient presentation and diagnosis.Remarkable advances have been made in surgical approach, physical therapy, and rehabilitation of these patients.Dedicated centers of excellence with multidisciplinary teams have been developed and continue to lead the way in future research.

View Article: PubMed Central - PubMed

Affiliation: Division of Vascular Surgery, Department of Surgery, The Johns Hopkins Hospital, 720 Rutland Avenue, Ross 759, Baltimore, MD 21205, USA.

ABSTRACT
The diagnosis of thoracic outlet syndrome was once debated in the world of vascular surgery. Today, it is more understood and surprisingly less infrequent than once thought. Thoracic outlet syndrome (TOS) is composed of three types: neurogenic, venous, and arterial. Each type is in distinction to the others when considering patient presentation and diagnosis. Remarkable advances have been made in surgical approach, physical therapy, and rehabilitation of these patients. Dedicated centers of excellence with multidisciplinary teams have been developed and continue to lead the way in future research.

No MeSH data available.


Related in: MedlinePlus