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The brachial plexus of nerves and the subclavian/axillary artery and vein comprise a neurovascular bundle that is often compressed in the lower neck/upper thoracic region, causing a condition known as thoracic outlet syndrome (TOS). There are actually four different forms of TOS, each named for the region where the compression occurs (Image 1). One is called anterior scalene syndrome because the neurovascular contents are entrapped and compressed between the anterior and middle scalene muscles. The second is called costoclavicular syndrome because the entrapment/compression occurs between the first rib (cost is Latin for "rib") and the clavicle. The third is called pectoralis minor syndrome because the entrapment/ compression occurs between the pectoralis minor and the rib cage. The fourth type of TOS occurs due to the presence of a genetic anomaly that creates what is called a cervical rib, which is a formation of bone off the seventh cervical vertebra (C7). The first three types of TOS—anterior scalene, costoclavicular, and pectoralis minor syndromes—are caused by soft- tissue postural dysfunction and will respond well to manual and movement therapy care. Therefore, the emphasis for anyone in the field of bodywork should be placed on these forms of TOS. The fourth type—cervical rib TOS—being due to a relatively rare bony anomaly (which occurs in approximately 1–2 percent of the population) is not readily treatable with manual and movement therapy and is therefore of less importance to bodyworkers. The Brachial Plexus and Thoracic Outlet Syndrome Understanding Signs and Symptoms By Joseph E. Muscolino, DC Middle scalene Anterior scalene Brachial plexus trunks Musculocutaneous nerve Median nerve Ulnar nerve Axillary nerve Radial nerve Pectoralis minor Brachial plexus cords Subclavius Subclavian artery Cervical rib T1 C8 C7 C6 C5 C3 C6 1st rib Axillary artery and vein Thoracic outlet syndrome is the name given to a set of neurovascular compression syndromes that affect the brachial plexus of nerves and/or the subclavian/axillary artery and vein where they outlet from the thorax into the upper extremity. Note the presence of a cervical rib on the model's left side. Images courtesy Joseph E. Muscolino. Illustrations by Giovanni Rimasti. Photography by Yanik Chauvin and Joseph E. Muscolino. 60 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 7 1

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