Abstract
The clinical diagnosis of NTOS remains controversial and challenging. Fortunately, modern medical imaging, particularly MRI, provides excellent evaluation of the brachial plexus, the surrounding soft tissues and bones, and the dynamic changes that occur in the thoracic outlet on movement of the upper extremity. This chapter details the imaging anatomy of the thoracic outlet, including the component anatomic tunnels that comprise the thoracic outlet, the brachial plexus, and the dynamic changes of the thoracic outlet seen on movement of the upper extremity. Imaging findings of NTOS, as defined by pathologic entrapment of the brachial plexus, are demonstrated and defined, including soft tissue anomalies, bony anomalies, and pathologic dynamic changes that cause narrowing of the anatomic tunnels of the thoracic outlet and resultant entrapment of the brachial plexus. A simple and straightforward algorithm for reviewing an imaging study of a patient with TOS is provided. The reader will understand the important anatomic landmarks and tunnels of the thoracic outlet, the soft tissue or bony anomalies and pathologic changes that occur in the thoracic outlet, and the difference between normal and abnormal changes that occur on movement of the upper extremity, along with the resulting entrapment of the brachial plexus.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. Neurologist. 2008;14(6):365–73.
Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome. Hand Clin. 2004;20(1):27–36.
Atasoy E. Thoracic outlet compression syndrome. Orthop Clin North Am. 1996;27(2):265–303.
Atasoy E. History of thoracic outlet syndrome. Hand Clin. 2004;20(1):15–6, v.
Fugate M, Rotellini-Coltvet L, Freischlag J. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. 2009;11(2):176–83.
Wilbourn AJ. The thoracic outlet syndrome is overdiagnosed. Arch Neurol. 1990;47(3):328–30.
Roos DB. The thoracic outlet syndrome is underrated. Arch Neurol. 1990;47(3):327–8.
Wilbourn AJ. Thoracic outlet syndrome is overdiagnosed. Muscle Nerve. 1999;22(1):130–6, discussion 136–7.
Roos DB. Thoracic outlet syndrome is underdiagnosed. Muscle Nerve. 1999;22(1):126–9, discussion 137–8.
Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med. 1998;5(4):337–42 (Official journal of the Society for Academic Emergency).
Demirbag D, Unlu E, Ozdemir F, et al. The relationship between magnetic resonance imaging findings and postural maneuver and physical examination tests in patients with thoracic outlet syndrome: results of a double-blind, controlled study. Arch Phys Med Rehabil. 2007;88(7):844–51.
Rayan GM. Thoracic outlet syndrome. J Shoulder Elbow Surg. 1998;7(4):440–51.
Rayan G, Jensen C. Thoracic outlet syndrome: provocative examination maneuvers in a typical population. J Shoulder Elbow Surg. 1995;4:113–7.
Telford ED, Mottershead S. Pressure at the cervico-brachial junction. J Bone Joint Surg Br. 1948;30-B(2):249.
Remy-Jardin M, Doyen J, Remy J, Artaud D, Fribourg M, Duhamel A. Functional anatomy of the thoracic outlet: evaluation with spiral CT. Radiology. 1997;205(3):843–51.
Ranney D. Thoracic outlet: an anatomical redefinition that makes clinical sense. Clin Anat. 1996;9(1):50–2.
Atasoy E. Thoracic outlet syndrome: anatomy. Hand Clin. 2004;20(1):7–14, v.
Chiles C, Davis KW, Williams DW. Navigating the thoracic inlet. Radiographics. 1999;19(5):1161–76 (A review publication of the Radiological Society of North America, Inc.).
Rapoport S, Blair DN, McCarthy SM, Desser TS, Hammers LW, Sostman HD. Brachial plexus: correlation of MR imaging with CT and pathologic findings. Radiology. 1988;167(1):161–5.
Matsumura JS, Rilling WS, Pearce WH, Nemcek AA, Vogelzang RL, Yao JS. Helical computed tomography of the normal thoracic outlet. J Vasc Surg. 1997;26(5):776–83.
Perlas A, Chan VWS, Simons M. Brachial plexus examination and localization using ultrasound and electrical stimulation: a volunteer study. Anesthesiology. 2003;99(2):429–35.
Sheppard DG, Iyer RB, Fenstermacher MJ. Brachial plexus: demonstration at US. Radiology. 1998;208(2):402–6.
van Es HW, Bollen TL, van Heesewijk HPM. MRI of the brachial plexus: a pictorial review. Eur J Radiol. 2010;74(2):391–402.
Van Es HW. MRI of the brachial plexus. Eur Radiol. 2001;11(2):325–36.
Demondion X, Boutry N, Drizenko A, Paul C, Francke JP, Cotten A. Thoracic outlet: anatomic correlation with MR imaging. AJR Am J Roentgenol. 2000;175(2):417–22.
Sherrier RH, Sostman HD. Magnetic resonance imaging of the brachial plexus. J Thorac Imaging. 1993;8(1):27–33.
Blair DN, Rapoport S, Sostman HD, Blair OC. Normal brachial plexus: MR imaging. Radiology. 1987;165(3):763–7.
Kellman GM, Kneeland JB, Middleton WD, et al. MR imaging of the supraclavicular region: normal anatomy. AJR Am J Roentgenol. 1987;148(1):77–82.
Juvonen T, Satta J, Laitala P, Luukkonen K, Nissinen J. Anomalies at the thoracic outlet are frequent in the general population. Am J Surg. 1995;170(1):33–7.
Kirgis HD, Reed AF. Significant anatomic relations in the syndrome of the scalene muscles. Ann Surg. 1948;127(6):1182–201.
Gage M, Parnell H. Scalenusanticus syndrome. Am J Surg. 1947;73(2):252–68.
Leinberry CF, Wehbé MA. Brachial plexus anatomy. Hand Clin. 2004;20(1):1–5.
Bowen BC, Pattany PM, Saraf-Lavi E, Maravilla KR. The brachial plexus: normal anatomy, pathology, and MR imaging. Neuroimaging Clin N Am. 2004;14(1):59–85, vii–viii.
Cooper A, Travers B. On exostosis. 3rd ed. 1821. p. 167–224.
Coote H. Exostosis of the left transverse process of the seventh cervical vertebra, surrounded by blood vessels and nerves-successful removal. Lancet. 1861;1:360–1.
Todd TW. “Cervical Rib”: factors controlling its presence and its size. Its bearing on the morphology and development of the shoulder. J Anat Physiol. 1912;46(Pt 3):244–88.
Adson AW, Coffey JR. Cervical rib: a method of anterior approach for relief of symptoms by division of the scalenus anticus. Ann Surg. 1927;85(6):839.
Dow DR. The anatomy of rudimentary first thoracic ribs with special reference to the arrangement of the brachial plexus. J Anat. 1925;59(Pt 2):166.
Sabapathy SR, Venkatramani H, Bhardwaj P. Pseudarthrosis of cervical rib: an unusual cause of thoracic outlet syndrome. J Hand Surg Am. 2010;35(12):2018–21.
Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg. 2002;36(1):51–6.
Criado E, Berguer R, Greenfield L. The spectrum of arterial compression at the thoracic outlet. J Vasc Surg. 2010;52(2):406–11.
Gilliatt R, Le Quesne P, Logue V, Sumner AJ. Wasting of the hand associated with a cervical rib or band. Br Med J. 1970;33(5):615–24.
Roos DB. Experience with first rib resection for thoracic outlet syndrome. Ann Surg. 1971;173(3):429–42.
Roos D. Congenital anomalies associated with thoracic outlet syndrome: anatomy, symptoms, diagnosis, and treatment. Am J Surg. 1976;132(6):771–8.
Terabayashi N, Ohno T, Nishimoto Y, et al. Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: a case report. J Shoulder Elbow Surg. 2010;19(6):e20–3.
Panegyres P, Moore N, Gibson R. Thoracic outlet syndromes and magnetic resonance imaging. Brain. 1993;116(Pt 4):823–41.
O’Brien PJ, Ramasunder S, Cox MW. Venous thoracic outlet syndrome secondary to first rib osteochondroma in a pediatric patient. J Vasc Surg. 2011;53(3):811–3.
Yeow KM, Hsieh HC. Thoracic outlet syndrome caused by first rib hemangioma. J Vasc Surg. 2001;33(5):1118–21.
Haniuda M, Morimoto M, Nishimura H. A case of chondrosarcoma arising from the left first rib. Kyobu Geka. 1990;43(10):835–8 (The Japanese journal of thoracic surgery).
Nehme A, Tricoire J, Giordano G, Rouge D, Chiron P, Puget J. Coracoclavicular joints. Reflections upon incidence, pathophysiology and etiology of the different forms. Surg Radiol Anat. 2004;26(1):33–8.
Hama H, Matsusue Y, Ito H, Yamamuro T. Thoracic outlet syndrome associated with an anomalous coracoclavicular joint. A case report. J Bone Joint Surg Am. 1993;75(9):1368–9.
Khu KJ, Midha R. Clavicle pseudarthrosis: a rare cause of thoracic outlet syndrome. Can J Neurol Sci. 2010;37(6):863–5.
Bilbey JH, Lamond RG, Mattrey RF. MR imaging of disorders of the brachial plexus. J Magn Reson Imaging. 1994;4(1):13–8.
Kitsis CK, Marino AJ, Krikler SJ, Birch R. Late complications following clavicular fractures and their operative management. Injury. 2003;34(1):69–74.
Jain S, Monbaliu D, Thompson JF. Thoracic outlet syndrome caused by chronic retrosternal dislocation of the clavicle. Successful treatment by transaxillary resection of the first rib. J Bone Joint Surg Br. 2002;84(1):116–8.
Kapickis M. Neurogenic thoracic outlet syndrome caused by subacute clavicle osteomyelitis. Acta Chir Latviensis. 2011;10(2):124–6.
Durham JR, Yao JS, Pearce WH, Nuber GM, McCarthy WJ. Arterial injuries in the thoracic outlet syndrome. J Vasc Surg. 1995;21(1):57–69, discussion 70.
Todd TW. The relations of the thoracic operculum considered in reference to the anatomy of cervical ribs of surgical importance. J Anat Physiol. 1911;45(Pt 3):293–304.
Stopford JSB, Telford ED. Compression of the lower trunk of the brachial plexus by a first dorsal rib. With a note on the surgical treatment. Br J Surg. 1919;7(26):168–77.
Brickner W. Brachial plexus pressure by the normal first rib. Ann Surg. 1927;85(6):858–72.
Murphy T. Brachial neuritis caused by pressure of first rib. Aust Med J. 1910;15:582–5.
Ochsner A, Gage M. Scalenusanticus (Naffziger) syndrome. Am J Surg. 1935;28:669.
Swank RL, Simeone FA. The scalenus anticus syndrome: types, their characterization, diagnosis and treatment. Arch Neurol Psychiatry. 1944;51(5):432.
Roos D. New concepts of thoracic outlet syndrome that explain etiology, symptoms, diagnosis, and treatment. Vasc Endovascular Surg. 1979;13(5):313–21.
Roos DB. Pathophysiology of congenital anomalies in thoracic outlet syndrome. Acta Chir Belg. 1980;79(5):353–61.
Lindgren SH, Ribbe EB, Norgren LE. Two year follow-up of patients operated on for thoracic outlet syndrome. Effects on sick-leave incidence. Eur J Vasc Surg. 1989;3(5):411–5.
Law AA. Adventitious ligaments simulating cervical ribs. Ann Surg. 1920;72(4):497.
Gaughran GRL. Suprapleural membrane and suprapleural bands. Anat Rec. 1964;148(4):553–9.
Poitevin L. Proximal compressions of the upper limb neurovascular bundle. An anatomic research study. Hand Clin. 1988;4(4):575–84.
Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg. 1992;16(4):534–42, discussion 542–5.
Harry W, Bennett J, Guha S. Scalene muscles and the brachial plexus: anatomical variations and their clinical significance. Clin Anat. 1997;10(4):250–2.
Paraskevas G, Ioannidis O, Papaziogas B, Natsis K, Spanidou S, Kitsoulis P. An accessory middle scalene muscle causing thoracic outlet syndrome. Folia Morphol (Warsz). 2007;66(3):194–7.
Hug U, Burg D, Meyer V. Cervical outlet syndrome due to an accessory part of the trapezius muscle in the posterior triangle of the neck. J Hand Surg Eur Vol. 2000;25(3):311–3.
O’Sullivan ST, Kay SP. An unusual variant of the levator claviculae muscle encountered in exploration of the brachial plexus. J Hand Surg Br. 1998;23(1):134–5.
Darwish H, Ibrahim A. Three muscles in the upper costovertebral region: description and clinical anatomy. Clin Anat. 2009;22(3):352–7. doi:10.1002/ca.20773.
Rajanigandha V, Ranade A, Pai M, Rai R, Prabhu L, Nayak S. The scalenus accessorious muscle. Int J Morph. 2008;26(2):385–8.
Goubran E, Carlos J, Ayad S. A bifurcated anterior scalene muscle: a case report. Clin Chiropr. 2010;13(2):153–5.
Cooke R. Thoracic outlet syndrome-aspects of diagnosis in the differential diagnosis of hand-arm vibration syndrome. Occup Med. 2003;53(5):331–6.
Lee J, Laker S, Fredericson M. Thoracic outlet syndrome. PM R. 2010;2(1):64–70.
Safran MR. Nerve injury about the shoulder in athletes, part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004;32(4):1063–76.
Esposito MD, Arrington JA, Blackshear MN, Murtagh FR, Silbiger ML. Thoracic outlet syndrome in a throwing athlete diagnosed with MRI and MRA. J Magn Reson Imaging. 1997;7(3):598–9.
Rayan G. Lower trunk brachial plexus compression neuropathy due to cervical rib in young athletes. Am J Sports Med. 1988;16(1):77–9.
Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression syndrome. Histochemical and morphometric studies. Arch Surg. 1986;121(10):1141–4.
Sanders RJ, Ratzin Jackson CG, Banchero N, Pearce WH. Scalene muscle abnormalities in traumatic thoracic outlet syndrome. Am J Surg. 1990;159(2):231–6.
Ozçakar L, Güney MS, Ozdağ F, et al. A sledgehammer on the brachial plexus: thoracic outlet syndrome, subclavius posticus muscle, and traction in aggregate. Arch Phys Med Rehabil. 2010;91(4):656–8.
Akita K, Ibukuro K, Yamaguchi K, Heima S, Sato T. The subclavius posticus muscle: a factor in arterial, venous or brachial plexus compression. Surg Radiol Anat. 2000;22(2):111–5.
Thompson JF, Winterborn RJ, Bays S, White H, Kinsella DC, Watkinson AF. Venous thoracic outlet compression and the paget-schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol. 2011;34(5):903–10.
Demondion X, Bacqueville E, Paul C, Duquesnoy B, Hachulla E, Cotten A. Thoracic outlet: assessment with MR imaging in asymptomatic and symptomatic populations. Radiology. 2003;227(2):461–8.
Turgut H, Anil A, Peker T, Barut C. Insertion abnormality of bilateral pectoralis minimus. Surg Radiol Anat. 2000;22(1):55–7.
Clarys J, Barbaix E, Vanrompaey H, Caboor D, Vanroy P. The muscular arch of the axilla revisited: its possible role in the thoracic outlet and shoulder instability syndromes. Man Ther. 1996;1(3):133–9.
Duwayri YM, Emery VB, Driskill MR, et al. Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete. J Vasc Surg. 2011;53(5):1329–40.
Ikezawa T, Iwatsuka Y, Asano M, Kimura A, Sasamoto A, Ono Y. Upper extremity ischemia in athletes: embolism from the injured posterior circumflex humeral artery. Int J Angiol. 2000;9(3):138–40.
Gelabert HA, Machleder HI. Diagnosis and management of arterial compression at the thoracic outlet. Ann Vasc Surg. 1997;11(4):359–66.
Uysal II, Seker M, Karabulut AK, Büyükmumcu M, Ziylan T. Brachial plexus variations in human fetuses. Neurosurgery. 2003;53(3):676–84, discussion 684.
Natsis K, Totlis T, Tsikaras P, Anastasopoulos N, Skandalakis P, Koebke J. Variations of the course of the upper trunk of the brachial plexus and their clinical significance for the thoracic outlet syndrome: a study on 93 cadavers. Am Surg. 2006;72(2):188–92.
Pellerin M, Kimball Z, Tubbs RS, et al. The prefixed and postfixed brachial plexus: a review with surgical implications. Surg Radiol Anat. 2010;32(3):251–60.
Lindgren K, Manninen H, Rytkönen H. Case of the month. Thoracic outlet syndrome-a functional disturbance of the thoracic upper aperture? Muscle Nerve. 1995. doi:10.1002/mus.880180508.
Remy-Jardin M, Remy J, Masson P, et al. CT angiography of thoracic outlet syndrome: evaluation of imaging protocols for the detection of arterial stenosis. J Comput Assist Tomogr. 2000;24(3):349.
Gillard J, Pérez-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, Herbinet P, van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. 2006;26(6):1735–50 (A review publication of the Radiological Society of North America, Inc.).
Nord KM, Kapoor P, Fisher J, et al. False positive rate of thoracic outlet syndrome diagnostic maneuvers. Electromyogr Clin Neurophysiol. 2008;48(2):67–74.
Ozçakar L, Dönmez G, Yörübulut M, et al. Paget-schroetter syndrome forerunning the diagnosis of thoracic outlet syndrome and thrombophilia. Clin Appl Thromb Hemost. 2010;16(3):351–5.
Laban MM, Zierenberg AT, Yadavalli S, Zaidan S. Clavicle-induced narrowing of the thoracic outlet during shoulder abduction as imaged by computed tomographic angiography and enhanced by three-dimensional reformation. Am J Phys Med Rehabil. 2011;90(7):572–8.
Remy-Jardin M, Remy J, Masson P, et al. Helical CT angiography of thoracic outlet syndrome: functional anatomy. AJR Am J Roentgenol. 2000;174(6):1667–74.
Brantigan CO, Johnston RJ, Roos DB. Appendix: use of multidetector CT and three-dimensional reconstructions in thoracic outlet syndrome: a preliminary report. Hand Clin. 2004;20(1):123–6, viii.
Bilbey JH, Müller NL, Connell DG, Luoma AA, Nelems B. Thoracic outlet syndrome: evaluation with CT. Radiology. 1989;171(2):381–4.
Longley DG, Yedlicka JW, Molina EJ, Schwabacher S, Hunter DW, Letourneau JG. Thoracic outlet syndrome: evaluation of the subclavian vessels by color duplex sonography. AJR Am J Roentgenol. 1992;158(3):623–30.
Odderson IR, Chun ES, Kolokythas O, Zierler RE. Use of sonography in thoracic outlet syndrome due to a dystonic pectoralis minor. J Ultrasound Med. 2009;28(9):1235–8 (Official journal of the American Institute of Ultrasound in Medicine).
Vargas MI, Viallon M, Nguyen D, Beaulieu JY, Delavelle J, Becker M. New approaches in imaging of the brachial plexus. Eur J Radiol. 2010;74(2):403–10.
Chin C. Magnetic resonance neurography. In: Nerve and vascular injuries in sports medicine. New York: Springer; 2009. p. 27–39.
Filler A. MR Neurography and diffusion tensor imaging: origins, history and clinical impact of the first 50,000 cases with an assessment of efficacy and utility in a prospective 5,000 patient study group. Neurosurgery 2009;65(Suppl 4):A29.
Filler A, Maravilla K, Tsuruda J. MR neurography and muscle MR imaging for image diagnosis of disorders affecting the peripheral nerves and musculature. Neurol Clin. 2004;22(3):643–82.
van Es H. MR imaging of the brachial plexus. Utrecht: University Hospital; 1997.
Es HW, Witkamp TD, Feldberg MAM. MRI of the brachial plexus and its region: anatomy and pathology. Eur Radiol. 1995;5(2):145–51.
Filler A. MR neurography and brachial plexus neurolysis in the management of thoracic outlet syndromes. In: Yao J, Pearce W, editors. Advances in vascular surgery. 2002. p. 499–523.
Maravilla K, Bowen B. Imaging of the peripheral nervous system: evaluation of peripheral neuropathy and plexopathy. AJNR Am J Neuroradiol. 1998;19(6):1011–23.
Demondion X, Herbinet P, Boutry N, Fontaine C, Francke J-P, Cotten A. Sonographic mapping of the normal brachial plexus. American Journal of Neuroradiology 2003;24(7):1303–9.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2013 Springer-Verlag London
About this chapter
Cite this chapter
Werden, S. (2013). Radiographic Imaging in Diagnosis and Assessment of NTOS. In: Illig, K., Thompson, R., Freischlag, J., Donahue, D., Jordan, S., Edgelow, P. (eds) Thoracic Outlet Syndrome. Springer, London. https://doi.org/10.1007/978-1-4471-4366-6_18
Download citation
DOI: https://doi.org/10.1007/978-1-4471-4366-6_18
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-4471-4365-9
Online ISBN: 978-1-4471-4366-6
eBook Packages: MedicineMedicine (R0)