Thoracic Outlet Syndrome

TYPES OF THORACIC OUTLET SYNDROME (TOS)

Healthcare providers classify thoracic outlet syndrome according to the structure suffering compression.

Vascular Thoracic Outlet Syndrome

This type of TOS occurs when one or more veins or arteries under the collarbone are compressed. In venous TOS, patients present with a sudden onset of arm swelling and pain. An ultrasound will show a clot in the subclavian vein. Arterial TOS presents with diminished blood flow to the arm and hand, sometimes combined with painful fingertips from thrombus emboli. An ultrasound can elicit compression and irregularity of the subclavian artery. Vascular TOS is most commonly present in young adults and athletes, such as baseball players and swimmers, who are involved in repetitive overhead motion.

Neurogenic Thoracic Outlet Syndrome

This form of TOS is the most common. It is characterized by compression of the brachial plexus, the network of nerves that come from the spinal cord and control muscle movements and sensation in your shoulder, arm and hand. Neurogenic TOS is complex and can present with varied symptoms, including neck pain, arm pain, headaches, tingling numbness in the arm and hand, and sharp pain starting in the collar bone area and radiating to the arm that gets worse with repetitive activities. It tends to occur in people who perform repetitive overhead arm movements in their jobs or participate in sports like swimming or baseball.

Neurogenic thoracic outlet syndrome can also develop in people who experience trauma to the neck or chest, including whiplash, from a car accident or a fall. Sometimes, they are born with a malformed first rib or a cervical rib, which can cause compression on the nerves.

Venous Thoracic Outlet Syndrome

Venous thoracic outlet syndrome is caused by the compression of a subclavian vein, which lies beneath the collarbone and carries blood from the shoulders, arms, and hands to the heart. A venous obstruction can lead to life-threatening blood clots. Patients often have a swollen and painful arm with dark blue discoloration. People with venous TOS are frequently born with a narrowed space from where the vein extends from the shoulder to the heart. Overuse of the arm and shoulder causes the thoracic outlet veins to compress.

Arterial Thoracic Outlet Syndrome

Compression of the subclavian artery, the main arty from the chest to the arm, causes arterial thoracic outlet syndrome. A large first rib or an abnormal cervical rib can cause arterial TOS. Repeated compression can lead to arterial trauma and result in the formation of blood clots traveling down the arm toward the hand.

Nonspecific-Type Thoracic Outlet Syndrome

Also known as disputed thoracic outlet syndrome, patients with this form have chronic pain in the area of the thoracic outlet that intensifies with activity, but a specific cause of the pain cannot be determined.

SIGNS AND SYMPTOMS

TOS symptoms can vary widely, depending on which structures are compressed. Symptoms of neurological TOS include:

• Muscle wasting in the fleshy base of your thumb, also called Gilliatt-Sumner hand
• Numbness or tingling in the arms or fingers
• Neck, shoulder or hand aches and pain
• Weakening grip

Signs and symptoms of vascular TOS can include:

• Bluish discoloration of the hand
• Arm pain and swelling
• Blood clots in veins or arteries in the upper part of your body
• Lack of color in one or more of your fingers or your entire hand
• Weak or no pulse in the affected arm
• Cold fingers, hands or arms
• Arm fatigue with activity
• Numbness or tingling in your fingers
• Weakness of the neck or arm
• Throbbing lump near your collarbone

CAUSES and RISK FACTORS

Nerve compression or blood vessel compression in the thoracic outlet is the cause of TOS, but some conditions can make you more prone to developing it, including:

• Anatomical defects that are inherited, such as an extra rib above the first rib or an abnormally tight fibrous band connecting your spine to your ribs
• Poor posture, involving dropping your shoulders or holding your head forward can cause compression
• Trauma, including vehicular accidents, can cause internal changes that compress the nerves. The onset of symptoms after a traumatic accident is often delayed
• Repetitive activity can, over time, wear on your body. Movements such as typing on a computer, working on an assembly line or lifting things above your head can cause compression. Athletes such as swimmers and baseball pitchers can develop TOS from years of repetitive movements

Women are far more likely to be diagnosed with TOS than men. It’s also more common in adults between 20 and 40 years old.

Occupational Factors

Patients involved in some occupations also appear to be more prone to developing thoracic outlet syndrome. Work activities that involve maintaining restrictive postures over a long period are involved. Examples of occupations where workers are at higher risk include dental hygienists, anyone typing on a computer, assembly line workers or warehouse workers and others who carry heavy shoulder loads or frequently reach for items above shoulder level are at risk. These motions can cause inflammation and swelling of muscles and tendons in the shoulders and upper arms. Contributing factors include weak shoulder muscles, sloped shoulders, poor posture and obesity.

EVALUATION AND TREATMENT

Dr. Sidhu can evaluate and diagnose all types of TOS and will discuss treatment options. For venous TOS, Dr. Sidhu will use clot-busting medication to dissolve the clot first, improve blood flow, and then decompress the thoracic outlet space by removing part of the first rib and freeing the muscles. For arterial TOS, the thoracic outlet space is decompressed. Sometimes, the subclavian artery will need reconstruction to restore blood flow to the arm. For neurogenic TOS, Dr. Sidhu will work very closely with your physical therapist to rule out any neck trauma or shoulder issues because the symptoms from neck and shoulder problems can mimic neurogenic TOS. The initial management for neurogenic TOS involves specific physical therapy.

Depending upon the symptoms, patients may need imaging tests like an MRI of the neck and brachial plexus, nerve conduction studies and even scalene muscle block. If conservative management fails, then decompression surgery of the thoracic outlet is recommended, along with freeing the nerve bundle to manage the complex nature of TOS.

For comprehensive treatment solutions involving thoracic outlet syndrome, visit Vein, Vascular, Primary Care & Aesthetic Associates. Our double-board-certified surgeon will recommend the most appropriate vascular and endovascular procedures following vascular ultrasound diagnostic testing. We serve the communities of Everett, Kirkland, Newcastle, Seattle and Sammamish. For more information or to make an appointment, call us today at 425-250-9999. For your convenience, you can use our online Request an Appointment form.