Thoracic Outlet Syndrome

Many people suffer unnecessarily every day due to thoracic outlet syndrome. Symptoms include pain in the neck, shoulder, and arms with numbness in the arms and fingers also occurring.
There are three subcategories of thoracic outlet syndrome;

• Neurogenic thoracic outlet syndrome
• Vascular thoracic outlet syndrome
• Nonspecific or disputed thoracic outlet syndrome

The first involved compression of the nerves in the brachial plexus, the second involves compression of the subclavian artery and other blood vessels, and the third has no specific source identified as the cause of the symptoms.

Due to pressure on blood vessels caused by the condition, some patients may also have cold extremities and even bluish discoloration of the fingers or hands. There is usually no clear observable cause for these symptoms, making patients understandably concerned and anxious to get a prompt diagnosis. Unfortunately many sufferers do not get a quick diagnosis and may be misdiagnosed with fibromyalgia, rotator cuff injury, cervical spinal stenosis or arthritis, multiple sclerosis, complex regional pain syndrome, or even tumors of the spinal cord.

In many sufferers the syndrome may be alleviated by simple physical therapy and medication. X-rays, MRI or CT scans usually highlight the problem if it is connected to the presence of an ‘extra’, cervical, rib or other structural anomaly putting pressure on the tissues in or around the thoracic outlet. Patients may find that their symptoms are exacerbated when lifting weights (or as the muscles grow larger), trauma to the area, inflammation, or simply raising their arm. Diagnosis takes the form of physical tests, such as applying pressure to the thoracic region, arm lifts, and scans such as x-rays to detect the presence of anomalous growths or pressure on the area.

How Thoracic Outlet Syndrome is treated

Treatment will usually involve surgery if the presence of a cervical rib is felt to be causing the compression in the area. The muscles attaching to the cervical rib will also be removed to free up space for the nerves and blood vessels. Other anomalous structural defects can cause thoracic outlet syndrome, such as osteophyte growth, ligament calcification, and extensive muscle growth with resulting nerve compression.

Thoracic Outlet Syndrome Causes

Thoracic outlet syndrome is caused by compression of nerves and/or blood vessels in the area between the bottom of the neck and the armpit, including the brachial plexus and the subclavian artery and vein. This is known as the thoracic area, including the thoracic outlet and contains numerous structures and tissues competing for space. There is a multitude of muscle, bone, blood vessels, and nerves in this area making any reduction in space highly likely to impinge upon those components. The condition is more likely to occur in women and the usual age of patients at diagnosis is 20-50yrs old.

Inflammation, due to infection or trauma can cause thoracic outlet syndrome, as can the enlargement of the muscles in the area through activities such as weightlifting or resistance training. Another common cause of thoracic outlet syndrome is the presence of an ‘extra’, cervical rib in the neck. In some people this has no negative effects, but in others it can cause serious reductions in the space available for other

important anatomical elements to pass through or function. This is particularly exacerbated by the fact that the cervical rib also has muscles connecting it to the other structures in the neck which are liable to become inflamed or strained causing increased space restrictions. If a contact sports injury involves trauma to the brachial plexus, and thoracic region, then symptoms of thoracic outlet syndrome may develop or worsen in cases where they are already present. Fractures of the cervical rib often lead to this condition and may require surgical intervention if the fracture does not heal correctly. Swimmers, football players, linemen, tennis players, and weightlifters are commonly amongst those diagnosed with the syndrome. Car accidents and work-related accidents and trauma can trigger symptoms in some cases.

The presence of a tumor causing compression in the area is highly unlikely, but is usually ruled out through blood tests and scans. Apical lung tumours, again rare, may occasionally cause thoracic outlet syndrome. Obese and overweight patients may find that their symptoms are significantly alleviated by achieving and maintaining a healthy weight. On many occasions there is no simple explanation for the presence of the syndrome and may simply be due to congenitally narrowed space in the thoracic outlet which is exacerbated by lifestyle factors, and felt more acutely when raising the arms or on movement of the neck and shoulders.

Symptoms of Thoracic Outlet Syndrome

Symptoms of thoracic outlet syndrome are reproduced when the arm is extended or raised above the shoulder. This movement puts extra pressure on the thoracic outlet space and causes compression of the structures in the area such as the nerves and blood vessels responsible for circulation and nerve signal transmission in the shoulders, neck, arms and hands. Pain can be felt acutely, chronically, intermittently, as a dull ache, or as intense burning or stabbing pain. Symptoms vary from person to person but generally include arm, shoulder, and neck pain with numbness and/or impaired circulation to the hands. Fingers may turn a bluish colour as the circulation is reduced to the area. As the blood flow returns this may cause intense pain such as is experienced by those with Raynaud’s disease. Weakness of the arms and hands, with reductions in manual dexterity, grip strength, and ability to conduct simple tasks, such as opening a jar, can all be signs of thoracic outlet syndrome.

Neurogenic TOS Symptoms

If neurogenic thoracic outlet syndrome is present then the patient is likely to feel pins and needles upon raising the affected arm above the shoulder. The presence of Gillat-Summer hand characterizes this condition and is noticeable as severe wasting of the flesh at the base of the thumb. Numbness, dull aching, or pain in the neck, shoulder and armpit are also symptoms of neurogenic thoracic outlet syndrome, as is loss of sensation along the bottom of the hand and arm. These symptoms may be confused with carpal tunnel syndrome in some cases, but are not part of the same condition.

Vascular TOS Symptoms

Vascular thoracic outlet syndrome commonly presents with a pallor to the palm in the affected hand, making the hand cold to touch, and spreading that circulatory loss up into the affected arm. This is likely to be increased or reproduced upon raising the affected arm and can lead to a noticeably different color in one arm from the other. The arm may also feel unnaturally heavy and numb and symptoms may appear in tandem with those of neurogenic thoracic outlet syndrome. Disputed or nonspecific thoracic outlet syndrome may preset with any or all of these symptoms and poses a difficult diagnostic puzzle for physicians.

Overlapping Symptoms

Commonly, symptoms are considered similar to those of herniated cervical discs, pinched nerves, and neurological damage. Diagnosis may be difficult due to the varied nature of the problem and the overlap of symptoms with more recognized conditions. Ensuring a full and frank disclosure of sensations, including their frequency, intensity, precipitating factors, and duration can aid a physician in making a diagnosis. Remaining stoic in the face of pain does not lead to a prompt diagnosis and adequate treatment. If the symptoms are acute and involve chest and neck pain with radiating pain down the arm then medical attention should be sought immediately as this can indicate alternative pathology such as a myocardial infarction (heart attack), or acute disc herniation in the cervical spine.

Diagnosis of Thoracic Outlet Syndrome

Thoracic outlet syndrome is becoming more widely known to general practitioners but is usually not the initial thought when determining a diagnosis. The symptoms can be varied, intermittent, and overlap with many other conditions such as disc bulging or herniated disc, pinched nerves, Raynaud’s syndrome, muscle strains, diabetic neuropathy, and numerous other medical ailments. Misdiagnosis as fibromyalgia, multiple sclerosis, rotator cuff injuries, cervical disc degeneration, spinal stenosis, cervical arthritis, complex regional pain syndrome, or tumors of the spine are unlikely but may delay the correct diagnosis and treatment of the condition thereby potentiating irreversible damage to the brachial plexus and blood vessels in the thoracic outlet.

Steps of Diagnosis

A physician will conduct a physician examination, and take a thorough history including trauma and history of infections. Car accidents and work-related injuries commonly trigger symptoms. Even repetitive minor trauma, such as from playing contact sports, can lead to thoracic outlet syndrome, making it very important to inform the diagnosing physician of such injuries. The doctor may ask the patient to raise their arms to see if the symptoms are reproduced. If the patient experiences numbness, tingling, pins and needles, in the arm and hands (particularly in the little finger) then this can indicate the presence of neurogenic thoracic outlet syndrome. If the palm of the hand turns pale and the fingers and forearm are cold to the touch upon elevation above shoulder height then the patient is likely to be diagnosed with vascular thoracic outlet syndrome. Disputed or nonspecific thoracic outlet syndrome poses a difficult diagnostic quandary for most physicians as symptoms may overlap and have no clear pathogenesis.

Reproducing Symptoms

Pressure placed on the area between the armpit and the lower neck can also reproduce the symptoms, as can stretching the neck away from the body. These reproductions of symptoms are caused by the movements decreasing the spaces in the thoracic region, putting the nerves and blood vessels under acute pressure. Measuring the pulse in the wrist whilst the arm is raised can also assist the physician in diagnosing thoracic outlet syndrome as the pulse is likely to weaken, or in extreme cases disappear altogether, where pressure is placed on the blood vessels in the thoracic outlet.

Diagnostic Tests

Nerve stimulation tests, such as electromyograms can support a diagnosis, as can angiograms and x-rays. MRI scans may show compression of the brachial plexus area and thoracic region and highlight any soft tissue inflammation, pinched nerves and compressed blood vessels. X-rays can be helpful in showing the presence of a cervical rib and the concomitant reduction of space in the thoracic region.

Treatment of Thoracic Outlet Syndrome

Conservative treatment of thoracic outlet syndrome is indicated in most cases with the aim being to reduce the pressure on the area by controlling inflammation and exacerbating activities such as weightlifting. Gentle stretching exercises that help to open the tissues in the thoracic outlet can be useful and are conducted with and without weights in the hands depending on the patient. These exercises can help bring the thoracic outlet to a relaxed position thus allowing the free flow of blood through the area and the correct nerve signal transmission, thereby minimizing pain and other symptoms of thoracic outlet syndrome. Attempting these exercises at home is not advisable as there are specialist in the area with knowledge of which movements can alleviate the syndrome and which ones will exacerbate the condition. The specialist is likely to give patients exercises they can conduct safely at home, such as shoulder-shrugs which work to relax the thoracic area.

Alleviating Thoracic Outlet Syndrome

Guidance on correct posture to alleviate thoracic outlet syndrome should be sought, and most likely will advise patients to avoid holding their arms overhead or outstretched for prolonged periods. Many people will need to alter their sleeping habits if they regularly sleep with their arm extended above the head. If working at computers for a large part of the day, care should be taken to minimize the time spent with the arms extended at the keyboard. Many employers will assist in providing ergonomic guidance and equipment, or adequate rest periods in order to keep their employees healthy and productive at work. Correct manual handling training is also paramount so as to avoid work-based injury, and heavy loads should not be lifted over the head by anyone suffering from thoracic outlet syndrome.

Medications for Thoracic Outlet Syndrome

Further benefits can be achieved if patients who are obese or overweight are assisted in managing their BMI and general health. By maintaining a healthy weight the symptoms may retreat or disappear entirely as the excess pressure put on the thoracic region by weight on the upper body is reduced. Improvements in overall fitness will also help these patients, especially as those who have a lot of adipose tissue (fat) have a higher level of pain production in the body. NSAIDs can help alleviate the condition if inflammation is present. Alternative anti-inflammatories may also be useful long-term to avoid some of the potential side-effects of NSAIDs. Analgesics and cortisone injections may also be used in some cases to reduce the intensity of severe pain.

Surgery for Thoracic Outlet Syndrome

As a last resort, if six months or so of conservative management has failed to alleviate symptoms to a manageable degree, surgery may be suggested. This can help to open up and decompress the thoracic outlet, and may involve removal of a cervical rib and its attached muscles so as to relieve the pressure on the nerves and blood vessels in the area. If surgery is delayed in extreme cases then the ongoing compression of the nerves and blood vessels may result in permanent damage. In rare cases there may be other surgery required to remove bony growths in the area, scar tissue from previous trauma, or even tumors, although these are all highly unlikely to be present in this region.