Roos Test

The Roos test is the most useful test. The arms are raised to the horizontal position and the elbows flexed to 90°. The hands are rapidly opened and closed. If numbness or pain is elicited in the hands and forearms, this is a sign of compression and thoracic outlet syndrome.

The history and physical examination is critical in the evaluation of thoracic outlet syndrome. Chest x-rays, concentrating on the possibility of cervical ribs or first rib abnormalities are essential. Electromyogram and ulnar nerve conduction velocity is controversial, however, they should be done. The test may be normal in effective individuals; nonetheless an abnormal test may be a more compelling indication that thoracic outlet syndrome does exist. If there are symptoms of vascular compromise, an angiogram should be obtained. A venogram may be required to evaluate the possibility of subclavian vein thrombosis. If the thoracic outlet syndrome involves arterial vascular compromise, surgery is mandatory, since physiotherapy will do little to relieve the symptoms of the vascular problem. However, if there is neurologic compromise only, a trial of physiotherapy is required. This involves various physical therapy exercises, including shoulder strengthening and arm exercises, as well as strengthening of the upper trapezius and proper posture. Sagging of the shoulder girdle, common among the middle-aged, is a major factor in the syndrome.

In the past, one of the primary surgical modalities for treating thoracic outlet syndrome was transection of the anterior scalene muscles or scalenotomy. This, however, was found to be of limited benefit and in general should only be used for "upper nerve" symptomatology, i.e. that involving the C5,6,7 nerve roots. The lower nerve roots, C8-T1, really are helped little by a scalenotomy, and the more effective treatment is resection of the first rib. It is very important that this resection be complete since partial first rib resections are known to cause recurrent symptoms of thoracic outlet syndrome. The surgical approach to the first rib is usually transaxillary.

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