Thoracic Outlet Syndrome

What is this syndrome?

Thoracic outlet syndrome refers to complications caused by a “tight space” for nerves, arteries and veins exiting the shoulder area as they travel into the arm. The formal anatomy of this space is the clavicle, first rib and muscular attachments between the two. This space is the thoracic outlet. Problems caused by the narrowing of this space for this syndrome include TOS, nTOS, vTOS, aTOS, Paget-Schroetter Syndrome, Subclavian Artery Aneurysm, Brachial Plexus Nerve Compression, Scalene Anticus Syndrome, Cervical Rib, Subclavian Vein Thrombosis.

What are the signs and symptoms of this problem?

You may feel pain, sometimes suddenly, in your neck or arms along with numbness and tingling in the arm and hand. Usually the pain gets worse when you lift your arms or with repetitive overhead motion. Your arms and hands may be swollen and appear blue, and easily tire. You may develop sores on your fingers that are slow to heal.

What is the cause of these problems?

The narrow space can compress nerves, the subclavian artery or subclavian vein on the side of the throat or upper chest. Occasionally there is an extra rib further narrowing the space which can injure the artery due to bony irritation or cause nerve irritation. Injury to the artery due to an abnormality in a neck rib or other bony irritation. Athletes can present with a swollen arm due to compression of the vein or clotting of the vein due to the space being narrowed by a muscular frame. Repetitive motions that stress the shoulder joint- think baseball pitchers – will also “tighten” the space for these structures and cause arterial, venous or nerve injuries.

How can this syndrome be diagnosed?

It is hard to make the diagnosis with 100% certainty. It all starts with a careful history and physical exam performed by a capable vascular surgeon.

Several type of tests are used to detect thoracic outlet syndrome and determine how to treat it: 

  • Computed tomography (CT) scan
  • Magnetic resonance imagining (MRI)
  • Catheter-based arteriography or venogram
  • Stress maneuver testing—placing the arm or head in certain positions—may be done with any of the above tests.
  • An anesthetic block injection can temporarily improve symptoms and aid diagnosis.
  • Occasionally surgery is necessary to not only make the diagnosis but treat the narrowing too.

What type of treatments are available for this problem?

  • Specialized physical therapy and injections to relieve muscle spasm may resolve your symptoms. This is the first line strategy. Shoulder girdle exercises can often open up the space and relieve the symptoms.
  • If symptoms are severe and persist and you are a good candidate for surgery, a procedure called thoracic outlet decompression is the next step. This entails removing the 1strib and releasing muscular attachments to widen the space.
  • If arterial compression is diagnosed, a surgery called thoracic outlet decompression is the next step. Depending on the damage to the artery, an arterial bypass may be part of this surgery.
  • If arm swelling or a blood clot in the vein is due to thoracic outlet compression, thoracic outlet decompression is the next step.
  • If there is a clot in the vein, you may be directed to have thrombolytic therapy. 
  • You may also benefit from some type of vein reconstruction: angioplasty, patch angioplasty, or venous bypass.

Metrohealth Vascular surgeons have treated this problem often and typically work in tandem with our shoulder surgeons and interventional heart doctors to optimize treatment for the each patient. 

Content reprinted with permission from the Society for Vascular Surgery® (SVS).

 

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