الفهرس 
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Abstract
Thoracic outlet is a Sp<JlR’: ~een the rib cage (thorax), and the
collar bone (clavicle) through which the main blood vessels and nerves
pass from the neck and thorax into the arm. The nerves and blood vessels
leave the neck between the two muscles, scalenus anticus and medius,
Thoracic outlet syndrome ) consists of symptoms that affect
the neck, shoulder & upper ii\Xtrem:, caused by compression or irritation
of the brachial plexus, subcluvian 1” & subclavian artery,
, I
A variety of terms have been used to describe this syndrome; first
rib syndrome, costaclavicular syndrome, shoulder hand syndrome &
scalenus anticus syndrome, The syndrome develops because of
abnormalities of the first rib, th~ scalenus anticus, the clavicle or a
cervical rib.
Pain and paraesthesia are commonly present due to nerve
compression, ederna and venous distention due to vein compression and
less commonly weakness and coldness of upper limb due to arterial
compression.
Careful history &. thorough examination arc imlXlrtant components
in establishing diagnosis of thoracic outlet syndrome: Plain x-ray may
show the cervical rib. also nerve conduction studies, CT & Doppler
ultrasonogaphy may help in diagnosis,
The treatment of thoracic outlet syndrome is either conservative or
surgical. The conservative program should be persuaded for as.long as it
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seems effectivl; & as long a’S the patient Cart tolerate symptoms. The
surgical treatment is considered if the pa ent has unacceptable symptoms
after adequate conservative t~tJnl,’Hlt- ,
The surgical approach depends . the cause. Cervical ribs, either
complete or fibrous and first rib shoul . be excised. Additional bands in
the scalenus medius are divided, If IV) obvious cause of compression is
found, division of the scalenus apteriof tt its insertion (scalenotomy) has
been widely practised in the past;.Ho~(:r definite evidence of vascular
or neurological thoracic outlet obstruction in the absence of a cervical rib
or fibrous band is now treated by excision of the first rib. tf’tnerc is
evidence of arterial damage such es !l significant post-stenotic dilatation
or an aneurysm of the subclavian artery, that section of the artery is
excised and replaced with a short length of vein or u prosthetic graft such
a s pol ytetrafl uoroethy lene,
Several approaches have been described to remove the first rib as
posterior pamscapular, transaxillay, supraclavicular mfraclavicular,
transthoracic, and through the bed of the resected clavicle. Also
scalenectomy and combined upproaches arc used.
Wher: an operation is performed for arterial obstruction. with a
dearly established diagnosis the results are excellent. If neurological
compression at the thoracic outlet has been diagnosed without doubt,
surgical relief of the obstruction will also produce a good outcome, If
there is muscle wasting of the small muscles of the hand recovery will be
slow; if this is long standing it is unlikely to improve, although. sensory
symptoms and pain are relieved immediately.