Case 8391

A case report of thoracic outlet

syndrome (TOS)
Published on 08.06.2010

DOI: 10.1594/EURORAD/CASE.8391
ISSN: 1563-4086
Section: Chest imaging
Case Type: Anatomy and Functional Imaging
Authors: Sabato M, Puccini I, Lauretti D, Perrone E, Gori
G, Bulleri A, Caramella D, Bartolozzi C
Patient: 67 years, female

Clinical History:

A 67-year-old woman with left hemithorax paresthaesia with irradiation to her left arm.
Imaging Findings:

A 67-year-old woman presented at our medical department with left hemithorax paresthaesia with irradiation to her
left arm. She had no history of trauma.
She was admitted to the clinical department with rheumatologic disorder.
A Chest RX was performed for evaluation of pulmonary involvement that has suggested the presence of an
accessory left rib (Fig. 1).
Computed Tomography was performed to characterize the parenchymal findings, demonstrating an anomalous
origin of the first left rib, which began from the fusion of C7 and T1 (Fig.2).
The combination of radiological and clinical findings suggested thoracic outlet syndrome (TOS).
Discussion:

The term thoracic outlet syndrome (TOS) indicates compression of one or several of the neurovascular structures
crossing the thoracic outlet. Thoracic outlet is bounded by the first thoracic vertebra, the superior border of the
manubrium sterni anteriorly, and the first rib and costal cartilage laterally. The structures passing through this area
and into the upper limb are the subclavian artery and vein, and the nervous structures of the brachial plexus.
The most common age range for this syndrome is 20–40 years, with a female-to-male ratio of 4:1. Potential causes
of TOS are a cervical rib, abnormal ligamentous tissue and hypertrophy of the scalenus anterior muscle, as well as
postural effects that interfere with the normal relationship between the first rib and those structures overlying it.
Five syndromes involving the thoracic outlet are described:
1. Arterial, due to a well formed cervical rib or to an abnormal first rib.
2. Neurological, related to the fibrous band associated with a rudimentary cervical rib or a giant transverse process
of C7.
3. Venous—‘effort thrombosis’.
4. Late post-traumatic, secondary to a fracture of the clavicle.
5. The syndrome previously called ‘scalenus anticus syndrome’, being due to either trauma, or hypotonic shoulder
muscles.
TOS can present with symptoms and signs of any of these. 90% of the patients present with neurological symptoms
— pain, paraesthaesia, arm and hand weakness — and 10% also have vascular problems. The most frequent
vascular presentation is Raynaud’s phenomenon, or less clearly defined symptoms of coldness, cyanosis and
swelling of the hands, possibly resulting from irritation of sympathetic fibres in the subclavian bundle.
Diagnosis of TOS is clinically based. Imaging may be helpful in informing the clinician as to the anatomic structures
undergoing compression, the location of that compression, and the anatomic structures responsible for it.
Radiographs may demonstrate predisposing bone abnormalities (elongated C7 transverse process, cervical rib). In
the case of neurogenic or neurovascular symptoms, MR imaging has proved useful, especially in demonstrating
brachial plexus compression and the existence of fibrous bands. CT with contrast medium and postural maneuvers
appears effective in demonstrating vascular compression by means of volume-rendered images, which allow
analysis of the relations with bony structures. Colour duplex sonographic examination and B-mode scanning is a
valuable supplementary imaging when the results of the latter prove negative.
A conservative approach is the rule in the initial treatment of neurogenic TOS. Therapeutic efforts are focused on
relaxing the scalene muscles and strengthening the postural muscles through physical therapy, hydrotherapy and
massage. Pain medication, nonsteroidal anti-inflammatory agents, and muscle relaxants are often useful adjuncts in
treatment. The initial treatment of arterial TOS is focused on revascularization in order to remedy acute ischemia if
necessary. Treatment of effort thrombosis generally involves contrast venography and catheter-directed thrombolytic
therapy.
First rib resection via a supraclavicular approach represents the predominant surgical treatment strategy, but some
teams have recently adopted a highly selective approach in which supraclavicular scalenectomy is the principal
surgical strategy and first-rib resection is reserved solely for vascular forms of TOS.
Differential Diagnosis List: Thoracic outlet syndrome (TOS)

Final Diagnosis: Thoracic outlet syndrome (TOS)

References:

Cooke RA (2003) Thoracic outlet syndrome—aspects of diagnosis in the differential diagnosis of handarm vibration
syndrome. Occupational Medicine 53:331-6 (PMID: 12890833)
Bilbey JH, Müller NL, Connell DG, Luoma AA, Nelems B (1989) Thoracic Outlet Syndrome: Evaluation with CT.
Radiology 171:381-4 (PMID: 2704801)
Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A (2006) Imaging Assessment of Thoracic
Outlet Syndrome. Radiographics 26:1735-50 (PMID: 17102047)
Figure 1
a

Description: 3D reconstructions show the anomalous origin of the first rib, which begins from the
fusion of C7-T1. Origin:
b

Description: 3D reconstructions show the anomalous origin of the first rib, which begins from the
fusion of C7-T1. Origin:
c

Description: 3D reconstructions show the anomalous origin of the first rib, which begins from the
fusion of C7-T1. Origin:
d

Description: 3D reconstructions show the anomalous origin of the first rib, which begins from the
fusion of C7-T1. Origin:
Figure 2
a

Description: Chest RX suggested the presence of an accessory left rib. Origin: