Anatomy of the Thoracic Outlet and Related Structures
Knowledge of anatomy is the key to understanding the thoracic outlet syndrome (TOS). By definition, TOS is hand and arm symptoms of pain, paresthesia, and weakness due to compression of the neurovascular bundle in the thoracic outlet area. While initially
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Anatomy of the Thoracic Outlet and Related Structures Richard J. Sanders
Abstract
Knowledge of anatomy is the key to understanding the thoracic outlet syndrome (TOS). By definition, TOS is hand and arm symptoms of pain, paresthesia, and weakness due to compression of the neurovascular bundle in the thoracic outlet area. While initially the scalene triangle was the focus of pathology in TOS, recent studies indicate that more than half of the patients thought to have TOS also have associated pectoralis minor compression, and in some patients this is the only diagnosis. Finally, it is important to recognize that the large majority of patients with anatomic abnormalities are asymptomatic unless neck trauma is also present – in other words, the mere presence of an abnormality does not mean it must be treated. Like many medical conditions, both an anatomic predisposition plus an environmental stressor are usually necessary for pathology to exist.
Introduction Knowledge of anatomy is the key to understanding the thoracic outlet syndrome (TOS). By definition, TOS is hand and arm symptoms of pain, paresthesia, and weakness due to compression of the neurovascular bundle in the thoracic outlet area. While initially the scalene triangle was the focus of pathology in TOS, recent studies indicate that more than half of the patients thought to have TOS also have associated pectoralis
minor compression, and in some patients this is the only diagnosis [1]. Finally, it is important to recognize that the large majority of patients with anatomic abnormalities are asymptomatic unless neck trauma is also present – in other words, the mere presence of an abnormality does not mean it must be treated. Like many medical conditions, both an anatomic predisposition plus an environmental stressor are usually necessary for pathology to exist.
Anatomical Spaces R.J. Sanders, MD Department of Surgery, HealthONE Presbyterian-St. Lukes Hospital, 4545 E. 9th Ave #240, Denver, CO 80220, USA e-mail: [email protected]
There are three anatomical spaces in the thoracic outlet area (Fig. 3.1a): The scalene triangle lying above the clavicle (Fig. 3.1b); the pectoralis minor
K.A. Illig et al. (eds.), Thoracic Outlet Syndrome, DOI 10.1007/978-1-4471-4366-6_3, © Springer-Verlag London 2013
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Middle scalene muscle
Scalene triangle Costoclavicular space
Anterior scalene muscle
Brachial plexus Phrenic nerve
Long thoracic nerve
a
Pectoralis minor space
b Subclavian artery and brachial plexus
Subclavian artery Clavicle
Subclavius muscle Costoclavicular ligament 1st rib
c
Anterior scalene muscle
Subclavian vein
Fig. 3.1 Three spaces. (a) Anatomy showing the three spaces. (b) Scalene triangle with phrenic nerve passing from lateral to medial as it crosses anterior scalene muscle and
long thoracic nerve exiting the middle scalene muscle. (c) Costoclavicular space (Reprinted from Sanders and Haug [2]. With permission from Lippincott Williams & Wilkins)
space, below the clavicle (Fig. 3.1c); and the costoclavicular space
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