=====Thoracic Outlet Syndrome=====

==== Thoracic outlet syndrome surgical management ====
William H. Pearce
Precourse Notes
https://www.assh.org/videos/precourse-5-surgical-management-of-thoracic-outlet-syndrome-38172?fs=true

====Anatomy====
  * shoulder - tripod on thorax
  * scalene muscles
  * vessels - fixed at posterior circumflex humeral and proximal subclavian
  * nerves - brachial plexus

====Pathoanatomy====
  * Cause: abnormal bony structure (cervical rib/clavicle fractures) vs normal structure in abnormal position (overhead positions - swimming/pitching)
  * Cervical rib: bony parts, fibrous, clavicular fractures
  * Site:
    * 3rd part of subclavian
    * or axillary - pect minor/ humeral head
    * posterior circumflex humeral artery

====Presentations====
  * splinter hemorrhages
  * arm claudication vs "fatigue"
  * digital gangrene/pain
  * raynaud's phenomenon - digital/ unilateral hand
  * neurogenic symptoms (30%) - true vs disputed
  * pulsatile neck mass

====Evaluation===
  * history: overuse/ direct trauma
  * physical
    - position of use
    - arterial exam

====Investigations====
  * need good imaging in correct position - {when to do CTA/3D Recon vs angiography?}
    * need proper angiogram in position of use

====Abnormal bony structures - principles of surgery====
  * decompression - remove aneurysm
  * reconstruction
  * peripheral emboli

====Surgery====
  * Prep: Ix: 3D recon with CTA
  * Access - supra and infra-clavicular incisions

====Pathoanatomy====
Normal structures in abnormal positions
  - first rib/ clavicle
  - scalene?
  - humeral head
  - quadrilateral space

Humeral head problems
  - mobilization
  - patch 
  - interposition
  - bypass

Quadrilateral space problem
  - between teres minor/ major/ two heads of triceps

====Summary====
  - unusual problems
  - flexible surgical approach
  - non-medical issues

febe
- shoulder - pect major nerve release
- ? triceps tight
- finger release

====Cases===
  - Female with shoulder and periscapular pain treated with botox and first rib excision: 
    * case: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966747/
    * transaxillary first rib excision: https://www.youtube.com/watch?v=4ADbPso_vyM

===See also====
https://wiki.nus.edu.sg/display/HS/Thoracic+Outlet+Syndrome