Thoracic Outlet Syndrome
If you've been experiencing symptoms such as numbness, tingling or pain in your shoulder or arm, it might be a sign of thoracic outlet syndrome (TOS). TOS occurs when the blood vessels or nerves just below your neck are compressed, leading to discomfort or more serious issues like blood clots in the affected areas. Consult a doctor for a proper diagnosis if these symptoms impact your daily life. Understanding more about TOS can empower you to be actively involved in your treatment planning with your healthcare provider, ensuring you receive the most appropriate care for your needs.
What Is Thoracic Outlet Syndrome?
Thoracic outlet syndrome (TOS) is a condition that occurs when nerves, arteries and veins of the arms are compressed as they exit your chest around your collar bone. This compression can lead to pain in the arm, shoulder and neck. The thoracic outlet is the space between your collarbone (clavicle) and your first rib. This narrow passageway is filled with blood vessels, muscles and nerves. Some people have tighter thoracic outlets than others, whether it be from repetitive movements (baseball players), large muscles (weightlifters) or unique anatomy (cervical rib). The squeezing of the nerves and blood vessels at the thoracic outlet can cause a range of symptoms collectively known as TOS.
Thoracic Outlet Syndrome Symptoms
Three types of TOS affect different areas and functions, which means the symptoms can be unique:
- Neurogenic thoracic outlet syndrome (NTOS) is the most common form and can lead to what is known as the “Gilliatt-Sumner hand,” which is characterized by severe weakening in the fleshy base of the thumb. Other symptoms might include a "pins-and-needles" sensation or numbness in the fingers and hand, changes in hand color, cold hands and a dull, aching pain in the neck, shoulder and armpit.
- Venous thoracic outlet syndrome (VTOS) might cause your arm to appear swollen, pale and feel cool to the touch compared to the unaffected arm. You may notice a weak or absent pulse in the affected arm, numbness, tingling, aching or swelling of the arm and fingers, and weakness in the neck or arm.
- Arterial thoracic outlet syndrome (ATOS) can change the color of your hands and fingers and make them more sensitive to cold. Symptoms also include swelling, heaviness, a "pins-and-needles" sensation or numbness and poor blood circulation in the arms, hands and fingers.
A range of factors can cause thoracic outlet syndrome (TOS). Understanding them can help your healthcare team manage and treat your condition effectively:
- Injury: Trauma to the neck or upper chest, such as from a car accident or repetitive movements in sports (such as from being a baseball pitcher or volleyball server) can lead to TOS. Symptoms can be worsened by repeatedly lifting items over your shoulders, such as when stacking boxes.
- Disease: Conditions that cause inflammation or degeneration of the muscles and bones in the thoracic outlet area can also result in TOS.
- Congenital Issues: Some people are born with anatomical differences, like a cervical rib (a condition wherein there is an extra rib above the first rib), which increases their risk of developing TOS.
- Lifestyle Factors: The condition is more common in women than men. Other factors like poor posture and obesity can worsen the problem.
- Psychological Changes: Patients with TOS often experience psychological changes, though it's unclear whether these are a cause or a result of the syndrome.
How To Diagnose Thoracic Outlet Syndrome?
Diagnosing TOS often involves ruling out other conditions that have similar symptoms. Sometimes, a multidisciplinary team may be involved in your diagnosis and treatment. This team could include an orthopedic surgeon, a physical medicine and rehabilitation specialist (physiatrist), physical therapists, a peripheral nerve surgeon and a vascular surgeon. Such a comprehensive approach helps ensure that the diagnosis is as accurate as possible to help create an effective treatment plan for your condition.
Our doctors start by learning about your medical history and conducting a physical examination. We will ask about your symptoms, when they started and how long they have been. We may try to reproduce your symptoms by examining your arm and hand in several positions, checking for:
- Tenderness near the clavicle
- Weakness or a "pins-and-needles" feeling when you raise your hands
- Weakness in the fifth finger
- Paleness in your palm when you raise them above your shoulders with fingers pointing to the ceiling.
Our doctors may also perform other thoracic outlet syndrome tests if needed, such as:
- Anterior Scalene Block: This involves referral to one of our pain management partners for an ultrasound-guided injection of numbing medicine to the anterior scalene muscle in the thoracic outlet, which may provide temporary relief and guide us on whether surgery may still be needed.
- Imaging Tests: Your doctor may order X-rays, CT scans, MRI scans or ultrasounds to get a clearer view of the affected area.
- Additional Diagnostic Tests: These may include nerve conduction studies, electromyography, and special blood circulation tests to explore symptoms further and eliminate other possible causes of your condition.
Surgery is usually considered when TOS dramatically affects your daily life and other nonsurgical treatments are not enough to ease pain. The main goal of surgery is to relieve the pressure in the thoracic outlet by removing or adjusting the tissues that are pressing on the nerves and blood vessels. Deciding to proceed with surgery involves carefully weighing the potential benefits against the risks. Each type of surgery has its advantages and drawbacks. While surgery can be effective in treating TOS, it does carry risks, just like any medical procedure. Talk to your doctor to help you consider how surgery may help improve your symptoms and overall health and the specific surgical approach that might be best for your situation.
Nonsurgical treatment options will be considered first to treat TOS:
- Physical Therapy: Exercises to strengthen the muscles around the shoulder can help better support the collarbone, reducing compression.
- Postural Exercises: These exercises can improve your posture, alleviating pressure on the nerves and blood vessels.
- Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs), like naproxen and ibuprofen, can help ease pain and reduce swelling.
- Weight Loss: Some patients may benefit from reducing their weight if they are overweight, helping decrease stress on the shoulder muscles that support the collarbone.
- Lifestyle Changes: Adjusting your workstation, avoiding strenuous activities and modifying daily activities can help manage symptoms without requiring surgery.
If nonsurgical treatment options fail to relieve symptoms, surgery might be considered. Common surgical interventions include:
- Partial resection of the first rib and anterior scalene muscle.
- Removal of scar tissue around the brachial plexus nerves (neurolysis).
- Removal of scar tissue around the blood vessels (venolysis).
The choice of surgical approach is often based on the patient’s specific conditions and the preference of the surgical team:
- Supraclavicular (SC) Approach: This approach allows for a comprehensive view and extensive decompression of the brachial plexus, a network of nerves on each side of the body that provides sensation and movement to the hand, arm and shoulder.
- Transaxillary (TA) Approach: Complete resection of the first rib through the axillary area (armpit region), typically offering the favorable cosmetic results.
- Paraclavicular (PC) Approach: This approach, used mostly for vascular thoracic outlet syndrome (ATOS and/or VTOS), allows for complete removal of the first rib and associated structures to help relieve pain.
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