Pathophysiology of Thoracic Outlet Syndrome

The thoracic outlet is a space that located within the lower part of the neck, start from above
and behind the clavicle and extending to the upper part of the arm. Thoracic outlet is formed by
clavicle, the first rib, the anterior and posterior scalene muscles, and the subclavius muscle that
located in costoclavicular space.[1] This region contain neurovascular bundle that consist of
subclavian vein, subclavian artery and brachial plexus. In thoracic outlet, the neurovascular bundle
pass through three regions or spaces.[1,2]

The first region is scalene triangle. It is bordered by the anterior scalene muscle, the middle
scalene muscle, and the upper border of the first rib. Trunk of the bracial plexus and subclavian
artery pass through this region. The interscalene triangle is the most common site for neural and
vascular compression that lead to thoracic outlet syndrome. The second space is the costoclavicular
triangle. This area is bordered by the clavicle, first rib, and scapula and contains the subclavian
artery and vein, and the brachial nerves. The third and final space, the subcoracoid space, is located
beneath the coracoid process just deep to the pectoralis minor tendon.[2,3]

Figure 1. Thoracic outlet anatomy and region[2]

In normal condition, those spaces must be kept free and broad in order to let the
neurovascular bundle pass through. But in some pathologic condition, thoracic outlet space may
get narrowed and caused compression of subclavian vein, subclavian artery and brachial plexus.
This compression will develop group of symptom and problem that called the thoracic outlet
syndrome (TOS).[4]

Figure 2. Thoracic Outlet Compression[2]

Changes of compression of thoracic outlet, regardless of the etiology will cause the
symptom of thoracic outlet syndrome.[4] As mentioned before, there are three types of thoracic
outlet syndrome. Neurogenic TOS is the most common type of TOS. Neurogenic TOS most
commonly is associated with a history of neck trauma. This type of TOS will happen when the
brachial flexus got compressed.[5]
Brachial flexus is a somatic nerve plexus formed by intercommunications among the
ventral rami (roots) of the lower 4 cervical nerves (C5-C8) and the first thoracic nerve (T1), and it
is responsible for the motor innervation of all of the muscles of the upper extremity, with the
exception of the trapezius and levator scapula.[6] Compression in this plexus will cause slight
wasting and weakness of the muscle that innervated by it, such as hypothenar, interosseous,
adductor pollicis, and deep flexor muscles of the fourth and fifth fingers. Weakness of the flexor
muscles of the forearm may be present in advanced cases. In addition, intermittent aching of the
arm, particularly of the ulnar side, and of numbness and tingling along the ulnar border of the
forearm and hand also commonly present. A loss of superficial sensation around the area where
pain manifested commonly occur in this case. Vascular features are often absent or minimal in
patients with the neurologic form of the syndrome.[7,8]

Arterial TOS often is associated with cervical ribs or a rudimentary first rib. This abnormal
anatomy leads to repeated compression of subclavian artery coinciding with arm movement. This
repetitive localized trauma leads to intimal lesions, focal arterial stenosis, poststenotic dilatation,
aneurysmal change, and subsequent thromboembolic complications.[9] This condition will results
in ischemia of the limb, may be complicated by digital gangrene and retrograde embolization in
some rare cases.[7,9]

Venous TOS usually results from compression of the subclavian vein by the subclavius
and the costoclavicular ligament. Abnormal anatomy structure and extreme injury or activity have
big role in causing venous TOS.[10] Vascular TOS, especially venous TOS is most often seen in
patients who engage in repetitive motions that place the shoulder at the extreme of abduction and
external rotation. Compression or spontaneous thrombosis of the subclavian vein commonly will
cause a dusky discoloration, venous distention, and edema of the arm. The vein may become
thrombosed after prolonged exercise or in cases of a clotting diathesis in cancer patients.[7,10]
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5. Eskandari M, Yao JT. Thoracic Outlet Obstruction. Medscape. 2016
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thoracic outlet syndrome. Am Surg. 2009 Mar. 75(3):235-9
10. Kemp CD, Rushing GD, Rodic N, McCarthy E, Yang SC. Thoracic outlet syndrome
caused by fibrous dysplasia of the first rib. Ann Thorac Surg. 2012 Mar. 93(3):994-6