The Steps in the conduct of a supraclavicular thoracic outlet decompression
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Introduction:

The patient is a 48 year-old woman with a history of repetitive upper extremity factory work and bilateral carpal tunnel release in the past. For several years, she noted the slow onset of severe right shoulder and arm pain, which has progressively worsened. She had severe sharp pains in the right neck, shoulder, lateral upper arm, and forearm, especially with elevation of the arm. There was occasional numbness and paresthesia. In addition, she occasionally had grasp weakness, including dropping drinking cups without warning.

EMG was essentially negative. Cervical spine films revealed degenerative disc disease throughout the cervical spine along with osteophytes and narrowing of the right neural foramina at C5-6 and C6-7. Chest x-ray was negative for cervical ribs. MRI showed only mild abnormalities and cervical spine decompression was not felt to be indicated. Thoracic outlet syndrome (TOS) was felt to be the patient's primary problem and treatment was suggested. She underwent a program of physical therapy with which she was quite compliant but this has afforded little relief.

On examination, she appeared well. The carotid, radial, and ulnar pulses were strong. There was supraclavicular tenderness as well as some tenderness in the deltoid region. The was no edema. The neurologic exam was grossly intact. Elevation abduction stress test (EAST) was strongly positive for pain after only 10 sec. She requested surgical thoracic outlet decompression.


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http://www.pvss.org/Cases/tos/tos2.htm