From anterior to posterior at the thoracic outlet the listed structures include: - _______ - _______ - _______ - _______ - _______ - _______.

From anterior to posterior at the thoracic outlet the listed structures include: - Subclavian vein - Phrenic nerve - Anterior scalene attachment to 1st rib - Subclavian artery - Brachial plexus - Middle scalene muscle.

The three anatomical spaces where neurovascular compression can occur are: - _______ - _______ - _______.

The three anatomical spaces where neurovascular compression can occur are: - Interscalene triangle - Costoclavicular passage - Subcoracoid space.

The anterior scalene muscle attaches to the _______ and to the _______.

The anterior scalene muscle attaches to the anterior tubercles of C3-C6 and to the scalene tubercle on the upper surface of the 1st rib.

The phrenic nerve runs along the _______ and injury to it can cause _______.

The phrenic nerve runs along the anterior scalene muscle and injury to it can cause ipsilateral diaphragm paralysis.

The middle scalene muscle attaches to the _______ and to the _______.

The middle scalene muscle attaches to the posterior tubercles and intertubercular lamellae of cervical vertebrae and to the quadrangular area of the 1st rib.

The long thoracic nerve runs along the _______ and its injury can cause a _______.

The long thoracic nerve runs along the middle scalene muscle and its injury can cause a winged scapula.

Features of the first rib: it is the _______ rib, is an _______, and its upper surface has _______ plus _______.

Features of the first rib: it is the broadest and flattest rib, is an atypical rib with only one articular facet, and its upper surface has scalene and quadrangular tubercles plus three grooves for subclavian vein, artery and lower trunk of brachial plexus.

The costoclavicular passage transmits the _______ through a tight space formed by the _______, _______, and the _______; posteriorly the artery and nerves can also be compressed.

The costoclavicular passage transmits the subclavian vein through a tight space formed by the clavicle, subclavius muscle, and the costoclavicular ligament; posteriorly the artery and nerves can also be compressed.

The subclavius muscle is attached to the _______ and inserts into the _______.

The subclavius muscle is attached to the costochondral junction of the 1st rib and inserts into the subclavian groove on the inferior surface of the clavicle.

Three key components defining the subcoracoid space are: - _______ - _______ - _______.

Three key components defining the subcoracoid space are: - Coracoid process - Pectoralis minor muscle - Clavipectoral fascia.

Pectoralis minor attachments: it attaches to the _______ and to the _______.

Pectoralis minor attachments: it attaches to the bodies of the 3rd, 4th and 5th ribs and to the medial border of the coracoid process.

The clavipectoral fascia fills the space between the clavicle and pectoralis minor, splits around the subclavius, and its superior portion can thicken to form the _______.

The clavipectoral fascia fills the space between the clavicle and pectoralis minor, splits around the subclavius, and its superior portion can thicken to form the costocoracoid ligament.

Normally the phrenic nerve runs _______; a rare anomaly is the phrenic nerve compressing the vein anteriorly and, in rare developmental cases, running through other structures.

Normally the phrenic nerve runs anterior to the subclavian vein; a rare anomaly is the phrenic nerve compressing the vein anteriorly and, in rare developmental cases, running through other structures.

Thoracic outlet syndrome (TOS) includes subtypes: _______, _______, and _______.

Thoracic outlet syndrome (TOS) includes subtypes: neurogenic (nTOS), venous (vTOS), and arterial (aTOS).

Incidence figures: anomalous first ribs _______, cervical ribs _______, and congenital bands up to _______ in the general population.

Incidence figures: anomalous first ribs 0.76%, cervical ribs 0.75%, and congenital bands up to 63% in the general population.

Common etiologies for neurogenic TOS (nTOS): _______ and _______.

Common etiologies for neurogenic TOS (nTOS): Scalene Triangle compression - most common and Cervical Rib and Anomalous First Rib.

Common etiologies for arterial TOS (aTOS): _______ and _______.

Common etiologies for arterial TOS (aTOS): Cervical Rib and Anomalous First Rib - most common and Scalene Triangle compression.

Common etiologies for venous TOS (vTOS): _______ and _______.

Common etiologies for venous TOS (vTOS): Costoclavicular Passage - most common and Subcoracoid Space.

Key presentation points to assess: _______, _______, and _______.

Key presentation points to assess: timing of symptoms, exclude history of trauma like clavicle fracture and malunion, and associated symptoms (headache, visual disturbance, upper limb neurology).

Presentation specific features: patients with vTOS may present _______ and have _______; patients with aTOS need _______.

Presentation specific features: patients with vTOS may present acutely and have acute or sub-acute upper limb DVT; patients with aTOS need urgent investigation and assessment given risk of ischemia.

Adson Test: with the arm _______ palpate radial pulse; then _______ — positive if radial pulse is reduced or obliterated.

Adson Test: with the arm extended, abducted and externally rotated palpate radial pulse; then rotate and laterally flex the neck to the ipsilateral side while inhaling deeply — positive if radial pulse is reduced or obliterated.

Roos / EAST Test: patient seated, both arms _______; _______ or until pain or paraesthesia.

Roos / EAST Test: patient seated, both arms abducted 90° and externally rotated with elbows flexed at 90°; open and close hands for 3 minutes or until pain or paraesthesia.

Elvey's Test: _______; test is positive if _______. A further maneuver is lateral head flexion to each side; pain on the contralateral side is positive.

Elvey's Test: abduct both arms to 90° with elbows extended and dorsiflex both wrists; test is positive if pain is elicited as wrists dorsiflex. A further maneuver is lateral head flexion to each side; pain on the contralateral side is positive.

Vascular lab studies for TOS include: _______, _______, and _______; these can be performed with _______.

Vascular lab studies for TOS include: Digital Brachial Index (DBI), Arterial Duplex (can identify subclavian artery aneurysms), and Venous Duplex; these can be performed with provocative maneuvers.

Axial imaging roles: _______, _______, and _______.

Axial imaging roles: CTV commonly performed in acute upper limb DVT and suspicion of vTOS, CTA for evaluation of aTOS and excluding other causes of embolisation, and MRI for further evaluation of the anatomy and related neurovascular compression.

Angiography and other studies: in vTOS some advocate _______; for nTOS use _______ and _______ can be diagnostic if it gives temporary relief.

Angiography and other studies: in vTOS some advocate upper extremity venogram with provocative maneuvers; for nTOS use electromyography and nerve conduction studies and scalene block can be diagnostic if it gives temporary relief.

Transaxillary first rib resection advantages: _______ and _______.

Transaxillary first rib resection advantages: cosmetically more appealing with a limited hidden scar and allows removal of a significant portion of the rib anteriorly and posteriorly.

Transaxillary approach disadvantages: _______, _______ and _______.

Transaxillary approach disadvantages: difficult to visualize the anatomy and dependent on good assistance, risk of injury to T1 nerve root, phrenic nerve, long thoracic, brachial plexus, subclavian vein and artery and not able to approach cervical ribs, scalene triangle or patch vein.

Supraclavicular approach: Advantages include _______ and it is _______.

Disadvantage: _______.

Supraclavicular approach: Advantages include good access to the scalene triangle and cervical rib resection and it is required for arterial TOS if arterial reconstruction is necessary.

Disadvantage: unable to decompress venous compression or visualize the vein adequately.

Infraclavicular approach: Advantages include _______ and _______.

Disadvantage: _______.

Infraclavicular approach: Advantages include good access for venous decompression and allows excision of the subclavius muscle and costoclavicular ligament.

Disadvantage: unable to expose the subclavian artery or decompress the brachial plexus.

Paraclavicular approach: Advantage is _______.

Disadvantage is _______.

Paraclavicular approach: Advantage is useful for mixed etiology TOS to decompress all neurovascular structures.

Disadvantage is requires two incisions, one above and one below the clavicle.

Postoperative hemorrhage with hemodynamic instability and ipsilateral effusion on chest x-ray should prompt _______.

Postoperative hemorrhage with hemodynamic instability and ipsilateral effusion on chest x-ray should prompt return to the OR for exploration and hemorrhage control.

Management of chyle leak: initial management is _______; persistent leak requires _______; _______ has also been effective.

Management of chyle leak: initial management is adequate drainage and a medium-chain fatty acid diet; persistent leak requires wound exploration and thoracic duct ligation or VATS ligation; IR embolization has also been effective.

Venous TOS (vTOS) incidence is _______ and typically affects ages _______ with _______.

Venous TOS (vTOS) incidence is 2/100,000 persons and typically affects ages 18 to 30 years with male predominance.

Paget-Schroetter Syndrome: it is _______ and accounts for _______.

Paget-Schroetter Syndrome: it is synonymous with vTOS and accounts for 10-20% of all upper extremity deep vein thrombosis.

Typical presentation of vTOS includes _______, _______, and _______.

Typical presentation of vTOS includes upper limb edema that is characteristically non-pitting, pain on exertion described as stabbing, aching, or tightness, and collateral vein dilatation over shoulder, neck, and anterior chest wall.

Reported incidence of pulmonary embolism following upper limb DVT is _______.

Reported incidence of pulmonary embolism following upper limb DVT is <12%.

Diagnostic evaluation: an upper extremity venogram can demonstrate compression when combined with _______.

Diagnostic evaluation: an upper extremity venogram can demonstrate compression when combined with provocative maneuvers such as 90° arm abduction and external rotation.

Differential diagnosis for upper limb DVT includes _______, _______, _______, _______, and _______.

Differential diagnosis for upper limb DVT includes vTOS, congenital phrenic nerve anomaly, history of clavicular fracture/malunion, repetitive arm provocative maneuvers/occupation/bodybuilding, and pectoralis minor hypertrophy.

Management goals for vTOS include: _______, _______, _______, and _______.

Management goals for vTOS include: prevent immediate risk, return patient to unrestricted use of the affected extremity, prevent recurrence of thrombosis without long-term anticoagulation, and prevent long-term post-phlebitic limb syndrome.

Initial medical management for upper extremity DVT as per ACCP guidelines is _______.

Initial medical management for upper extremity DVT as per ACCP guidelines is anticoagulation regardless of etiology.

Initial management of venous thoracic outlet syndrome (vTOS) is _______ regardless of etiology.

Initial management of venous thoracic outlet syndrome (vTOS) is anticoagulation regardless of etiology.

Limitations of anticoagulation alone include _______ leading to _______ and _______.

Limitations of anticoagulation alone include slow recanalization of the thrombus leading to valvular damage and intravenous scarring.

Catheter Directed Thrombolysis (CDT) is considered superior to anticoagulation alone for vTOS because it _______ and _______.

Catheter Directed Thrombolysis (CDT) is considered superior to anticoagulation alone for vTOS because it minimizes valvular damage due to residual clot and carries a lower risk of intracranial hemorrhage.

Systemic thrombolysis for vTOS is _______ due to the _______.

Systemic thrombolysis for vTOS is not favored due to the risk of intracranial hemorrhage.

Optimal timing for CDT is _______ of thrombosis onset; excellent results reported if initiated before 14 days.

Optimal timing for CDT is within 14 days of thrombosis onset; excellent results reported if initiated before 14 days.

After initial management vTOS surgical options commonly include: - _______ - _______

After initial management vTOS surgical options commonly include: - first rib resection (rib resection) and decompression of the subclavian vein - venolysis and vein patch plasty (surgical or endovenous)

For severe resistant subclavian vein stenosis in vTOS, recommended surgical approach is _______ with _______.

For severe resistant subclavian vein stenosis in vTOS, recommended surgical approach is rib resection by paraclavicular approach with vein patch plasty.

If venous occlusion in vTOS persists and patients remain symptomatic, treatment options include _______ or _______.

If venous occlusion in vTOS persists and patients remain symptomatic, treatment options include jugular turn down or venous bypass to internal jugular (IJ) or SVC.

Post-recanalization management controversies include options: - _______ - _______ - _______

Post-recanalization management controversies include options: - defer decompression 1-3 months after thrombolysis - perform decompression during same admission as thrombolysis - post-decompression venography and treatment 2 weeks after rib resection

In Lugo et al's review, symptom relief after follow-up was more likely with: - _______ - _______ compared to _______ (p<0.0001).

In Lugo et al's review, symptom relief after follow-up was more likely with: - First Rib Resection (FRR) 95% - FRR + endovenous venoplasty 93% compared to no rib removed 54% (p<0.0001).

Lugo et al concluded patients are more likely to have better long-term results with _______ compared to _______ after thrombolysis.

Lugo et al concluded patients are more likely to have better long-term results with first rib resection (FRR) compared to no first rib resection after thrombolysis.

Most common presentation of arterial thoracic outlet syndrome (aTOS) is _______ often with _______ and a _______.

Most common presentation of arterial thoracic outlet syndrome (aTOS) is hand ischemia due to arterial compression or microembolization often with subclavian artery aneurysm and a pulsatile supraclavicular mass.

Anatomical abnormalities causing aTOS include: - _______ - _______ - _______ - _______ - _______

Anatomical abnormalities causing aTOS include: - Cervical Rib (60%) - Anomalous First Rib (18%) - Fibrocartilaginous band (15%) - Clavicular Fracture (6%) - Enlarged C7 transverse process (1%)

Clinical examination findings in aTOS can include: - _______ - _______ - _______ - _______

Clinical examination findings in aTOS can include: - audible bruit / palpable thrill over the supraclavicular fossa - pulsatile mass - distal ischemic lesions (splinter hemorrhages) - positive Adson Test

The most useful vascular studies for aTOS are _______ to identify aneurysm or sites of embolization; _______.

The most useful vascular studies for aTOS are pulse volume recordings (PVR) and duplex to identify aneurysm or sites of embolization; stress test is not reliable for diagnosis.

Scher staging of aTOS: - _______ - _______ - _______ - _______

Scher staging of aTOS: - Stage 0: Asymptomatic - Stage 1: Stenosis with minor post-stenotic dilatation, no intimal disruption - Stage 2: Subclavian artery aneurysm with intimal damage and mural thrombus - Stage 3: Distal embolisation

Surgical approach: _______ is most suitable for adequate arterial reconstruction; _______ may allow more complete rib resection but _______ via transaxillary approach.

Surgical approach: Supraclavicular rib resection is most suitable for adequate arterial reconstruction; transaxillary approach may allow more complete rib resection but arterial repair is not possible via transaxillary approach.

Subclavian artery repair is necessary in _______ and in some cases _______; conduits described include _______ and _______ offers good patency and resistance to kinking.

Subclavian artery repair is necessary in Scher Stages 2 and 3 and in some cases Stage 1; conduits described include GSV, Femoral Vein, or prosthetic and ringed PTFE offers good patency and resistance to kinking.

Neurogenic TOS (nTOS) demographics: _______, typical ages _______, with common features of _______ and often a _______.

Neurogenic TOS (nTOS) demographics: ~70% female (F>M), typical ages 20-40, with common features of occupational exposure and often a recent history of neck trauma.

Common nTOS symptoms include: - _______ - _______ - _______ - _______ - _______

Common nTOS symptoms include: - Paraesthesia (98%) - Trapezius pain (92%) - Neck/shoulder/arm pain (88%) - Supraclavicular pain with/without occipital headache (76%) - Chest pain (72%)

Management priorities for nTOS include: - _______ - _______ - _______ - _______

Management priorities for nTOS include: - Exclude other causes - Confirm diagnosis with neurophysiologic tests (EMG and NCS) - Seek alternate opinion - Trial of physiotherapy and non-operative management (6-week course focusing on scalene and pectoralis stretch)

Patients should undergo a _______ course of physical therapy for non-operative management.

Patients should undergo a 6 week course of physical therapy for non-operative management.

Physical therapy for this condition focuses on: - _______ - _______ - _______ - _______

Physical therapy for this condition focuses on: - scalene stretching - pectoralis stretching - improving shoulder mobility - strengthening the arm

An anterior scalene lidocaine block may provide temporary symptom relief for approximately _______ and can help identify patients likely to benefit from surgical decompression.

An anterior scalene lidocaine block may provide temporary symptom relief for approximately 7 days and can help identify patients likely to benefit from surgical decompression.

Botulinum injection may give an average of _______ of symptom relief.

Botulinum injection may give an average of 6 weeks of symptom relief.

Clinicians should be _______ when choosing patients for surgical intervention.

Clinicians should be selective when choosing patients for surgical intervention.

Rib resection surgery is often performed via the _______ or _______ approach, especially when _______ or _______ is necessary.

Rib resection surgery is often performed via the transaxillary or supraclavicular approach, especially when scalenectomy or cervical rib resection is necessary.