الفهرس 
Anatomy of thoracic outletOnly 14 pages are availabe for public view
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Abstract
Anatomically, the area between the scalene muscles and 1st rib is termed the thoracic inlet; compression at this region is termed the thoracic outlet syndrome.
The scalenus anticus muscle, which inserts on the scalene tubercle of the 1st rib divides the costoclavicular space into two compartment, which contains subclavian vein, and the scalene triangle which contains the subclavian artery and the brachial plexus.
Thoracic outlet syndrome involves compression, injury, Or irritation to neurovascular structure at the thoracic inlet in the root of the neck or upper thoracic region due to trauma to shoulder, neck, postural distortion, and congenital anomalies.
There are 3 district types of thoracic outlet syndrome, neurogenic, venous & arterial TOS. The large majority of patient are neurogenic and not arterial.
Cervical spine & chest X- ray films are special investigation evaluated to determine whether there is contributing facture from skeletal structures.
The role of arteriography in TOS is a very limited one but it helps the surgeon plan arterial reconstruction.
Doppler ultrasonography has the advantages of enabling assessment of blood flew and used to confirm the clinical suspicion of arterial TOS.
C.T angiography is performed to grade the arterial stenosis.
MRI is a non invasive technique which provides a good view of the brachial plexus and also demonstrates fibrous bands.
EMG can test the brachial plexus motor component at the root or cord level but may be not sensitive enough in patients with a milder form of the disease.
The conservative approach is the rule in the initial treatment of neurogenic TOS. Therapeutic efforts are focused on relaxing the scalene muscle and strengthening of the postural muscle through physical therapy combined with hydrotherapy & massage.
Pain medication, non steroidal anti-inflammatory agents, and muscle relaxants are often useful adjuncts in treatment.
Botox injection scalene muscle is helpful for diagnosis and used more for treating symptoms of the syndrome specially after surgical intervention.
Multiple surgical modalities exist, and depend largely on the patient’s anatomy and the surgeon’s performance. Surgeons can perform a cervical rib resection and a first rib resection, using either a cervical or transaxillary approach anterior scalenotomy or scalenectomy, or a combination of these.
Surgery is indicated in:
1-failure of a carefully supervised exercise and postural program.
2-Intractable pain.
3-Significant neurological deficit.
4-Impending vascular catastrophe.
5-Complete & successful initial treatment of subclavian vein thrombosis.
The supraclavicular approach has been a successful route for thoracic outlet decompression it permits many more options than the transaxillary route.