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DOI: 10.1148/rg.266055079
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Imaging Assessment of Thoracic Outlet Syndrome1

Xavier Demondion, MD, Pascal Herbinet, MD, Serge Van Sint Jan, PhD, Nathalie Boutry, MD, Christophe Chantelot, MD and Anne Cotten, MD

1 From the Departments of Musculoskeletal Radiology (X.D., P.H., N.B., A.C.) and Orthopedic Surgery B (C.C.), Hôpital Roger Salengro, Bd du Professeur Jules Leclercq, 59037 Lille Cedex, France; the Anatomy Laboratory, Faculté de Médecine Henri Warembourg, Lille, France (X.D.); and the Anatomy Laboratory, Faculté de Médecine, Université Libre de Bruxelles, Brussels, Belgium (S.V.S.J.). Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received April 6, 2005; revision requested June 1 and received January 12, 2006; accepted February 6. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Diagram shows the three compartments of the thoracic outlet and their components. AS = anterior scalene muscle, BP = brachial plexus, C = clavicle, CC = costoclavicular space, IT = interscalene triangle, MS = middle and posterior scalene muscles, Pmi = pectoralis minor muscle, RP = retropectoralis minor space, SA = subclavian artery, SM = subclavius muscle, SV = subclavian vein.

 

Figure 2
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  		Figure 2a.  Anatomic sections show the compartments of the thoracic outlet. (a) Section obtained after removal of the pectoralis major muscle shows the costoclavicular space (red oval) and retropectoralis minor space (yellow oval). Pmi = pectoralis minor muscle. (b) Section obtained after removal of the pectoralis minor muscle shows the neurovascular bundle. C = clavicle, straight black arrow = axillary artery, curved black arrow = axillary vein, white arrow = brachial plexus.

 

Figure 2
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  		Figure 2b.  Anatomic sections show the compartments of the thoracic outlet. (a) Section obtained after removal of the pectoralis major muscle shows the costoclavicular space (red oval) and retropectoralis minor space (yellow oval). Pmi = pectoralis minor muscle. (b) Section obtained after removal of the pectoralis minor muscle shows the neurovascular bundle. C = clavicle, straight black arrow = axillary artery, curved black arrow = axillary vein, white arrow = brachial plexus.

 

Figure 3
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  		Figure 3a.  Assessment of the interscalene triangle with different imaging modalities. Sagittal gross anatomic section (a), computed tomographic (CT) image (b), T1-weighted magnetic resonance (MR) image (c), and sonogram (d) show the anterior scalene muscle (AS), clavicle (C), fifth cervical nerve root (C5), sixth cervical nerve root (C6), seventh cervical nerve root (C7), eighth cervical nerve root (C8), first rib (FR), middle and posterior scalene muscles (MS), subclavian artery (SA), subclavian vein (SV), and first thoracic nerve root (T1).

 

Figure 3
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  		Figure 3b.  Assessment of the interscalene triangle with different imaging modalities. Sagittal gross anatomic section (a), computed tomographic (CT) image (b), T1-weighted magnetic resonance (MR) image (c), and sonogram (d) show the anterior scalene muscle (AS), clavicle (C), fifth cervical nerve root (C5), sixth cervical nerve root (C6), seventh cervical nerve root (C7), eighth cervical nerve root (C8), first rib (FR), middle and posterior scalene muscles (MS), subclavian artery (SA), subclavian vein (SV), and first thoracic nerve root (T1).

 

Figure 3
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  		Figure 3c.  Assessment of the interscalene triangle with different imaging modalities. Sagittal gross anatomic section (a), computed tomographic (CT) image (b), T1-weighted magnetic resonance (MR) image (c), and sonogram (d) show the anterior scalene muscle (AS), clavicle (C), fifth cervical nerve root (C5), sixth cervical nerve root (C6), seventh cervical nerve root (C7), eighth cervical nerve root (C8), first rib (FR), middle and posterior scalene muscles (MS), subclavian artery (SA), subclavian vein (SV), and first thoracic nerve root (T1).

 

Figure 3
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  		Figure 3d.  Assessment of the interscalene triangle with different imaging modalities. Sagittal gross anatomic section (a), computed tomographic (CT) image (b), T1-weighted magnetic resonance (MR) image (c), and sonogram (d) show the anterior scalene muscle (AS), clavicle (C), fifth cervical nerve root (C5), sixth cervical nerve root (C6), seventh cervical nerve root (C7), eighth cervical nerve root (C8), first rib (FR), middle and posterior scalene muscles (MS), subclavian artery (SA), subclavian vein (SV), and first thoracic nerve root (T1).

 

Figure 4
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  		Figure 4a.  Assessment of the costoclavicular space with different imaging modalities. Sagittal gross anatomic section (a), sagittal CT image (b), sagittal T1-weighted MR image (c), and sonogram obtained with a supraclavicular approach (d) show the anterior scalene muscle (AS), clavicle (C), first rib (FR), lateral nerve cord (LC), medial nerve cord (MC), omohyoid muscle (OH), posterior nerve cord (PC), subclavian artery (SA), subclavius muscle (SM), and subclavian vein (SV).

 

Figure 4
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  		Figure 4b.  Assessment of the costoclavicular space with different imaging modalities. Sagittal gross anatomic section (a), sagittal CT image (b), sagittal T1-weighted MR image (c), and sonogram obtained with a supraclavicular approach (d) show the anterior scalene muscle (AS), clavicle (C), first rib (FR), lateral nerve cord (LC), medial nerve cord (MC), omohyoid muscle (OH), posterior nerve cord (PC), subclavian artery (SA), subclavius muscle (SM), and subclavian vein (SV).

 

Figure 4
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  		Figure 4c.  Assessment of the costoclavicular space with different imaging modalities. Sagittal gross anatomic section (a), sagittal CT image (b), sagittal T1-weighted MR image (c), and sonogram obtained with a supraclavicular approach (d) show the anterior scalene muscle (AS), clavicle (C), first rib (FR), lateral nerve cord (LC), medial nerve cord (MC), omohyoid muscle (OH), posterior nerve cord (PC), subclavian artery (SA), subclavius muscle (SM), and subclavian vein (SV).

 

Figure 4
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  		Figure 4d.  Assessment of the costoclavicular space with different imaging modalities. Sagittal gross anatomic section (a), sagittal CT image (b), sagittal T1-weighted MR image (c), and sonogram obtained with a supraclavicular approach (d) show the anterior scalene muscle (AS), clavicle (C), first rib (FR), lateral nerve cord (LC), medial nerve cord (MC), omohyoid muscle (OH), posterior nerve cord (PC), subclavian artery (SA), subclavius muscle (SM), and subclavian vein (SV).

 

Figure 5
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  		Figure 5a.  Assessment of the retropectoralis minor space with different imaging modalities. Sagittal gross anatomic section (a), CT image (b), T1-weighted MR image (c), and sonogram (d) show the axillary artery (AA), axillary vein (AV), clavicle (C), lateral nerve cord (LC), medial nerve cord (MC), posterior nerve cord (PC), pectoralis minor muscle (Pmi), pectoralis major muscle (Pmj), serratus anterior muscle (Sea), and scapula (SP).

 

Figure 5
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  		Figure 5b.  Assessment of the retropectoralis minor space with different imaging modalities. Sagittal gross anatomic section (a), CT image (b), T1-weighted MR image (c), and sonogram (d) show the axillary artery (AA), axillary vein (AV), clavicle (C), lateral nerve cord (LC), medial nerve cord (MC), posterior nerve cord (PC), pectoralis minor muscle (Pmi), pectoralis major muscle (Pmj), serratus anterior muscle (Sea), and scapula (SP).

 

Figure 5
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  		Figure 5c.  Assessment of the retropectoralis minor space with different imaging modalities. Sagittal gross anatomic section (a), CT image (b), T1-weighted MR image (c), and sonogram (d) show the axillary artery (AA), axillary vein (AV), clavicle (C), lateral nerve cord (LC), medial nerve cord (MC), posterior nerve cord (PC), pectoralis minor muscle (Pmi), pectoralis major muscle (Pmj), serratus anterior muscle (Sea), and scapula (SP).

 

Figure 5
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  		Figure 5d.  Assessment of the retropectoralis minor space with different imaging modalities. Sagittal gross anatomic section (a), CT image (b), T1-weighted MR image (c), and sonogram (d) show the axillary artery (AA), axillary vein (AV), clavicle (C), lateral nerve cord (LC), medial nerve cord (MC), posterior nerve cord (PC), pectoralis minor muscle (Pmi), pectoralis major muscle (Pmj), serratus anterior muscle (Sea), and scapula (SP).

 

Figure 6
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  		Figure 6a.  Effect of arm elevation on the interscalene triangle in an asymptomatic subject. Sagittal T1-weighted MR images obtained with the arm alongside the body (a) and after arm elevation (b) show narrowing of the space between the anterior scalene muscle and the clavicle with physiologic compression of the subclavian vein (arrow). No other modifications of the interscalene triangle occurred after arm elevation.

 

Figure 6
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  		Figure 6b.  Effect of arm elevation on the interscalene triangle in an asymptomatic subject. Sagittal T1-weighted MR images obtained with the arm alongside the body (a) and after arm elevation (b) show narrowing of the space between the anterior scalene muscle and the clavicle with physiologic compression of the subclavian vein (arrow). No other modifications of the interscalene triangle occurred after arm elevation.

 

Figure 7
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  		Figure 7a.  Effect of arm elevation on the costoclavicular space in an asymptomatic subject. Sagittal T1-weighted MR images obtained with the arm alongside the body (a) and after arm elevation (b) show narrowing of the costoclavicular space.

 

Figure 7
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  		Figure 7b.  Effect of arm elevation on the costoclavicular space in an asymptomatic subject. Sagittal T1-weighted MR images obtained with the arm alongside the body (a) and after arm elevation (b) show narrowing of the costoclavicular space.

 

Figure 8
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  		Figure 8a.  Effect of arm elevation on the retropectoralis minor space in an asymptomatic subject. Sagittal T1-weighted MR images obtained with the arm alongside the body (a) and after arm elevation (b) show narrowing of the retropectoralis minor space.

 

Figure 8
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  		Figure 8b.  Effect of arm elevation on the retropectoralis minor space in an asymptomatic subject. Sagittal T1-weighted MR images obtained with the arm alongside the body (a) and after arm elevation (b) show narrowing of the retropectoralis minor space.

 

Figure 9
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  		Figure 9.  Cervical plain radiograph of a 27-year-old woman shows both a cervical rib (arrow) and an elongated C7 transverse process (arrowhead).

 

Figure 10
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  		Figure 10a.  Fibrous band in a 42-year-old woman with neurovascular symptoms. Contiguous sagittal (a, b) (b obtained lateral to a) and coronal (c) T1-weighted MR images of the interscalene triangle show a tiny fibrous band (arrowhead), which pushes forward the subclavian artery (arrow in a and b). Arrow in c = elongated C7 transverse process.

 

Figure 10
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  		Figure 10b.  Fibrous band in a 42-year-old woman with neurovascular symptoms. Contiguous sagittal (a, b) (b obtained lateral to a) and coronal (c) T1-weighted MR images of the interscalene triangle show a tiny fibrous band (arrowhead), which pushes forward the subclavian artery (arrow in a and b). Arrow in c = elongated C7 transverse process.

 

Figure 10
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  		Figure 10c.  Fibrous band in a 42-year-old woman with neurovascular symptoms. Contiguous sagittal (a, b) (b obtained lateral to a) and coronal (c) T1-weighted MR images of the interscalene triangle show a tiny fibrous band (arrowhead), which pushes forward the subclavian artery (arrow in a and b). Arrow in c = elongated C7 transverse process.

 

Figure 11
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  		Figure 11a.  Excessive callus of the clavicle in a 36-year-old patient with neurologic TOS. Anteroposterior plain radiograph of the clavicle (a) and sagittal T1-weighted MR images obtained with the arms alongside the body (b) and after hyperabduction (c) show excessive callus (curved arrow). A close relationship between the posterior part of the brachial plexus (straight arrow in b and c) and the excessive callus is seen after arm elevation.

 

Figure 11
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  		Figure 11b.  Excessive callus of the clavicle in a 36-year-old patient with neurologic TOS. Anteroposterior plain radiograph of the clavicle (a) and sagittal T1-weighted MR images obtained with the arms alongside the body (b) and after hyperabduction (c) show excessive callus (curved arrow). A close relationship between the posterior part of the brachial plexus (straight arrow in b and c) and the excessive callus is seen after arm elevation.

 

Figure 11
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  		Figure 11c.  Excessive callus of the clavicle in a 36-year-old patient with neurologic TOS. Anteroposterior plain radiograph of the clavicle (a) and sagittal T1-weighted MR images obtained with the arms alongside the body (b) and after hyperabduction (c) show excessive callus (curved arrow). A close relationship between the posterior part of the brachial plexus (straight arrow in b and c) and the excessive callus is seen after arm elevation.

 

Figure 12
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  		Figure 12a.  Scalenus minimus muscle in a 35-year-old woman with neurologic TOS. Sagittal gross anatomic section (a) and sagittal T1-weighted MR image (b) show a scalenus minimus muscle (straight arrow), which passes between the C8 nerve root (arrowhead) and subclavian artery (curved arrow).

 

Figure 12
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  		Figure 12b.  Scalenus minimus muscle in a 35-year-old woman with neurologic TOS. Sagittal gross anatomic section (a) and sagittal T1-weighted MR image (b) show a scalenus minimus muscle (straight arrow), which passes between the C8 nerve root (arrowhead) and subclavian artery (curved arrow).

 

Figure 13
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  		Figure 13a.  Arterial compression in a 37-year-old man. (a, b) Sagittal reformatted CT images, obtained before the entrance to the costoclavicular space (a) and inside the costoclavicular space (b) after arm hyperabduction, show a 50% reduction in the cross-sectional area of the subclavian artery (arrow) at the entrance to the costoclavicular space. (c) Three-dimensional reformatted view shows the arterial compression and the relationship of the artery (arrow) to the surrounding anatomic structures.

 

Figure 13
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  		Figure 13b.  Arterial compression in a 37-year-old man. (a, b) Sagittal reformatted CT images, obtained before the entrance to the costoclavicular space (a) and inside the costoclavicular space (b) after arm hyperabduction, show a 50% reduction in the cross-sectional area of the subclavian artery (arrow) at the entrance to the costoclavicular space. (c) Three-dimensional reformatted view shows the arterial compression and the relationship of the artery (arrow) to the surrounding anatomic structures.

 

Figure 13
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  		Figure 13c.  Arterial compression in a 37-year-old man. (a, b) Sagittal reformatted CT images, obtained before the entrance to the costoclavicular space (a) and inside the costoclavicular space (b) after arm hyperabduction, show a 50% reduction in the cross-sectional area of the subclavian artery (arrow) at the entrance to the costoclavicular space. (c) Three-dimensional reformatted view shows the arterial compression and the relationship of the artery (arrow) to the surrounding anatomic structures.

 

Figure 14
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  		Figure 14.  Venous compression in a 29-year-old woman. Axial CT image obtained after venous administration of contrast material shows collateral pathways (straight arrows), which are a consequence of subclavian vein thrombosis (curved arrow). Venous compression is frequently observed in asymptomatic persons after arm hyperabduction; therefore, this finding must be interpreted carefully. Venous thrombosis and collateral circulation are objective but delayed signs of pathologic venous compression.

 

Figure 15
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  		Figure 15a.  Arterial compression in a 24-year-old woman. (a, b) Sagittal T1-weighted MR images, obtained after arm hyperabduction, show compression of the subclavian artery (arrow) in the costoclavicular space. Compare the cross-sectional area of the artery inside the costoclavicular space (a) with the cross-sectional area at the exit from the costoclavicular space (b). (c) MR angiogram shows the arterial stenosis (arrow).

 

Figure 15
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  		Figure 15b.  Arterial compression in a 24-year-old woman. (a, b) Sagittal T1-weighted MR images, obtained after arm hyperabduction, show compression of the subclavian artery (arrow) in the costoclavicular space. Compare the cross-sectional area of the artery inside the costoclavicular space (a) with the cross-sectional area at the exit from the costoclavicular space (b). (c) MR angiogram shows the arterial stenosis (arrow).

 

Figure 15
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  		Figure 15c.  Arterial compression in a 24-year-old woman. (a, b) Sagittal T1-weighted MR images, obtained after arm hyperabduction, show compression of the subclavian artery (arrow) in the costoclavicular space. Compare the cross-sectional area of the artery inside the costoclavicular space (a) with the cross-sectional area at the exit from the costoclavicular space (b). (c) MR angiogram shows the arterial stenosis (arrow).

 

Figure 16
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  		Figure 16a.  Arterial compression in a 47-year-old man. Contiguous sagittal T1-weighted MR images, obtained after arm elevation, show compression of the subclavian artery (arrow) by a cervical rib (arrowhead) in the costoclavicular space.

 

Figure 16
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  		Figure 16b.  Arterial compression in a 47-year-old man. Contiguous sagittal T1-weighted MR images, obtained after arm elevation, show compression of the subclavian artery (arrow) by a cervical rib (arrowhead) in the costoclavicular space.

 

Figure 16
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  		Figure 16c.  Arterial compression in a 47-year-old man. Contiguous sagittal T1-weighted MR images, obtained after arm elevation, show compression of the subclavian artery (arrow) by a cervical rib (arrowhead) in the costoclavicular space.

 

Figure 17
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  		Figure 17a.  Neurovascular TOS in a 20-year-old woman. Consecutive sagittal T1-weighted MR images of the costoclavicular space, displayed from medial (a) to lateral (c), show compression of the brachial plexus (arrowhead) in a and b and compression of the subclavian artery (arrow) in a. Compare the caliber of the artery in a and in b and c and the morphology of the brachial plexus in a and b and in c.

 

Figure 17
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  		Figure 17b.  Neurovascular TOS in a 20-year-old woman. Consecutive sagittal T1-weighted MR images of the costoclavicular space, displayed from medial (a) to lateral (c), show compression of the brachial plexus (arrowhead) in a and b and compression of the subclavian artery (arrow) in a. Compare the caliber of the artery in a and in b and c and the morphology of the brachial plexus in a and b and in c.

 

Figure 17
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  		Figure 17c.  Neurovascular TOS in a 20-year-old woman. Consecutive sagittal T1-weighted MR images of the costoclavicular space, displayed from medial (a) to lateral (c), show compression of the brachial plexus (arrowhead) in a and b and compression of the subclavian artery (arrow) in a. Compare the caliber of the artery in a and in b and c and the morphology of the brachial plexus in a and b and in c.

 

Figure 18
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  		Figure 18a.  Neurogenic TOS in a 44-year-old woman. Sagittal T1-weighted MR images, obtained with the arms alongside the body (a) and after arm elevation (b), show narrowing of the costoclavicular space after hyperabduction and compression of the brachial plexus (straight arrow) between the clavicle (curved arrow) and first rib (arrowhead).

 

Figure 18
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  		Figure 18b.  Neurogenic TOS in a 44-year-old woman. Sagittal T1-weighted MR images, obtained with the arms alongside the body (a) and after arm elevation (b), show narrowing of the costoclavicular space after hyperabduction and compression of the brachial plexus (straight arrow) between the clavicle (curved arrow) and first rib (arrowhead).

 




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