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86 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 7 The brachial plexus is the group of nerves in the lower cervical and upper thoracic region that is vulnerable to compression and tension pathology in the various thoracic outlet syndromes. The brachial plexus is comprised of nerve fibers that originate at the nerve roots from the C5 to T1 level. Important anatomical relationships make portions of it more vulnerable to compression and tension pathology in this region. Adverse nerve compression can occur when the lower portion of the brachial plexus is pressed against underlying structures. Therefore, the fibers that are contained within the inferior trunk and eventually split off into the medial cord of the brachial plexus are the ones most vulnerable (Image 2). Notice from this image that the T1 nerve root is actually lower than the first rib. As a result, its fibers are under greater tension when other obstructions like a cervical rib are present. In TOS, vascular structures may also be compressed in this region. The most common problems occur to the subclavian artery or vein. Both these structures follow a curved pathway over the top of the first rib. Obstructions in their path, such as a cervical rib, fibrous bands, or narrow opening between the scalene muscles, make them vulnerable to compression in this region. The scalene muscles play a key role in thoracic outlet pathologies. However, it is only the anterior and middle scalene muscles that may potentially compress neurological or vascular structures (Image 3). Nerves and the subclavian artery course between these two muscles in what is referred to as the you could be discussing potential tissue pathologies that exist anywhere within the shaded region of Image 1. Anatomically, the upper opening of the rib cage is defined as the thoracic inlet (as the respiratory and digestive tracts enter the thorax). Consequently, the lower opening of the rib cage is the thoracic outlet. However, the lower opening of the rib cage is a long way from where the nerve and vascular compression occurs in TOS. The term thoracic outlet is more commonly applied to the superior opening of the rib cage. The use of this term in relation to the upper opening of the rib cage is likely attributed to the focus of vascular surgeons on the aorta and its exit from the upper rib cage, and, therefore, it would be more appropriately termed an outlet with that view. To fully understand the development of problems in this area, we need to dig deeper into some of the key anatomical relationships. technique SCIENCE OF NERVES The Many Faces of Thoracic Outlet Syndromes By Whitney Lowe 1 General Region of thoracic outlet. Image is from 3D4Medical's Complete Anatomy application. Thoracic outlet syndrome (TOS) is both common and highly misunderstood. One reason for the confusion around this condition is that the term can refer to a number of different syndromes involving different tissues. More accurately, the variety of pathologies should be categorized in the plural as thoracic outlet syndromes and named more accurately according to the tissues involved: cervical rib compression, anterior scalene, costoclavicular, and pectoralis minor syndromes. In this column, we explore the details of the four variations that can be involved in thoracic outlet syndrome, the tissues that may be involved, anatomical anomalies, expected symptoms of each, and massage therapy strategies that are helpful. ANATOMICAL BACKGROUND What makes this syndrome even more convoluted is that there isn't full agreement on where the thoracic outlet is. When you speak of "thoracic outlet syndrome,"

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