Torasik Outlet Sendromu
Özet
Torasik outlet sendromu (TOS), omuz kavşağındaki servikoaksiller kanal içinde subklavian arter, subklavian ven ve brakial pleksus dallarının basıya uğramasıyla ortaya çıkan, kadınlarda daha sık görülen bir semptomlar topluluğudur. Etiyolojisinde servikal kot gibi konjenital kemik anomalileri, edinsel anatomik bozukluklar, travmalar ve tekrarlayıcı üst ekstremite hareketleri yer alır. Etkilenen yapıya göre nörojenik (%90), venöz ve arteriyel olmak üzere üç alt tipe ayrılır. Nörojenik TOS'ta omuz, kol ve elde ağrı, parestezi ve motor kayıplar görülürken; venöz tipte tromboz ve ödem, arteriyel tipte ise iskemi bulguları ve anevrizma gelişebilir. Tanıda Roos, Adson ve üst ekstremite gerilim testleri gibi provokatif fizik muayene yöntemlerinin yanı sıra Doppler ultrasonografi, BT, MR ve ulnar sinir ileti hızını ölçen elektronöromyografik incelemelerden yararlanılır. Tedavide ilk adım, postür düzenleme ve kas güçlendirmeyi içeren konservatif fizik tedavidir. Konservatif yaklaşıma dirençli vasküler ve gerçek nörolojik olgularda ise transaksiller veya supraklaviküler yaklaşımla birinci kot rezeksiyonunu içeren cerrahi tedavi uygulanır.
Thoracic outlet syndrome (TOS) is a symptom complex, more prevalent in women, caused by the compression of the subclavian artery, subclavian vein, and brachial plexus branches within the cervicoaxillary canal at the shoulder girdle. Its etiology includes congenital bone anomalies such as cervical ribs, acquired anatomical irregularities, trauma, and repetitive upper extremity movements. Based on the affected neurovascular component, TOS is classified into neurogenic (90%), venous, and arterial subtypes. Neurogenic TOS presents with pain, paresthesia, and motor loss in the shoulder, arm, and hand; venous TOS leads to thrombosis and edema, while arterial TOS causes ischemic symptoms and potential aneurysm development. Diagnosis relies on provocative physical examination maneuvers like the Roos, Adson, and upper limb tension tests, alongside Doppler ultrasonography, CT, MRI, and electroneuromyographic studies measuring ulnar nerve conduction velocity. The primary therapeutic approach is conservative treatment, focusing on physical therapy for posture correction and muscle strengthening. For vascular and true neurogenic cases refractory to conservative management, surgical intervention involving first rib resection via transaxillary or supraclavicular approaches is indicated.
Referanslar
LoCicero J, Feins RH, Colson YL et al. Thoracic outlet syndrome. (Edt) Shields TW. General thoracic surgery 8th edition. Philedephia, 2019, p: 1298 – 1317
Huang JH, Zager EL. Thoracic Outlet Syndrome. Neurosurgery, 2004, 55(4):897–903.
Türk F, Yüncü G. Toraksın Çıkış sendromu. (Edt) Ökten İ, Kavukçu HŞ. Göğüs Cerrahisi. İstanbul medikal sağlık ve yayıncılık, İstanbul, 2013:663-681
Akal M. Torasik outlet sendromu. (Edt), Ökten İ, Güngör A. Göğüs Cerrahisi. Sim matbaacılık Ankara, 2003:747-762
Kuhn JE, Lebus CF, Bible JE. Thoracic Outlet Syndrome. J Am Acad Orthop Surg 2015;23(4):222-232.
Jones MR, Prabhakar A, Viswanath O et al. Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment, Pain Ther (2019) 8:5–18
Povlsen S, Povlsen BO. Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions Diagnostics. 2018: 8-21
Kuthan kavaklı Torasik outlet Sendromu. Göğüs Cerrahisi Ders notları 2021
Stewman C, Vitanzo PC, Harwood MI. Neurologic thoracic outlet syndrome: summarizing a complex history and evolution. Curr Sports Med Rep. 2014;13(2):100–6.
Ferrante MA The thoracic outlet syndromes. Muscle Nerve. 2012;45(6):780–95.
Raptis CA, Sridhar S, Thompson RW et al. Imaging of the patient with thoracic outlet syndrome. RadioGraphics. 2016;36(4):984-1000
Abdolrazaghi H, Riyahi A, Taghavi M. Concomitant neurogenic and vascular thoracic outlet syndrome due to multiple exostoses. Ann Card Anaesth. 2018;21(1):71-3.
Juvonen T, Satta J, Laitala P et al. Anomalies at the thoracic outlet are frequent in the general population. Am J Surg. 1995, 170(1):33-7
Ferrante MA, Ferrante ND. The thoracic outlet syndromes: Part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017;56(4):663-73
Davis GA, Knight SR. Pancoast Tumors. Neurosurg. Clin N Am. 2008;19(4):545-57
Ibrahim R, Dashkova I, Williams M, et al. Paget–Schroetter syndrome in the absence of common predisposing factors: a case report. Thromb J. 2017;15:20.
Duwayri YM, Emery VB, Driskill MR et al. Thompson RW. Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete. J Vasc Surg. 2011 May;53(5):1329-40
Leventoğlu A. Torasik çıkış sendromu: Nörojenik Torasik Çıkış Sendromunda Elektrofizyolojik değerlendirme. Toraks Cerrahisi Bülteni, 5, 2014:62-65. E-ISSN 2146-3050.
Smith TM, Sawyer SF, Sizer PS et al. The double crush syndrome: a common occurrence in cyclists with ulnar nerve neuropathy - a case - control study. Clin J Sport Med. 2008;18(1):55–61.
Tsao BE, Ferrante MA, Wilbourn AJ et al. Electrodiagnostic features of true neurogenic thoracic outlet syndrome. Muscle Nerve. 2014;49(5):724–7
Tanabe H, Miyamori D, Shigenobu Y et al. Two Patients with Paget-Schroetter Syndrome That Were Successfully Diagnosed by Doppler Ultrasonography: Case Studies with a Literature Review. Intern Med . 2020, 15;59(20):2623-2627.
Bishop L, Bartlett M. Doppler waveform analysis during provocative manoeuvres in the assessment for arterial thoracic outlet syndrome results in high false-positive rates; a cross-sectional study JRSM Cardiovasc Dis. 2021, 1;10: 20480040211006571.
Freischlag J, Orion K. Understanding thoracic outlet syndrome. Scientifica (Cairo). 2014;2014:1-6.
Weaver M, Lum Y. New diagnostic and treatment modalities for neurogenic thoracic outlet syndrome. Diagnostics. 2017;7(2):28.
Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome. Neurologist. 2008;14(6):365-73.
Gillard J, Pe´rez-Cousin M, Hachulla E et al. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001;68(5):416–24.
Demondion X, Vidal C, Herbinet P. Et al. Ultrasonographic Assessment of Arterial Cross-sectional Area in the Thoracic Outlet on Postural Maneuvers Measured With Power Doppler Ultrasonography in Both Asymptomatic and Symptomatic Populations. Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine, 2006, 25(2):217-24
Wadhwani R, Chaubal N, Sukthankar R. Et al. Color Doppler and duplex sonography in 5 patients with thoracic outlet syndrome. J Ultrasound Med. 2001 Jul;20(7):795-801.
Khalilzadeh O, Glover M, Torriani M. et al. Imaging Assessment of Thoracic Outlet Syndrome. Thorac Surg Clin. 2021, 31(1):19-25.
Aralasmak A, Cevikol C, Karaali K et al. MRI findings in thoracic outlet syndrome. Skeletal Radiol, 2012 Nov;41(11):1365-74.
Peet PM, Henrksen JD, Anderson TP, Martin GM. Thoracic outlet syndrome: evaluation of a therapeutic exercise program. Mayo Clin Proc 1956 May 2;31(9):281-7.
Wilboum AJ, Porter JM. Neurogenic Thoracic Outlet Sydrome: Surgical Versus Conservative Therapy. Clinical research and vascular surgery. 1992, 15(5):880-880
Mackinnon S, Patterson GA, Urschel HC. Thoracic Outlet Syndrome. (Edt.) Pearson FG, Ginsberg RJ, Cooper JD. (in) Thoracic Surgery. Churchill Livingstone, second edition, 1995: Volume:2, p:1393-1415
Urschel HC Jr. Thoracic Outlet Syndrome. Edt. Shields TW. General Thoracic Surgery. Williams & Wilkins, fourth edition,1994: Volume:1, p:564-571
Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet syndrome. Ann Surg.1966, 163:354
