Download PDF
Zentralbl Chir 2017; 142(01): 104-112
DOI: 10.1055/s-0042-121611
Übersicht – Thoraxchirurgie
Georg Thieme Verlag KG Stuttgart · New York

Thoracic-Outlet-Syndrom

Thoracic Outlet Syndrome
Sven Seifert
Klinik für Thorax-, Gefäß- und endovaskuläre Chirurgie, Klinikum Chemnitz gGmbH, Deutschland
,
Pavel Sebesta
Klinik für Thorax-, Gefäß- und endovaskuläre Chirurgie, Klinikum Chemnitz gGmbH, Deutschland
,
Marian Klenske
Klinik für Thorax-, Gefäß- und endovaskuläre Chirurgie, Klinikum Chemnitz gGmbH, Deutschland
,
Mirko Esche
Klinik für Thorax-, Gefäß- und endovaskuläre Chirurgie, Klinikum Chemnitz gGmbH, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
16 March 2017 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Einleitung Das Thoracic-Outlet-Syndrom (TOS) gehört zu den am längsten und intensivsten diskutierten Diagnosen. Es existiert kein einheitliches Erkrankungsbild und keine klare Definition. Das TOS vereint eine Vielzahl von Symptomen und Beschwerden, die ihre Ursache in einer Kompression vaskulärer oder nervaler Strukturen in einer der 3 Engen der oberen Thoraxapertur haben.

Methoden Anhand einer umfangreichen Literaturrecherche werden Ätiologie, Epidemiologie, Diagnostik, Möglichkeiten und Ergebnisse der chirurgischen Therapie dargestellt.

Ergebnisse Das TOS wird aktuell in 3 Hauptformen unterschieden: das vaskuläre TOS (vasTOS) mit einem arteriellen (aTOS) und einem venösen TOS (vTOS), das neurologische TOS (nTOS), welches sich in ein typisches (nTOS) und in ein atypisches (disTOS) unterteilt, und eine Mischform von vaskulärem und neurogenem TOS (nvasTOS). Die Diagnostik ist umfangreich und schwierig, da bis zu 90 % aller Patienten einem atypischen (disTOS) zugeordnet werden müssen. Neben dem Versuch einer konservativen Therapie des nTOS stehen zur Dekompression der neurovaskulären Strukturen chirurgische Therapieverfahren mit einer signifikanten primären Verbesserung der Beschwerden in bis zu 92 % der Fälle zur Verfügung. Der supraklavikuläre und der transaxilläre Zugangsweg sind die am häufigsten verwendeten. Langfristig profitieren 50–80 % der Patienten von einer operativen Therapie. Die Raten an vaskulären oder neurologischen Komplikationen in Zentren liegen dabei bei 0–2 %, Minorkomplikationen wie Pneumothorax, Nachblutung und Lymphfisteln werden in bis zu 25 % der Fälle beobachtet.

Zusammenfassung Die meisten Patienten profitieren unabhängig von der Form des TOS von einer chirurgischen Therapie. Entscheidend für einen Therapieerfolg sind neben Dauer der Symptomatik und sozioökonomischen Faktoren vor allem eine dezidierte Diagnostik und die Wahl eines adäquaten operativen Verfahrens durch erfahrene Zentren.

Abstract

Introduction Thoracic outlet syndrome (TOS) is one of the most extensively discussed diagnoses. There is neither a clear and homogenous clinical presentation nor an accepted definition. The term describes a complex of symptoms and complaints caused by the compression of nerves and vascular structures at one of the three defined constrictions of the upper thoracic aperture.

Methods Based on a comprehensive literature review, this article presents the etiology, epidemiology and clinical diagnostics as well as the possibilities and outcomes of surgical treatment.

Results The thoracic outlet syndrome is currently subdivided into three main forms: vascular TOS (vasTOS) including arterial TOS (aTOS) and venous TOS (vTOS), neurogenic TOS (nTOS), which is further subdivided into typical (nTOS) and atypical TOS (disTOS), and a mixed form of nTOS and vasTOS (nvasTOS). The diagnosis is complex and difficult since the disTOS group comprises over 90 % of all patients. In addition to conservative treatment attempts, nTOS may be treated by surgical procedures focusing on the decompression of neurovascular structures. A significant improvement after surgery was found in up to 92 % of cases. The most common access sites are supraclavicular and transaxillary. 50 to 80 % of patients benefit from surgery in the long run. The rates of vascular or neurological complications reported by specialised centres are 0 to 2 %; minor complications such as pneumothorax, bleeding and lymphatic fistula are reported in up to 25 % of cases.

Summary Most patients suffering from any form of TOS benefit from surgical treatment. Duration of symptoms, socioeconomic factors and, most notably, stringent diagnostic workup and an adequate operative procedure performed by an experienced centre are crucial to success.

Schlüsselwörter

TOS - Thoracic-Outlet-Syndrom - nTOS - aTOS - vTOS - disTOS

Key words

TOS - nTOS - aTOS - vTOS - disTOS - thoracic outlet syndrome
 

  • Literatur

  • 1 Gruß JD. Das Thoracic-outlet-Syndrom. Gefässchirurgie 2006; 11: 371-380
    CrossrefPubMedGoogle Scholar
  • 2 Bürger T, Gebauer T, Baumbach H. et al. Das vaskuläre Thoracic-outlet-Syndrom. Gefässchirurgie 2013; 18: 184-195
    CrossrefPubMedGoogle Scholar
  • 3 Mayo H. Exostosis of the first rib with strong pulsations of the subclavian artery. Lon Med Phys J 1835; 11: 40
    PubMedGoogle Scholar
  • 4 Willshire WH. Refered to clinical records: Supernumary first rib. Lancet 1860; 2: 633
    PubMedGoogle Scholar
  • 5 Coote H. Exostosis of the left transverse process of the seventh cervical vertebera, surrounded by blood vessels and nerves, successful removal. Lancet 1861; 1: 360-361
    PubMedGoogle Scholar
  • 6 Gruber W. Über die Halsrippen des Menschen mit vergleichenden anatomischen Bemerkungen. VII. Mém Acad Imp Sc St. Petersburg 1869; 12.
    PubMedGoogle Scholar
  • 7 Cooper A, Travers B. On Exostosis. In: Cooper A, Travers B. eds. Surgical Essays. London: Cox and Son, Longman, Hunt, Rees, London Constrable, Edinburgh, Smith and Son, Glasgow, Hodges and McArthur Dublin; 1817: 21-24
    Google Scholar
  • 8 Nafziger HC, Grant WT. Neuritis of the brachial plexus mechanical in origin. Surg Gynecol Obstet 1938; 67: 722-730
    PubMedGoogle Scholar
  • 9 Ochsner A, Gage M, DeBakey M. Scalenus anterior (Nafziger) syndrome. Am J Surg 1935; 28: 695-699
    PubMedGoogle Scholar
  • 10 Falconer MA, Weddel G. Costoclavicular compression of the subclavian artery and vein: relation to scalenus anticus syndrome. Lancet 1943; 242: 539-543
    CrossrefPubMedGoogle Scholar
  • 11 Peet RM, Hendriksen JD, Anderson TP. et al. Thoracic outlet syndrome: evaluation of a therapeutic exercise program. Proc Staff Meet Mayo Clin 1956; 31: 281-287
    PubMedGoogle Scholar
  • 12 Junoven T, Satta J, Laitala P. et al. Abnormalities at the thoracic outlet are frequent in the general population. Am J Surg 1995; 170: 33-37
    CrossrefPubMedGoogle Scholar
  • 13 Edwards DP, Mulkern E, Raja AN. et al. Trans-axillary first rib excision for thoracic outlet syndrome. J R Coll Surg Edinb 1999; 44: 362-365
    PubMedGoogle Scholar
  • 14 Eckstein HH. Kompressionssyndrome der oberen Thoraxapertur. Gefässchirurgie 2013; 18: 175-176
    CrossrefPubMedGoogle Scholar
  • 15 Wilbourn AJ. Thoracic outlet syndrome is overdiagnosed. Arch Neurol 1990; 47: 323-330
    PubMedGoogle Scholar
  • 16 Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12: 295-309
    PubMedGoogle Scholar
  • 17 Urschel jr. HC, Razzuk MA. Neurovascular compression in the thoracic outlet syndrome: changing management over 50 years. Ann Surg 1998; 228: 609-617
    CrossrefPubMedGoogle Scholar
  • 18 Czihal M, Banafsche R, Hoffmann U. et al. Vascular compression syndromes. Vasa 2015; 44: 419-434
    CrossrefPubMedGoogle Scholar
  • 19 Leonhard V, Smith R, Caldwell G. et al. Anatomical variations in the brachial plexus roots: implications for diagnosis of neurogenic thoracic outlet syndrome. Ann Anat 2016; 206: 21-26
    CrossrefPubMedGoogle Scholar
  • 20 Demos NJ, Rubenstein H, Restivo sr. C. Role of scalenotomy for relief of positional vertebra-basilar ischemia. J Med Soc N J 1980; 6: 419-422
    PubMedGoogle Scholar
  • 21 Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery 2004; 55: 897-902
    CrossrefPubMedGoogle Scholar
  • 22 Sadeghi-Azandaryani M, Bürklein D, Ozimek A. et al. Thoracic outlet syndrome: do we have clinical tests as predictors for the outcome after surgery?. Eur J Med Res 2009; 14: 443-446
    CrossrefPubMedGoogle Scholar
  • 23 Degeorges R, Reynaud C, Becquemin JP. Thoracic outlet syndrome surgery: long-term functional results. Ann Vasc Surg 2004; 18: 558-565
    CrossrefPubMedGoogle Scholar
  • 24 Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg 2007; 46: 601-604
    CrossrefPubMedGoogle Scholar
  • 25 Plewa MC, Delinger M. The false positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med 1998; 5: 337-342
    CrossrefPubMedGoogle Scholar
  • 26 Cornelis F, Zuazo I, Bonnefoy O. et al. Diagnosis of thoracic outlet syndrome. Value of angiography in the sitting position. J Radiol 2008; 89: 47-52
    CrossrefPubMedGoogle Scholar
  • 27 Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010; 51: 1538-1547
    CrossrefPubMedGoogle Scholar
  • 28 Sajid MS, Ahmed N, Desai M. et al. Upper limb deep vein thrombosis: a literature review to streamline the protocol for management. Acta Haematol 2007; 118: 10-18
    CrossrefPubMedGoogle Scholar
  • 29 König RW, Pedro MT, Kapapa T. et al. Neurogenes Thoracic-outlet-Syndrom (nTOS). Gefässchirurgie 2013; 18: 201-205
    CrossrefPubMedGoogle Scholar
  • 30 Ozoa G, Alves D, Fish DE. Thoracic outlet syndrome. Phys Med Rehabil Clin N Am 2011; 22: 473-483
    CrossrefPubMedGoogle Scholar
  • 31 Brooke BS. Conservative management of chronic upper extremity venous outflow occlusion. Phlebology 2016; 31 (01) Suppl. S34-S40
    PubMedGoogle Scholar
  • 32 Thompson JF, Winterborn RJ, Bays S. et al. Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol 2011; 34: 903-910
    CrossrefPubMedGoogle Scholar
  • 33 Luoma A, Nelems B. Thoracic outlet syndrome. Thoracic surgery perspective. Neurosurg Clin N Am 1991; 2: 187-226
    PubMedGoogle Scholar
  • 34 Glynn RW, Tawfick W, Elsafty Z. et al. Supraclavicular scalenectomy for thoracic outlet syndrome-functional outcomes using the DASH scoring system. Vasc Endovascular Surg 2012; 46: 157-162
    CrossrefPubMedGoogle Scholar
  • 35 Kara HV, Balderson SS, Tong BC. et al. Video assisted transaxillary first rib resection in treatment of thoracic outlet syndrome (TOS). Ann Cardiothorac Surg 2016; 5: 67-69
    PubMedGoogle Scholar
  • 36 Sanders RJ, Annest SJ. Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome. J Vasc Surg 2015; 61: 821-825
    CrossrefPubMedGoogle Scholar
  • 37 Hempel GK, Rusher jr. AH, Wheeler CG. et al. Supraclavicular resection of the first rib for thoracic outlet syndrome. Am J Surg 1981; 141: 213-215
    CrossrefPubMedGoogle Scholar
  • 38 Siracuse JJ, Johnston PC, Jones DW. et al. Infraclavicular first rib resection for the treatment of acute venous thoracic outlet syndrome. J Vasc Surg Venous Lymphat Disord 2015; 3: 397-400
    PubMedGoogle Scholar
  • 39 Kline DG, Kott J, Bames G. et al. Exploration of selected brachial plexus lesions by the posterior subscapular approach. J Neurosurg 1978; 49: 872-880
    CrossrefPubMedGoogle Scholar
  • 40 Loscertales J, Congregado M, Jiménez Merchán R. First rib resection using videothorascopy for the treatment of thoracic outlet syndrome. Arch Bronconeumol 2011; 47: 204-207
    PubMedGoogle Scholar
  • 41 Neville RF, Gharagozloo F, Meyer M. et al. Robotic thoracoscopic first rib resection and scalenectomy for treatment of Paget-Schroetter syndrome. J Vasc Surg 2011; 54: 1854-1855
    PubMedGoogle Scholar
  • 42 Gharagozloo F, Meyer M, Tempesta BJ. et al. Robotic first rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results. Innovations (Phila) 2012; 7: 39-44
    CrossrefPubMedGoogle Scholar
  • 43 Terzis JK, Kokkalis ZT. Supraclavicular approach for thoracic outlet syndrome. Hand 2010; 5: 326-337
    CrossrefPubMedGoogle Scholar
  • 44 Johnston PC, Conte MS, Eichler CM. et al. Infraclavicular first rib resection for focused and effective treatment of venous thoracic outlet syndrome. J Vasc Surg 2010; 52: 525-526
    PubMedGoogle Scholar
  • 45 Wishchuk JR, Dougherty CR. Therapy after thoracic outlet release. Hand Clin 2004; 20: 87-97
    CrossrefPubMedGoogle Scholar
  • 46 Caparelli DJ, Freischlag J. A unified approach to axillosubclavian venous thrombosis in a single hospital admission. Semin Vasc Surg 2005; 18: 153-157
    CrossrefPubMedGoogle Scholar
  • 47 Hixson KM, Horris HB, McLeod TC. et al. The diagnostic accuracy of clinical diagnostic tests for thoracic outlet syndrome. J Sport Rehabil 2016; DOI: 10.1123/jsr.2016-0051.
    CrossrefPubMedGoogle Scholar
  • 48 Hooper TL, Denton J, McGalliard MK. et al. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. J Man Manip Ther 2010; 18: 77-83
    PubMedGoogle Scholar
  • 49 Povlsen B, Hansson T, Povlsen SD. Treatment for thoracic outlet syndrome (review). Cochrane Database Syst Rev 2014; (11) CD007218
    PubMedGoogle Scholar
  • 50 Orlando MS, Likes KC, Mirza S. et al. A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. J Am Coll Surg 2015; 220: 934-939
    CrossrefPubMedGoogle Scholar
  • 51 Chang DC, Rotellini-Coltvet LA, Mukherjee D. et al. Surgical intervention for thoracic outlet syndrome improves patientʼs quality of life. J Vasc Surg 2009; 49: 630-637
    CrossrefPubMedGoogle Scholar
  • 52 Axelrod DA, Proctor MC, Geisser ME. et al. Outcomes after surgery for thoracic outlet syndrome. J Vasc Surg 2001; 33: 1220-1225
    CrossrefPubMedGoogle Scholar
  • 53 Balzer KM. Transaxilläre oder supraklavikuläre Dekompression bei Kompressionssyndromen der oberen Thoraxapertur?. Gefässchirurgie 2013; 18: 177-183
    CrossrefPubMedGoogle Scholar
  • 54 Mingoli A, Feldhaus RJ, Farina C. et al. Long-term outcome after transaxillary approach for thoracic outlet syndrome. Surgery 1995; 118: 840-844
    CrossrefPubMedGoogle Scholar
  • 55 Toso C, Robert J, Berney T. et al. Thoracic outlet syndrome: influence of personal history and surgical technique on long-term results. Eur J Cardiothorac Surg 1999; 16: 44-47
    CrossrefPubMedGoogle Scholar
  • 56 Urschel HC, Razzuk MA. Thoracic Outlet Syndrome. In: Sabiston E, Spencer F. eds. Surgery of the Chest. 5th ed.. Philadelphia: Elsevier; 1990: 536-553
    Google Scholar
  • 57 Han S, Yildirim E, Dural K. et al. Transaxillary approach in thoracic outlet syndrome, the importance of the resection of the first rib. Eur J Cardiothorac Surg 2003; 24: 428-433
    CrossrefPubMedGoogle Scholar
  • 58 Karamustafaoglu YA, Yoruk Y, Tarladacalisir T. et al. Transaxillary approach for thoracic outlet syndrome: results of surgery. Thorac Cardiovasc Surg 2011; 59: 349-352
    Article in Thieme ConnectPubMedGoogle Scholar
  • 59 Vögelin S, Haldemann L, Constantinescu MA. et al. Long-term outcome analysis of the supraclavicular surgical release for the treatment of thoracic outlet syndrome. Neurosurgery 2010; 66: 1085-1091 discussion 1091–1092
    CrossrefPubMedGoogle Scholar
  • 60 Yavuzer S, Atinkaya C, Tokat O. Clinical predictors of surgical outcome in patients with thoracic outlet syndrome operated on via transaxillary approach. Eur J Cardiothorac Surg 2004; 173-178
    PubMedGoogle Scholar
  • 61 Maxey TS, Reece TB, Ellman PI. et al. Safety and efficiency of the supraclavicular approach to thoracic outlet decompression. Ann Thorac Surg 2003; 76: 396-400
    CrossrefPubMedGoogle Scholar