Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a condition caused by compression of nerves or blood vessels in the thoracic outlet.  This is the area between the base of the neck and the upper arm, including the front of the shoulders and chest.

There are two types of TOS:

1. Vascular. This can be a compression of the artery or vein.
2. Neurogenic. The nerves become comprefssed from an extra cervical rib present at birth or from scar tissue.

Symptoms
TOS may include the following symptoms:

• Neck, shoulder, and arm pain
• Numbness in the arm, hand or fingers
• Impaired circulation to the extremities (causing discoloration)
• Weakness in the shoulders, arm and hands

Causes
TOS is caused by an enlargement or change of the tissues in or near the thoracic outlet. Causes of enlargement of the tissues may include:

• Trauma or injury
• Weight lifting
• Cervical rib (an extra rib extending from the neck present at birth)
• Weight gain
• Growth of a tumor

Often, there is no direct cause found in patients suffering from TOS.

 
Diagnosis
Proper diagnosis of TOS requires the expert attention of experienced neurologists and nerve specialists. Diagnosis will include:

• A comprehensive clinical exam, including neurological exams
• Complete medical history
• Imaging studies such as X-rays and/or MRI (Magnetic Resonance Imaging)
• Electrodiagnostic studies (EMG)

Diagnosis is necessary to determine the cause of TOS, so the appropriate treatment plan, including a surgical option is considered.

Treatment
There are several forms of treatment for patients with TOS. These may include:

• Physical therapy with careful nerve stretching movements performed by a qualified and experienced physical therapist with experience treating TOS.
• Injections with nerve blocking agents to suppress pain and reduce swelling and compression.
• Acupuncture. Some patients with TOS have found relief using acupuncture.

Surgical Intervention
There are two types or approaches to TOS surgery.  Your thoracic surgeon is the appropriate professional to consult when deciding on surgery as treatment for TOS.

1. Supraclavicular Approach
   (above the collar bone approach)
   The thoracic surgeon will attempt to decompress the nerves in the brachial plexus or the adjacent blood vessel. The anterior scalene muscle is usually divided and any bands constricting the nerves or vessels are cut or removed.  The first rib (or cervical rib, if present) is removed.
2. Transaxillary Approach
   The surgeon will access the nerves or blood vessels through the armpit.   The remainder of the procedure is performed like the supraclavicular approach, as above.

Factors in Surgical Intervention
When physical therapy and other forms of non-surgical treatment fail, surgery is the best option to restore function and alleviate pain.

Recovery
Patients who have surgery for TOS should expect to stay two nights in the hospital. Most patients fully recover within six weeks.