What Is Thoracic Outlet Syndrome?
Thoracic outlet syndrome is essentially a compression in the blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) that causes numbness in your fingers and pain in your shoulders and neck. Failure to be treated soon after you first notice symptoms may result in progressive nerve damage and may even require surgery.
What Are the Symptoms for Thoracic Outlet Syndrome?
Depending on which structures are compressed, thoracic outlet syndrome symptoms can vary. You should see your doctor if you consistently experience any of these signs and symptoms.
When nerves are compressed, this is called neurogenic (neurological) thoracic outlet syndrome. Symptoms can include:
- Weakening grip
- Numbness or tingling in your extremities
- Pain or aching in your hand, neck, or shoulder
- Wasting in the fleshy base of your thumb (Gilliatt-Sumner hand)
When one or more of the veins or arteries under the collarbone are compressed, this is called vascular thoracic outlet syndrome. Symptoms can include:
- Cold fingers, hands, or arms
- Numbness or tingling in your fingers
- Weakness in your arm or neck
- Arm pain and swelling
- Discoloration of your hand (bluish color)
- Weak or no pulse in the affected arm
- Lack of color in one or more of your fingers
- Throbbing lump near your collarbone
Why Do I Have Thoracic Outlet Syndrome?
Thoracic outlet syndrome generally occurs due to a compression of the nerves or blood vessels in the thoracic outlet. The cause of the compression varies and can include:
- Trauma: Internal changes from a traumatic event, such as a car accident, can compress the nerves in the thoracic outlet. The onset of symptoms in this instance are often delayed.
- Repetitive activity: You may notice symptoms if your job requires you to repeat a movement continuously (typing, assembly line work, repeatedly lifting over your head). Athletes, such as baseball pitchers and swimmers, are particularly susceptible due to years of repetitive movements.
- Anatomical defects: Congenital defects may include an extra rib located above the first rib or an abnormally tight fibrous band connecting your spine to your rib.
- Poor posture: Habitually drooping your shoulders or maintaining your head in a forward position can lead to compression in the thoracic outlet area.
- Pregnancy: Because joints loosen during pregnancy and weight gain places undue pressure on the joints, pregnant woman often exhibit symptoms.
To diagnose thoracic outlet syndrome, your doctor may review your symptoms and medical history and conduct a physical examination. Because symptoms and their severity can vary greatly among people with thoracic outlet syndrome, diagnosing it can be difficult.
What Are My Treatment Options for Thoracic Outlet Syndrome?
Most people’s symptoms generally improve through conservative approaches such as physical therapy and pain relief measures. In some cases, however, surgical intervention may be necessary.
- Physical therapy: This is the first line of treatment. Exercises are introduced to improve your range of motion and improve your posture. Over time, these may take the pressure off your blood vessels and nerves in the thoracic outlet.
- Medications: Anti-inflammatory medications such as ibuprofen, pain medications or muscle relaxants are introduced to reduce pain and encourage muscle relaxation.
- Clot-dissolving medications: Thrombolytics (clot-dissolving) and anticoagulants may be introduced to dissolve blood clots and prevent future blood clots from forming.
If you’re experiencing ongoing symptoms, surgery may be required for effective treatment.
This may be performed using several different approaches, including:
- Transaxillary approach: This requires an incision in your chest to access the first rib, divide the muscles in front of the rib and, remove a portion of the first rib to relieve compression.
- Supraclavicular approach: This requires an incision just under your neck to expose your brachial plexus region. Signs of trauma or muscles contributing to compression are explored. The compressed blood vessel is repaired. The muscles causing the compression, and/or first rib may be removed to relieve compression.
- Infraclavicular approach: A more invasive approach to treat compressed veins that require extensive repair. This approach requires an incision under your collarbone and across your chest.
How Can I Prevent Thoracic Outlet Syndrome?
The anatomy of the thoracic outlet is bordered by the clavicle and the first rib, between which the subclavian artery and vein pass. The scalene triangle between the anterior and middle scalene muscles is where the brachial plexus passes, innervating the upper extremity. Congenital anomalies such as cervical ribs and muscular anomalies cannot be prevented, but Thoracic Outlet Syndrome (TOS) progression can.
Treatment is indicated only for those with signs and symptoms; prevention of signs and symptoms is by eliminating the risk of compression due to injuries or physical activities responsible for neurovascular compression. Prevention and treatment often are dictated by the specific structure compressed, i.e., subclavian artery, subclavian vein, or brachial nerve plexus.
Prevention of Symptomatic TOS
- Physical therapy to decrease tension from the scalene musculature, encourage proper posture, and avoid undue scalene muscular hypertrophy
- Injections of anesthetics, steroids, or Botox into the thoracic outlet, scalene triangle, or scalene muscles
- In subclavian vein compression, anticoagulant or thrombolytic therapy to prevent or dissolve venous thrombus formation. In arterial ischemia due to an arterial thrombus or embolus, catheter-directed thrombolysis or embolectomy is indicated
- Surgery to remove cervical or other anomalous ribs, correct distortion of clavicular anatomy from injury, or to release tension from the scalene musculature