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Abstract Thoracic outlet is a tight anatomical space containing the neurovascular bundle supplying the upper limb involving the subclavian artery, vein and the brachial plexus. There are three narrow anatomical parts of the outlet which are scalene triangle, costoclavicular triangle, and the subcoracoid space. Though the subclavian vein is passing anterior to the scalenus anterior (outside the scalene triangle) it could be entrapped in the remaining other two narrow spaces which are the costoclavicular and subcoracoid triangles. The actual pathogenesis of the thoracic outlet syndrome is the result of the repetitive or continuous compression inflected upon the neurovascular structures, resulting from the narrow one or more narrow spaces mentioned before to give the picture of one or more of the following types of thoracic outlet syndrome: 1) Neurologic thoracic outlet syndrome. 2) Arterial thoracic outlet syndrome. 3) Venous thoracic outlet syndrome. 4) Disputed (non specific) thoracic outlet syndrome. The diagnosis of the thoracic outlet syndrome is based on: 1) Careful history taking: (trauma, similar diseases ...etc) 2) Complete Neurological and vascular examination. A number of provocative maneuvers have been proposed for the clinical diagnosis of thoracic outlet syndrome. All tests make use of movements that restrict the space through which the neurovascular bundle pass, these involve: 158 Summary and Conclusion *Morley test. *wrist-fit test. *Adson test. *Roos test. *Halsted tests. 3) Proper investigations involving: A – Lab studies. To exclude systemic diseases. B – Radiological studies: (plain X-rays., U/S, CT exam., MRI.) C – Neurophysiologic studies. (EMG, NCV, ..etc) D – Angiographic studies. The thoracic outlet syndrome is considered as highly controversial presenting disease which is misdiagnosed with various other differential conditions :( Cervical radiculopathy, Peripheral nerve compression …etc). The treatment of the thoracic outlet syndrome is mainly a conservative one, where it is considered as the mainstay of the management, these involving: (weight reduction, pain and edema control, education program, postural correction, physiotherapy ...etc). The scalene muscle block is used as a diagnostic maneuver as well as therapeutic one, where the scalenus anterior is paralyzed through intra muscular Botox injection. The surgery for the thoracic outlet syndrome is indicated where Failure of a carefully supervised exercise and postural program, Intractable resistant pain, Significant neurological deficit, Impending vascular catastrophe, could occur. 159 Summary and Conclusion The surgical maneuvers are applied to decompress the entrapped neurovascular bundle through: Scalenectomy, 1st rib resection, removal of a fibrous band, brachial plexus neurolysis, and vascular reconstruction. The surgical approaches are: *Transaxillary approach, *supraclavicular approach, *infraclavicular approach, *Paraclavicular approach, * Posterior subscapular approach, The transaxillary approach is favored by most surgeons, where it gives good exposure to the first rib through a hidden plastic incision. The supraclavicular approach is applied to give sufficient view of the brachial plexus, the two scalene muscles, and even the first rib with satisfactory access to the vascular elements. The infraclavicular approach allows adequate exposure of the subclavian vein and the costoclavicular space. The Paraclavicular Approach is a combination of supra and infraclavicular approaches. The posterior subscapular approach gives good view of brachial plexus and first rib. 160 Summary and Conclusion The endoscopic surgery is a new era of thoracic outlet syndrome treatment; there are two main applicable maneuvers: 1. Port access first rib resection, 2. Endoscopic assessed transaxillary first rib resection. The surgery for thoracic outlet syndrome may result in some complications which may be intra, or post operative complications involving: 1. Pneumothorax. 2. Vascular complications. 3. Nervous complications. 4. Decompression failure. The urgent interventional procedures are applied to deal with the urgent vascular problems. These maneuvers include: 1. Arterial procedures; It consists of decompression and repair of the arterial lesion, and management of the associated ischemic problems of the extremity. 2. Venous procedures: With the ordinary operative decompression, surgeon could do transcatheter thrombolytic therapy; Balloon angioplasty and stenting are added in cases of residual stricture. |