Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique

Abstract

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed “thoracic outlet syndrome,” with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up. Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed “thoracic outlet syndrome,” with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up. Unlike other compressive neuropathies in the upper extremity, thoracic outlet syndrome (TOS) is less common and often more challenging to manage.1Atroshi I. Gummesson C. Johnsson R. Ornstein E. Ranstam J. Rosén I. Prevalence of carpal tunnel syndrome in a general population.JAMA. 1999; 282: 153-158Crossref PubMed Scopus (1294) Google Scholar, 2An T.W. Evanoff B.A. Boyer M.I. Osei D.A. The prevalence of cubital tunnel syndrome: a cross-sectional study in a U.S. metropolitan cohort.J Bone Joint Surg Am. 2017; 99: 408-416Crossref PubMed Scopus (63) Google Scholar, 3Mondelli M. Grippo A. Mariani M. et al.Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners.Neurophysiol Clin. 2006; 36: 245-253Crossref PubMed Scopus (42) Google Scholar, 4Jones M.R. Prabhakar A. Viswanath O. et al.Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment.Pain Ther. 2019; 8: 5-18Crossref PubMed Scopus (74) Google Scholar Broadly categorized as neurogenic TOS (NTOS) or vascular TOS (VTOS) (Table 1), approximately 90% to 95% of cases are neurogenic.5Kuhn J.E. Lebus V.G.F. Bible J.E. Thoracic outlet syndrome.J Am Acad Orthop Surg. 2015; 23: 222-232Crossref PubMed Scopus (74) Google Scholar,6Sanders R.J. Annest S.J. Thoracic outlet and pectoralis minor syndromes.Semin Vasc Surg. 2014; 27: 86-117Crossref PubMed Scopus (26) Google Scholar The brachial plexus and accompanying subclavian vessels (Fig. 1) are subject to multiple potential sites of compression through the neck, supraclavicular and infraclavicular spaces, axilla, and upper arm.5Kuhn J.E. Lebus V.G.F. Bible J.E. Thoracic outlet syndrome.J Am Acad Orthop Surg. 2015; 23: 222-232Crossref PubMed Scopus (74) Google Scholar Traditionally, neurogenic symptoms were postulated to arise exclusively from brachial plexus compression between the anterior and middle scalenes or between the clavicle and first rib. This guided decades of treatment toward open first rib resection and scalenectomy for TOS in general, despite subpar results from this treatment in NTOS subgroups compared with those in VTOS subgroups.7Peek J. Vos C.G. Ünlü Ç. van de Pavoordt H.D.W.M. van den Akker P.J. de Vries J.P.M. Outcome of surgical treatment for thoracic outlet syndrome: systematic review and meta-analysis.Ann Vasc Surg. 2017; 40: 303-326Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 8Vemuri C. Wittenberg A.M. Caputo F.J. et al.Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome.J Vasc Surg. 2013; 57: 1345-1352Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 9Yin Z.G. Gong K.T. Zhang J.B. Outcomes of surgical management of neurogenic thoracic outlet syndrome: a systematic review and Bayesian perspective.J Hand Surg Am. 2019; 44: 416.e1-416.e17Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 10Ambrad-Chalela E. Thomas G.I. Johansen K.H. Recurrent neurogenic thoracic outlet syndrome.Am J Surg. 2004; 187: 505-510Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar However, contemporary understanding of the dynamic role of the pectoralis minor (PM) influencing scapular kinematics and infraclavicular compression led to the recognition of pectoralis minor syndrome (PMS) as one of the principal etiologies underlying NTOS.11Sanders R.J. Rao N.M. The forgotten pectoralis minor syndrome: 100 operations for pectoralis minor syndrome alone or accompanied by neurogenic thoracic outlet syndrome.Ann Vasc Surg. 2010; 24: 701-708Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar This supported an alternate approach to the surgical management of NTOS by targeting the PM for simultaneous decompression of the brachial plexus and correction of scapular dyskinesia.6Sanders R.J. Annest S.J. Thoracic outlet and pectoralis minor syndromes.Semin Vasc Surg. 2014; 27: 86-117Crossref PubMed Scopus (26) Google Scholar,8Vemuri C. Wittenberg A.M. Caputo F.J. et al.Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome.J Vasc Surg. 2013; 57: 1345-1352Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,12Sanders R.J. Recurrent neurogenic thoracic outlet syndrome stressing the of pectoralis minor Surg. PubMed Scopus Google minor space, scalene results in and chronically protracted volume of retropectoralis minor on brachial plexus of the suprascapular nerve at the suprascapular of the anterior and middle scalene first rib to the costoclavicular the subclavian and to the subclavian costoclavicular are common the neck, and often accompanied by in the or are and and and with in the or are and over PM less over and the upper and in the are with in the with the scapular scapular PM with or suprascapular nerve at suprascapular with or scalene of the for dynamic vascular of the brachial of upper release or or suprascapular nerve or brachial plexus or subclavius rib resection or or or resection of anatomy in a new TOS and treatment for Thoracic outlet anatomy at the between with nerve open and less invasive endoscopic Thoracic outlet syndrome of pectoralis minor symptoms on a Google Scholar, C. et treatment of thoracic outlet syndrome in with PubMed Scopus Google Scholar, M. brachial plexus complete for neurogenic thoracic outlet syndrome: a 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, E. plexus endoscopic and with open 2015; PubMed Scopus (15) Google Scholar, release of the brachial Full Text Full Text PDF PubMed Scopus Google Scholar is patients with NTOS are often between procedures the correct diagnosis is in the treatment of thoracic outlet J. Google Scholar often the of pathology and and invasive This review a comprehensive of the dynamic pathophysiology, and endoscopic management techniques for complete infraclavicular thoracic outlet The thoracic outlet is broadly supraclavicular and infraclavicular fossae (Fig. The supraclavicular the scalene and costoclavicular M.R. and of the thoracic Surg Clin. Full Text Full Text PDF PubMed Scopus Google plexus Clin. 2004; Full Text Full Text PDF PubMed Scopus Google Scholar The subclavian the scalene and anterior to the brachial in to the first the subclavian anterior to the anterior scalene (Fig. Surgical anatomy of the subclavian and Google Scholar, O. subclavian Scholar, subclavian Scholar, A.M. J. and anatomy of the subclavian 8: PubMed Scopus Google Scholar The scalenes the first rib and the to the as from the of the anatomy of scalene of the Ther. 2010; Full Text Full Text PDF PubMed Scopus Google Scholar rib decreases the volume of the scalene and neck, Scholar The subclavian is in to the first and is the first in this subject to compression this dynamic M.R. and of the thoracic Surg Clin. Full Text Full Text PDF PubMed Scopus Google The anterior scalene in thoracic outlet compression syndrome. and Surg. PubMed Scopus (74) Google Scholar anterior scalene with and the M. E. of the scalene of Orthop Ther. PubMed Scopus Google Scholar The and of the the upper and middle are and and less to (Fig. B.A. plexus and PubMed Scopus Google M. of the brachial and anatomy of 2010; PubMed Scopus Google Scholar the anatomy of the scalene and of vessels to the sites of compression the scalene pathology is more to the and are the of the brachial plexus to the first rib and are the to by the scalene and Thoracic outlet J PubMed Scopus Google Scholar, J. van van Thoracic outlet decompression for as a of neurogenic thoracic outlet syndrome.J Vasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, A. C. Thoracic outlet syndrome: of Surg 2019; Full Text Full Text PDF PubMed Scopus Google Scholar the scalene triangle, the the costoclavicular This is anterior and to the scalene However, of the anatomy of the thoracic and the of this is to A. et of costoclavicular on compression of the subclavian in the thoracic outlet a Surg. 27: PubMed Scopus Google Scholar, C. costoclavicular as a in the of thoracic outlet syndrome in the costoclavicular Vasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, anatomy of the interscalene and the costoclavicular and to thoracic outlet syndrome: a study of Ther. Full Text Full Text PDF PubMed Scopus Google Scholar rib the subclavian to a the subclavian the of the clavicle (Fig. A. et of costoclavicular on compression of the subclavian in the thoracic outlet a Surg. 27: PubMed Scopus Google J. M. The of the costoclavicular in upper primary a study with by a J 2014; Full Text Full Text PDF PubMed Scopus Google Scholar subclavius or this R. J. The role of the subclavius in the subclavian syndrome of the with a review of the of the costoclavicular Orthop PubMed Scopus Google The subclavius a in or brachial plexus PubMed Scopus Google Scholar as or the volume in the anterior of the costoclavicular space, the subclavian J. The of in thoracic outlet syndrome.J Vasc Surg. 2013; 57: Full Text Full Text PDF PubMed Scopus (70) Google C. A. of thoracic outlet 2006; PubMed Scopus Google Scholar the and of the costoclavicular space, the brachial plexus is and from of compression the vessels (Fig. The in the infraclavicular thoracic outlet is the retropectoralis minor (Fig. 1), the or A. for Surg Google Scholar is by the through and PM (Fig. R.J. Recurrent neurogenic thoracic outlet syndrome stressing the of pectoralis minor Surg. PubMed Scopus Google J. Thoracic outlet syndrome: a and Ther. 2010; PubMed Scopus Google Scholar In this space, plexus to the and and the of the to the R. A. and upper Scholar The PM is the principal dynamic the retropectoralis minor R.J. Annest S.J. Thoracic outlet and pectoralis minor syndromes.Semin Vasc Surg. 2014; 27: 86-117Crossref PubMed Scopus (26) Google R.J. Rao N.M. The forgotten pectoralis minor syndrome: 100 operations for pectoralis minor syndrome alone or accompanied by neurogenic thoracic outlet syndrome.Ann Vasc Surg. 2010; 24: 701-708Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar,12Sanders R.J. Recurrent neurogenic thoracic outlet syndrome stressing the of pectoralis minor Surg. PubMed Scopus Google Scholar The PM from of the through and the of the as a dynamic scapular (Fig. of pectoralis minor and Orthop Ther. PubMed Scopus Google Scholar, E. of pectoralis minor and upper on scapular PubMed Scopus Google Scholar, et of of the pectoralis minor 40: PubMed Scopus Google Scholar The of the PM scapular repetitive with scapular as this the of the PM to rib of for the pectoralis minor Surg. 2006; Full Text Full Text PDF PubMed Scopus Google J. The pectoralis minor and and and PubMed Scopus Google Scholar a or PM and leading to scapular (Fig. and scapular to C. J. of pectoralis minor and scapular at Ther. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar with a PM scapular more to as scapulothoracic K.H. C. Outcome of pectoralis minor release and for the management of scapulothoracic Surg. Full Text Full Text PDF PubMed Scopus Google Scholar as scapular and of the compared with (Fig. The of versus pectoralis minor on scapular kinematics in Orthop Ther. PubMed Scopus Google Scholar The of scapular the of to scapulothoracic as the J.B. of the of the Orthop PubMed Scopus Google Scholar, of scapular kinematics dynamic in Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, of the in the scapular scapular and Bone Joint Surg Am. PubMed Scopus Google Scholar, in Google Scholar in and scapular the The role of the in J PubMed Scopus Google Scholar This pathologic cascade is and for overhead who as a a more protracted scapular and PM in A. C. A. with and the of PubMed Scopus Google Scholar, for and R. 2010; PubMed Scopus Google Scholar, A.M. of scapulothoracic and in J 2010; 44: PubMed Scopus (70) Google Scholar, A. scapular in overhead Ther. 2013; Full Text Full Text PDF PubMed Scopus Google Scholar, J.B. R. scapular in overhead PubMed Scopus Google Scholar et The of pathology The scapular the and Full Text Full Text PDF PubMed Scopus Google Scholar syndrome as causing anterior in overhead the with and of the de van The an of the pectoralis minor J PubMed Scopus Google Scholar This is to and is often in in repetitive overhead PM and with anterior decreases the volume of the retropectoralis minor A. for Surg Google Scholar the brachial plexus to the and upper the volume leads to compression of the and and is overhead of the PM scapulothoracic retropectoralis minor volume and creating brachial plexus compression in R.J. Annest S.J. minor syndrome: brachial plexus 2017; PubMed Scopus Google Scholar additional pathology from this cascade is suprascapular nerve and resultant at the suprascapular (Fig. The and management of suprascapular Am Acad Orthop Surg. Google diagnosis and 40: PubMed Scopus Google Scholar of the with symptoms of and at the of the by overhead activity and of the and suprascapular nerve and Surg. Full Text Full Text PDF PubMed Scopus Google Scholar NTOS is with patients symptoms and often as open brachial plexus and first rib with of A. for Surg Google A. C. E. diagnosis the of an with upper PubMed Scopus Google Scholar first between NTOS and on thoracic outlet anatomy and scapulothoracic as the creating compression in the retropectoralis minor is the of compression in the supraclavicular thoracic outlet at the scalene and/or costoclavicular is to are or sites of compression is by this of anatomy first in patients with The symptoms and of NTOS are (Table PM contracture and scapulothoracic to symptoms and activity of and Thoracic anterior upper scapular dyskinesia and to with additional the and upper over scapular dyskinesia compared to from as suprascapular nerve periscapular and over scapular dyskinesia with at and/or of additional over supraclavicular and additional and over supraclavicular in a new In to leading to patients VTOS with symptoms and sites of (Table the scalene the first rib compression is on the subclavian in the costoclavicular and the subclavian in the scalene (Fig. M. thoracic outlet syndrome: approach to diagnosis and treatment with on 2014; PubMed Scopus Google Scholar the subclavian is anterior to the subclavian and dynamic compression in the costoclavicular between the clavicle and first is VTOS is more common R. thoracic outlet 2015; PubMed Scopus Google M. thoracic outlet Surg. Full Text Full Text PDF PubMed Scopus Google Scholar in extremity, or and with advanced cases or thoracic outlet J Surg. 27: PubMed Scopus (63) Google Scholar is in with and upper for a of subclavian compression in the costoclavicular leading to repetitive comprehensive review of syndrome.J Vasc Surg. 2010; Full Text Full Text PDF PubMed Scopus Google Scholar The of as the of and in from J.E. and thoracic outlet syndrome: to from the Joint on of the and 2004; PubMed Scopus Google Scholar with to thoracic outlet as and and R.J. Rao N.M. of thoracic outlet syndrome.J Vasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, M. A. et al.Thoracic outlet syndrome: have as for the J PubMed Google Scholar, of of in thoracic outlet J Surg. 2006; PubMed Scopus Google Scholar In were and J. et of thoracic outlet syndrome Google Scholar The physical for are and a over the PM at the R.J. Annest S.J. minor syndrome: brachial plexus 2017; PubMed Scopus Google M. M. et of the pectoralis minor compression syndrome in patients for thoracic outlet syndrome.Ann Vasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar and symptoms are often by the the in and of to through compression of the brachial plexus between the PM and thoracic R.J. Rao N.M. of thoracic outlet syndrome.J Vasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar PM (Fig. from the of the to the of the rib at the and compared with the of pectoralis minor and Orthop Ther. PubMed Scopus Google Scholar alternate etiologies as alternate and and as the clavicle or as J. The of in thoracic outlet syndrome.J Vasc Surg. 2013; 57: Full Text Full Text PDF PubMed Scopus (70) Google R. of the clavicle and thoracic outlet syndrome.J PubMed Scopus Google as in an 2013; PubMed Scopus Google Scholar or as (Fig. or alternate of the brachial plexus sites of nerve or or pathology the plexus as or nerve J. J. 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