Thoracic outlet syndrome

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Thoracic outlet syndrome
Wikipedia medical illustration thoracic outlet syndrome brachial plexus anatomy with labels.jpg
The right brachial plexus, viewed from in front.
Specialty Vascular surgery, thoracic surgery
SymptomsPain, weakness, loss of muscle at the base of the thumb, swelling, paleness, bluish coloration [1] [2]
Usual onset20 to 50 years of age [1]
Types Neurogenic, venous, arterial [1]
CausesCompression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit [1]
Risk factors Trauma, repetitive arm movements, tumors, pregnancy, cervical rib [1]
Diagnostic method Nerve conduction studies, medical imaging [1]
Differential diagnosis Rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome [1]
TreatmentPain medication, surgery [1] [2]
Frequency~1% [3]

Thoracic outlet syndrome (TOS) is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit. [1] There are three main types: neurogenic, venous, and arterial. [1] The neurogenic type is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb. [1] [2] The venous type results in swelling, pain, and possibly a bluish coloration of the arm. [2] The arterial type results in pain, coldness, and paleness of the arm. [2]

Contents

TOS may result from trauma, repetitive arm movements, tumors, pregnancy, or anatomical variations such as a cervical rib. [1] The diagnosis may be supported by nerve conduction studies and medical imaging. [1] Other conditions that can produce similar symptoms include rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis, and complex regional pain syndrome. [1]

Initial treatment for the neurogenic type is with exercises to strengthen the chest muscles and improve posture. [1] NSAIDs such as naproxen may be used for pain. [1] Surgery is typically done for the arterial and venous types and for the neurogenic type if it does not improve with other treatments. [1] [2] Blood thinners may be used to treat or prevent blood clots. [1] The condition affects about 1% of the population. [3] It is more common in women than men and it occurs most commonly between 20 and 50 years of age. [1] The condition was first described in 1818 and the current term "thoracic outlet syndrome" first used in 1956. [2] [4]

Signs and symptoms

TOS affects mainly the upper limbs, with signs and symptoms manifesting in the shoulders, neck, arms and hands. Pain can be present on an intermittent or permanent basis. It can be sharp/stabbing, burning, or aching. TOS can involve only part of the hand (as in the pinky and adjacent half of the ring finger), all of the hand, or the inner aspect of the forearm and upper arm. Pain can also be in the side of the neck, the pectoral area below the clavicle, the armpit/axillary area, and the upper back (i.e., the trapezius and rhomboid area). Discoloration of the hands, one hand colder than the other hand, weakness of the hand and arm muscles, and tingling are commonly present.[ citation needed ]

TOS is often the underlying cause of refractory upper limb conditions like frozen shoulder and carpal tunnel syndrome that frequently defy standard treatment protocols[ citation needed ]. TOS can be related to forward head posture [ citation needed ].

A painful, swollen and blue arm, particularly when occurring after strenuous physical activity, could be the first sign of a subclavian vein compression related with an unknown TOS and complicated by thrombosis (blood clots), the so-called Paget–Schroetter syndrome or effort-induced thrombosis.

TOS can be related to cerebrovascular arterial insufficiency when affecting the subclavian artery. [5] It also can affect the vertebral artery, in which case it could produce vision disturbances, including transient blindness, [6] and embolic cerebral infarction. [7]

TOS can also lead to eye problems and vision loss as a circumstance of vertebral artery compression. Although very rare, if compression of the brain stem is also involved in an individual presentation of TOS, transient blindness may occur while the head is held in certain positions. [8] If left untreated, TOS can lead to neurological deficits as a result of the hypoperfusion and hypometabolism of certain areas of the brain and cerebellum. [9]

Causes

Thoracic outlet syndrome Thoracic Outlet Syndrome.png
Thoracic outlet syndrome

TOS can be attributed to one or more of the following factors: [10]

Diagnosis

Adson's sign and the costoclavicular maneuver lack specificity and sensitivity and should comprise only a small part of the mandatory comprehensive history and physical examination undertaken with a patient suspected of having TOS. There is currently no single clinical sign that makes the diagnosis of TOS with any degree of certainty.

Additional maneuvers that may be abnormal in TOS include Wright's Test, which involves hyperabducting the arms over the head with some extension and evaluating for loss of radial pulses or signs of blanching of the skin in the hands indicating a decrease in blood flow with the maneuver. The "compression test" is also used, exerting pressure between the clavicle and medial humeral head causes radiation of pain and/or numbness into the affected arm. [11]

Doppler arteriography, with probes at the fingertips and arms, tests the force and "smoothness" of the blood flow through the radial arteries, with and without having the patient perform various arm maneuvers (which causes compression of the subclavian artery at the thoracic outlet). The movements can elicit symptoms of pain and numbness and produce graphs with diminished arterial blood flow to the fingertips, providing strong evidence of impingement of the subclavian artery at the thoracic outlet. [12] Doppler arteriography does not utilize probes at the fingertips and arms, and in this case is likely being confused with plethysmography, which is a different method that utilizes ultrasound without direct visualization of the affected vessels. Doppler ultrasound (not really 'arteriography') would not be used at the radial artery in order to make the diagnosis of TOS. Finally, even if a Doppler study of the appropriate artery were to be positive, it would not diagnose neurogenic TOS, by far the most common subtype of TOS. There is plenty of evidence in the medical literature to show that arterial compression does not equate to brachial plexus compression, although they may occur together, in varying degrees. Additionally, arterial compression by itself does not make the diagnosis of arterial TOS (the rarest form of TOS). Lesser degrees of arterial compression have been shown in normal individuals in various arm positions and are thought to be of little significance without the other criteria for arterial TOS.

Classification

By structures affected and symptomatology

There are three main types of TOS, named according to the cause of the symptoms; however, these three classifications have been coming into disfavor because TOS can involve all three types of compression to various degrees. The compression can occur in three anatomical structures (arteries, veins and nerves), it can be isolated, or, more commonly, two or three of the structures are compressed to greater or lesser degrees. In addition, the compressive forces can be of different magnitude in each affected structure. Therefore, symptoms can be variable. [13]

  • Neurogenic TOS includes disorders produced by compression of components of the brachial plexus nerves. The neurogenic form of TOS accounts for 95% of all cases of TOS. [14]
  • Arterial TOS is due to compression of the subclavian artery. [14] This is less than one percent of cases. [2]
  • Venous TOS is due to compression of the subclavian vein. [14] This makes up about 4% of cases. [2]

By event

There are many causes of TOS. The most frequent cause is trauma, either sudden (as in a clavicle fracture caused by a car accident), or repetitive (as in a legal secretary who works with his/her hands, wrists, and arms at a fast paced desk station with non-ergonomic posture for many years)[ citation needed ]. TOS is also found in certain occupations involving lots of lifting of the arms and repetitive use of the wrists and arms [ citation needed ].

One cause of arterial compression is trauma, and a recent case involving fracture of the clavicle has been reported. [15]

The two groups of people most likely to develop TOS are those suffering from neck injuries due to traffic accidents and those who use computers in non-ergonomic postures for extended periods of time.[ citation needed ] TOS is frequently a repetitive stress injury (RSI) caused by certain types of work environments[ citation needed ]. Other groups which may develop TOS are athletes who frequently raise their arms above the head (such as swimmers, volleyball players, dancers, badminton players, baseball pitchers, and weightlifters), rock climbers, electricians who work long hours with their hands above their heads, and some musicians[ citation needed ].

By structure causing constriction

It is also possible to classify TOS by the location of the obstruction:

Some people are born with an extra incomplete and very small rib above their first rib, which protrudes out into the superior thoracic outlet space. This rudimentary rib causes fibrous changes around the brachial plexus nerves, inducing compression and causing the symptoms and signs of TOS. This is called a "cervical rib" because of its attachment to C-7 (the 7th cervical vertebra), and its surgical removal is almost always recommended. The symptoms of TOS can first appear in the early teen years as a child is becoming more athletic.

Treatment

Evidence for the treatment of thoracic outlet syndrome as of 2014 is poor. [16]

Physical measures

Stretching, occupational and physical therapy are common non-invasive approaches used in the treatment of TOS. The goal of stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, or tendons that are causing the problem.


TOS is rapidly aggravated by poor posture.[ citation needed ] Active breathing exercises and ergonomic desk setup and motion practices can help maintain active posture.[ citation needed ] Often the muscles in the back become weak due to prolonged (years of) "hunching" and other poor postures.[ citation needed ]

Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving blood circulation to them. While the whole arm generally feels painful in TOS, some relief can be seen when ice or heat is intermittently applied to the thoracic region (collar bone, armpit, or shoulder blades).

Medications

In a review, botox was compared to a placebo injected into the scalene muscles. No effect in terms of pain relief or improved movement was noted. However in a six-months follow-up, paresthesia (abnormal sensations such as in pins and needles) was seen to be significantly improved. [16]

Surgery

Surgical approaches have also been used successfully in TOS. Microsurgery can be used approaching the area from above the collar bone (supraclavicular) followed by neurolysis of the brachial plexus, removal of the scalene muscle (scalenectomy), and the release of the underlying (subclavicular) blood vessels. This approach avoids the use of resection, and has been found to be an effective treatment. [17] In cases where the first rib (or a fibrous band extending from the first rib) is compressing a vein, artery, or the nerve bundle, part of the first rib and any compressive fibrous tissue, can be removed in a first rib resection and thoracic outlet decompression surgical procedure; scalene muscles may also need to be removed (scalenectomy). This allows increased blood flow and the reduction of nerve compression. [18] In some cases there may be a rudimentary rib or a cervical rib that can be causing the compression, which can be removed using the same technique.

Physical therapy is often used before and after the operation to improve recovery time and outcomes. Potential complications include pneumothorax, infection, loss of sensation, motor problems, subclavian vessel damage, and, as in all surgeries, a very small risk of permanent serious injury or death.

Notable cases

Sports

Several Major League Baseball players, especially pitchers, have been diagnosed with thoracic outlet syndrome, including Matt Harvey, [19] Chris Carpenter, [20] Jaime Garcia, [21] Shaun Marcum, [22] Matt Harrison, [23] Clayton Richard, [24] and Noah Lowry. [25] Starting pitcher Chris Young, who previously struggled with shoulder problems, underwent surgery for TOS in 2013 and felt "completely different" post-recovery. [26] Young exceeded expectations on his return to the major leagues at age 35, becoming a valuable member of the 2014 Seattle Mariners' starting rotation. [27]

NHL defenseman Adam McQuaid was diagnosed with TOS in September 2012, and as a result was nominated for the Bill Masterton Memorial Trophy. [28] Forward Chris Kreider was diagnosed with a malformed rib in 2017. Kreider dealt with multiple symptoms prior to the diagnosis, such as shortness of breath on the ice, swelling/numbness in his right arm, coughing up blood and a blod clot in his right arm. Kreider underwent successful surgery to resect a rib in January 2018 (the same surgery as TOS) and has performed well since returning to the Rangers. [29]

NBA guard Markelle Fultz was diagnosed with TOS in December 2018. [30] [31]

UFC fighter Matt Serra had a rib removed to alleviate TOS. [32]

Music

Musician Isaac Hanson had a pulmonary embolism as a consequence of thoracic outlet syndrome. [33]

The Japanese band Maria disbanded in 2010 due to drummer Tattsu's TOS which made it impossible for her to continue playing. [34]

In 2015, singer Tamar Braxton had to leave Dancing With The Stars due to TOS. [35]

See also

Related Research Articles

Brachial plexus network of nerves formed by the ventral rami of the lower four cervical nerves and first thoracic nerve

The brachial plexus is a network (plexus) of nerves (formed by the anterior rami of the lower four cervical nerves and first thoracic nerve. This plexus extends from the spinal cord, through the cervicoaxillary canal in the neck, over the first rib, and into the armpit. It supplies afferent and efferent nerve fibers to the chest, shoulder, arm, forearm, and hand.

Phrenic nerve Nerve controlling the diaphragm

The phrenic nerve is a mixed motor/sensory nerve which originates from the C3-C5 spinal nerves in the neck. The nerve is important for breathing because it provides exclusive motor control of the diaphragm, the primary muscle of respiration. In humans, the right and left phrenic nerves are primarily supplied by the C4 spinal nerve, but there is also contribution from the C3 and C5 spinal nerves. From its origin in the neck, the nerve travels downward into the chest to pass between the heart and lungs towards the diaphragm.

Long thoracic nerve Large nerve

The long thoracic nerve supplies the serratus anterior muscle. This nerve characteristically arises from the anterior rami of three spinal nerve roots: the fifth, sixth, and seventh cervical nerves (C5-C7) although the root from C7 may be absent. The roots from C5 and C6 pierce through the scalenus medius, while the C7 root passes in front of the muscle.

Subclavian artery major arteries of the upper thorax, below the clavicle

In human anatomy, the subclavian arteries are paired major arteries of the upper thorax, below the clavicle. They receive blood from the aortic arch. The left subclavian artery supplies blood to the left arm and the right subclavian artery supplies blood to the right arm, with some branches supplying the head and thorax. On the left side of the body, the subclavian comes directly off the aortic arch, while on the right side it arises from the relatively short brachiocephalic artery when it bifurcates into the subclavian and the right common carotid artery.

Pancoast tumor tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae

A Pancoast tumor is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small cell cancers.

Adsons sign loss of the radial pulse in the arm by rotating head to the ipsilateral side with extended neck following deep inspiration

Adson's sign is the loss of the radial pulse in the arm by rotating head to the ipsilateral side with extended neck following deep inspiration.

In medicine, a stinger, also called a burner or nerve pinch injury, is a neurological injury suffered by athletes, mostly in high-contact sports such as ice hockey, rugby, American football, and wrestling. The spine injury is characterized by a shooting or stinging pain that travels down one arm, followed by numbness and weakness in the parts of the arms, including the biceps, deltoid, and spinati muscles. Many athletes in contact sports have suffered stingers, but they are often unreported to medical professionals.

Stellate ganglion Controls bloodflow to each leg, arm or hand; may amplify pain perception.

The stellate ganglion is a sympathetic ganglion formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion, which exists in 80% of cases. Sometimes the second and the third thoracic ganglia are included in this fusion. Stellate ganglion is relatively big compared to much smaller thoracic, lumbar and sacral ganglia and it is polygonal in shape. Stellate ganglion is located at the level of C7, anterior to the transverse process of C7 and the neck of the first rib, superior to the cervical pleura and just below the subclavian artery. It is superiorly covered by the prevertebral lamina of the cervical fascia and anteriorly in relation with common carotid artery, subclavian artery and the beginning of vertebral artery which sometimes leaves a groove at the apex of this ganglion.

Axillary artery Large blood vessel bringing oxygenated blood to the thorax

In human anatomy, the axillary artery is a large blood vessel that conveys oxygenated blood to the lateral aspect of the thorax, the axilla (armpit) and the upper limb. Its origin is at the lateral margin of the first rib, before which it is called the subclavian artery.

Thoracic inlet

The thoracic inlet, also known as the superior thoracic aperture, refers to the opening at the top of the thoracic cavity. It is also clinically referred to as the thoracic outlet, in the case of thoracic outlet syndrome; this refers to the superior thoracic aperture, and not to the lower, larger opening, the inferior thoracic aperture.

Scalene muscles Muscles on the sides of the neck

The scalene muscles are a group of three pairs of muscles in the lateral neck, namely the anterior scalene, middle scalene, and posterior scalene. They are innervated by the fourth, fifth, and sixth cervical spinal nerves (C4-C6).

Subclavius muscle

The subclavius is a small triangular muscle, placed between the clavicle and the first rib. Along with the pectoralis major and pectoralis minor muscles, the subclavius muscle makes up the Anterior Axioappendicular Muscles also known as anterior wall of the axilla.

Brachial plexus injury brachial plexus neuropathy characterized by an abnormality, usually caused by disease or trauma, located in the brachial plexus

A brachial plexus injury (BPI), also known as brachial plexus lesion, is an injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand. These nerves originate in the fifth, sixth, seventh and eighth cervical (C5–C8), and first thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm and hand.

May–Thurner syndrome

May–Thurner syndrome (MTS), also known as the iliac vein compression syndrome, is a condition in which compression of the common venous outflow tract of the left lower extremity may cause discomfort, swelling, pain or blood clots in the iliofemoral veins.

Cervical rib rib

A cervical rib in humans is an extra rib which arises from the seventh cervical vertebra. Their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.2% to 0.5% of the population. People may have a cervical rib on the right, left or both sides.

Subclavian nerve

The subclavian nerve or nerve to the subclavius is small branch of the upper trunk of the brachial plexus where C5 and C6 join. It contains axons derived from the ventral rami of the fifth (C5) and sixth (C6) cervical nerves. The subclavian nerve provides motor innervation to the subclavius muscle.

Subclavian triangle smaller division of the posterior triangle

The subclavian triangle, the smaller division of the posterior triangle, is bounded, above, by the inferior belly of the omohyoideus; below, by the clavicle; its base is formed by the posterior border of the sternocleidomastoideus.

Ulnar nerve entrapment condition where the ulnar nerve becomes physically trapped or pinched, resulting in pain, numbness, or weakness

Ulnar nerve entrapment is a condition where the ulnar nerve becomes physically trapped or pinched, resulting in pain, numbness, or weakness, primarily affecting the little finger and ring finger of the hand. Entrapment may occur at any point from the spine at cervical vertebra C7 to the wrist; the most common point of entrapment is in the elbow. Prevention is mostly through correct posture and avoiding repetitive or constant strain. Treatment is usually conservative, including medication, activity modification and exercise, but may sometimes include surgery. Prognosis is generally good, with mild to moderate symptoms often resolving spontaneously.

Brachial plexus block

Brachial plexus block is a regional anesthesia technique that is sometimes employed as an alternative or as an adjunct to general anesthesia for surgery of the upper extremity. This technique involves the injection of local anesthetic agents in close proximity to the brachial plexus, temporarily blocking the sensation and ability to move the upper extremity. The subject can remain awake during the ensuing surgical procedure, or s/he can be sedated or even fully anesthetized if necessary.

A First rib resection is a surgical procedure used in humans to treat thoracic outlet syndrome (TOS). It is often accompanied by scalenectomy, or removal of the nearby anterior scalene muscle. It involves the surgical removal of a segment of the first rib, which is the rib closest to the head, under the collar bone.

References

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