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Thoracic Outlet Syndrome

The spine is divided into three distinct sections: cervical, thoracic, and lumbar. The segment of the spine that is located in the upper back and abdomen is known as the thoracic spine. This section sits between the cervical spine (neck) and the lumbar spine (lower back). This thoracic region of the body contains vital structures of the cardiovascular, respiratory and digestive systems and is protected by the thoracic wall (rib cage and other skin and muscles).

What is Thoracic Outlet Syndrome (TOS)?

The passageway in the upper chest located between the collarbone and first rib is referred to as the thoracic outlet. Nerves and blood vessels travel through this narrow space to exit the chest to the upper extremities. If space in this passageway becomes too narrow, blood vessels and nerves traveling through may become compressed, causing thoracic outlet syndrome. This can result in pain and numbness throughout the shoulders, arms, hands, and fingers.

Causes

The primary cause of TOS is an insufficient passageway for nerves and blood vessels when they are passing through the thoracic outlet. There are various reasons that this passageway can become too small.

• Extra rib: Some patients may have an extra rib that is located right above their first rib. This bone will impact the size of the thoracic outlet.
• Obesity and Poor Posture: Excess fat or a slumped posture can increase pressure on the joints, causing the passageway to narrow.
• Repetitive Activities: Overuse of the upper extremities can damage tissues and muscles in the thoracic outlet, causing it to shrink.

Symptoms

There are various symptoms that can occur in each patient depending on which nerves and blood vessels have been compressed. The ability to lift objects over the head and a patient’s range of motion will be difficult if the thoracic outlet has narrowed. Some symptoms may include:

• Neck, arm and shoulder pain
• Weakness and easily fatigued shoulders, arms and hands
• Impaired circulation that may cause discoloration
• Numbness in the arms, hands and fingers
• Swelling and redness of the arms
• Cold arms, hands and fingers
• Blood clot in upper area of body

Diagnosis

To determine if TOS is causing a your pain, your OSC Specialist will do a physical examination, and have you do a few simple exercises to test the upper extremities. X-rays may be taken of the thoracic region, and if necessary, an MRI (Magnetic Resonance Imaging) scan to see the thoracic outlet structures better. A nerve conduction study of EMG can be done to test how well the nerve is working and where exactly it is being compressed.

Treatment

Most treatment methods for TOS are non-surgical. A physical therapy plan is often implemented to strengthen the upper body. If TOS has occurred because of extra weight, a weight loss program may be suggested. Some over-the-counter medications can be used to reduce the pain. If these methods are ineffective in relieving a patient’s symptoms, surgical options are available. A surgical procedure would involve removing part of the rib, or the extra rib if present, or rerouting nerves and blood vessels.

Thoracic Outlet Syndrome

by Mark W. McFarland, DO
Pain in the shoulder and neck and numbness in the fingers can be caused by several conditions, but all have nerve or blood flow issues in common. One condition that can cause these symptoms is Thoracic Outlet Syndrome (TOS).  The thoracic outlet is the area in your upper body from your neck to your armpit.
There are three types of Thoracic Outlet Syndrome, but here, I will deal with the type that involves nerve compression of the brachial plexus and is the type seen most often, Neurogenic (neurological) thoracic outlet syndrome. The brachial plexus is a web of nerves that emerges from your spinal cord, responsible for controlling muscle sensation and movements in your hand, arm and shoulder.
TOS can be caused by a trauma, such as a high-impact fall or car accident, a repetitive-use injury (often seen in professional baseball pitchers), pregnancy, poor posture, obesity, congenital anatomical defects or for an idiopathic (unknown) reason.  Females are more likely than males to get it and the age range for development is 20-50 years of age.
The main symptoms are: tingling, numbness and pain in the neck, shoulder, arm and fingers; a weak grip and muscle wasting at the base of your thumb. Vascular types can cause color and temperature changes of the skin, among other symptoms.
Diagnosis can be difficult, because symptoms vary greatly and can mimic other conditions, such as fibromyalgia, complex regional pain syndrome or multiple sclerosis.  A physical examination and medical history will be important. X-ray, MRI, CT or Ultrasound can all be used to identify anatomical abnormalities.  Electromyography and nerve conduction studies can help identify nerve damage.
Treatment is essential for TOS, to prevent permanent nerve damage, and follows a conservative treatment path first.  Physical Therapy is the first thing I recommend, because learning and practicing correct posture daily, along with therapeutic stretching, can help to open the thoracic outlet and take pressure off of the compromised brachial plexus.  Pain, inflammation and muscle tension is controlled by non-narcotic pain medication, NSAIDs or steroid medications and muscle relaxants.
If symptoms do not resolve, surgery rarely may be necessary, and is usually only done for vascular issues or if there is an extra rib causing the compression.  We do not perform surgery for thoracic outlet syndrome here at OSC, but would refer you to MCV or UVA for surgical treatment.  A Neurosurgeon or vascular/thoracic surgeon would address issues, such as the removal of an extra rib, removal of tumors or the surgical release of areas which may be compressing nerves or blood vessels.
It is important to accurately diagnose and treat TOS so that appropriate treatment can be given quickly to prevent damage to nerves.

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