Neurological thoracic outlet syndrome9/26/2023 ![]() The important thing to remember is that when assessing a patient with suspected thoracic outlet syndrome there are a large number of differential diagnoses that need to be excluded. Special and provocation testing (discussed below).Rotator cuff and glenohumeral joints tests.Active and passive ROM (of all relevant joints).Aggravating and relieving activities and positions.Detailed history including instances of macro or micro trauma.Detailed body chart of all symptoms including pain, neural symptoms, vascular symptoms.Such a comprehensive upper body examination should include: Thus, it is essential that you undertake a thorough subjective and objective examination. Unfortunately the diagnosis of TOS remains essentially clinical and is often one of exclusion with no objective sign or investigation being a specific predictor. When talking about thoracic outlet syndrome – this is the group of patients you are most likely to encounter. This group is the largest group of TOS presentations, and remains the most controversial (Rayan, 1998 Lee et al., 2006). ![]() Symptomatic TOS (sTOS): is associated with symptoms of TOS, however, there are no objective neurological, electro-physical or radiological abnormalities.True Neurological TOS (tnTOS): is associated with true neurological deficits (mostly muscular atrophy).Neurological TOS can be further divided into two groups, which are: Neurological Thoracic Outlet Syndrome (nTOS): represents approximately 97% of cases and compression is of the neural structures of the brachial plexus.Arterial TOS (aTOS): which involves compression of the subclavian or axillary artery and accounts for 1% of cases (Roos et al., 1987 Davidovic et al., 2003).Venous TOS (venTOS): which involves compression of the subclavian or axillary vein and accounts for 2% of cases.Vascular Thoracic Outlet Syndrome (vTOS): which represents approximately 3% of cases and compression is of the vascular structures. vTOS is generally easier to define, diagnose and treat than nTOS (Sharp et al., 2001).Therefore, thoracic outlet syndrome can be divided into 2 groups: In the sub-coracoid tunnel beneath the tendon of the pectoralis minor (removed in the image below) (Wright and Jennings, 2005).Ĭlassification of Thoracic Outlet SyndromeĪs suggested previously, there are different types of thoracic outlet syndrome which are based on the structures that are compressed.Beneath the clavicle in the costo-clavicular space, where the neural elements are already outside the thorax (clavicle is removed in the below image).However, this condition should technically be referred to as cervical outlet syndrome (Ranney, 1996). It is worth noting that the upper roots of the brachial plexus may also be compressed between the scalene muscles as they exit the cervical spine. This will result in compression of the lower roots of the brachial plexus. As they exit from the thoracic cavity and rise up over the first rib and pass between the anterior and middle scalene muscles.In fact, there are three possible sites of compression of the vessels and nerves. Quite obviously, this will result in a wide variety of symptoms dependent upon the structure that is compressed and the location of compression. The pain and discomfort of TOS are generally attributed to the compression of the This article will discuss the pathoanatomy, classifications, aetiology, assessment, diagnosis and management of thoracic outlet syndrome. “Thoracic outlet syndrome (TOS) is a symptom complex characterised by pain, paresthesia, weakness and discomfort in the upper limb which is aggravated by elevation of the arms or by exaggerated movements of the head and neck” (Lindgren and Oksala, 1995) Thoracic outlet syndrome is considered to be a collection of quite diverse syndromes rather than a single entity (Yanaka et al., 2004), and therefore, accurate diagnosis and enlightened treatment decisions can be very challenging. The condition discussed in this article, you will come to find, is quite complex and can be a battle for the physiotherapist and physical therapist.
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