A 30-year-old female presented to the emergency department complaining of ongoin

Question

A 30-year-old female presented to the emergency department complaining of ongoing coldness, numbness and pain in her right arm. A CT study demonstrated a compression of the right subclavi artery due to a rib anomaly, resulting in thoracic outlet syndrome. 1. What structures form the borders of the thoracic inlet or superior thoracic aperture? 2. What structures pass between the neck and the thoracic cavity through the superior thoraci aperture? 3. What are possible treatment options if any are there for this condition?

Explanation / Answer

The superior thoracic aperture or thoracic inlet is the path through which the thoracic cavity interacts with the roots of the neck. The clinicians call this as thoracic outlet because significant arteries and T1 spinal nerves come from thorax goes via this aperture to the root of the neck and upper limbs.

Thethoracic inlet is bounded by the first thoracic rib that is T1 posteriorly, first pair of ribs laterally resulting in a C-shaped structure from posterior to anterior area and the costal cartilage of the first rib and superior edge of manubrium on the anterior side. This comprise the thoracic inlet or the superior thoracic aperture.

The clavicle articulates with the manubrium anteriorly to form the border of thoracic inlet. Superiorly is the root of the neck and inferior is manubrium.The following parts pass through the thoracic inlet;

Arteries:

- Nerves

- Veins

- Muscles

- Lymphatics

- Other parts like trachea, esophagus, apices of left and right lung, domes of cervical pleura, anterior longitudinal ligament.

Thoracic Outlet Syndrome:

The subclavian artery and lower trunk of brachial plexus arch over the first rib, they can be pushed or stretched up by the presence of a congenital hypertrophied scalenus anterior muscle or cervical rib. This give rise to this syndrome.

In acute phases,

physical therapy is the first line of treatment if it is a neurogenic syndrome. Long term therapy can helps in releasing the pressure off the areas.

Thrombolytics that is clot dissolving medications if it is a venous or arterial syndrome. These medications are used to dissolve the clots followed by anticoagulants to prevent clot formation.

Anti-inflammatory drugs to control inflammation and pain

Surgical intervention are preferably if other modalities doesn't work on the problem. The procedure is named as thoracic Outlet decompression and these are done through three approaches like Transaxillary approach, supraclavicular or infraclavicular approach.

Lifestyle modifications like correct posture, avoid heavy weight lifting on shoulders, adequate nutrition and physical therapy and avoid activities which worsen the symptoms.

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