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23 Cards in this Set

  • Front
  • Back
What are the three types of thoracic outlet syndrome?
Three type of thoracic outlet syndrome:

1. neurogenic 95%
2. venous
3. arterial
Which nerve roots form the brachial plexus?
Nerve roots of the brachial plexus are C5-T1.
What are the contents of the thoracic outlet from medial to lateral?
Contents of the thoracic outlet:

Subclavian vein
anterior scalene muscle
subclavian artery
brachial plexus
middle scalene muscle
What nerve lies in front of anterior scalene? What are its nerve roots? What is its course of travel? What occurs with injury to this nerve?
The phrenic nerve (C3, C4, C5) lies in front of the anterior scalene traveling lateral to medial. Injury of the phrenic nerve causes paralysis of the ipsilateral hemidiaphragm.
What nerves travel through the belly of the middle scalene muscle? What are its nerve roots? What occurs with injury to this nerve?
The long thoracic nerve (C5,C6,C7) travels through the belly of the middle scalene muscle. Injury to the long thoracic nerve results in a winged scapula.
What is the most common muscular variation of the thoracic outlet?
The most common muscular variation of the thoracic outlet is the presence of a scalene minimus muscle.
What is Sibson's fascia?
SIbson's fascia is a fascial band that extends from the posterior surface of the anterior scalene to the pleural dome of the liver.
What are the two major histopathologic features of the anterior scalene associated with nTOS?
Histopathologic changes of the anterior scalene muscle associated with nTOS:

1. predominance of Type I (slow-twitch) fibers (78% instead of 50%)
2. endomysial fibrosis
What test must be performed during physical examination for nTOS? How is it performed?
A 3-minute elevated arm stress test (EAST) should be performed. Patient holds arms in the surrender position while opening and closing hands. Patient's typical symptoms occur after 30-60 seconds.
Describe patient positioning and preparation for transaxillary 1st rib resection.
Under general anesthesia, the patient is positioned supine with the back of the table raised about 30 degrees. A small towel pack is placed behind the shoulder to elevate the affected side. The arm is prepared circumferentially and wrapped in a stockinette, and the sterile field includes the neck, upper part of the chest, and posterior aspect of the shoulder to the scapula. The arm is not placed on a table or crossbar; rather, it is held and positioned by a reliable, flexible, and sturdy assistant
Discuss the incision made for transaxillary first rib resection.
A transverse skin incision is made at the lower border of the axillary hairline and extended from the anterior border of the latissimus dorsi to the lateral edge of the pectoralis major
What are the two most common injuries associated with surgery for TOS?
Two most common morbidities of surgery for TOS:

1. phrenic nerve palsy
2. Lymph leakage
What are the most common abnormalities associated with aTOS?
Anomalies associated with aTOS:

1. cervical rib 63%
2. anomalous first rib 22%
3. fibrocartilaginous band 10%
4. clavicle fracture 4%
5. enlarged C7 transverse process 1%
What are the presenting signs and symptoms of aTOS?
Presenting s/sx of aTOS:

hand ischemia
unilateral Raynaud's phenomenon
unilateral exertional arm pain
Describe the staging system for arterial TOS?
Sher Stage Arterial Complication Treatment

0: Asymptomatic subclavian artery compression. No treatment indicated

I: Stenosis of the subclavian artery with minor post-stenotic dilation. No intimal disruption. Decompression of the thoracic outlet

II: Subclavian artery aneurysm with intimal damage and mural thrombus . Decompression of the thoracic outlet with subclavian artery reconstruction

III: Distal embolization from subclavian artery pathology. Thrombolysis or thromboembolectomy. Decompression of the thoracic outlet with vascular reconstruction
What are the presenting signs and symptoms of vTOS? Venous TOS is also called ________.
Presenting s/sx of vTOS:

upper extremity edema (nonpitting) 93%
pain 66%
cyanosis 77%


VTOS is also called Paget-von Schroetter syndrome.
Arterial TOS is commonly preceded by _________. Venous TOS is commonly associated with __________.
Arterial TOS is commonly preceded by neck trauma ( MVA, clavicular fracture)

vTOS is commonly associated with repetitive motion oin a young healthy individual.
What are the two most severe complications of vTOS?
The two most severe potential complications of subclavian-axillary vein thrombosis are pulmonary embolism and upper extremity phlegmasia cerulea dolens (venous gangrene).
What modalities are used to diagnosis vTOS?
Modailities used to diagnose vTOS:

Duplex U/S
CTV
MRV
Venography
When diagnosing and treating vTOS which arm vein should be accessed? Why?
The basilic vein is percutaneously punctured under ultrasound guidance. Cephalic vein access will often result in an incomplete diagnostic study because the cephalic vein often drains directly into the subclavian vein, thereby bypassing the axillary vein.
What is the first step in the treatment of vTOS?
The first step in the treatment of vTOS is thrombolysis, maybe chemical (tPA, urokinase) or mechanical (angiojet, trellis).
What are the most common causes of secondary subclavian vein thrombosis ?
The most common causes of secondary subclavian vein thrombosis are catheter-induced thrombosis, cancer, and congestive heart failure.
What are the rick factors for upper extremity DVT?
Risk factors for upper extremity DVT:

Catheter-insertion
Cancer
CHF
obesity with BMI > 30
arm immobilization
OCP
family history of DVT
hypercoagulable state