Get ready to learn all about Thoracic Outlet Syndrome. Prior to being diagnosed I had absolutely no idea what Thoracic Outlet Syndrome (T.O.S) was. I was diagnosed with Neurogenic, Vascular and Arterial T.O.S.
Thoracic Outlet Syndrome is a disorder located in the thoracic region. It affects the space between the collar bone and first rib (thoracic outlet). There is an artery, vein and nerve that crosses over the first rib and continues down each arm. Problems occur when this area is compressed, has repetitive injuries, anatomical defects, or an obstruction. The closure of the thoracic outlet can put pressure on the nerves, veins and or arteries. I am sharing with you what I learned and have come to understand what Thoracic Outlet Syndrome is. Let’s get down and dirty with the medical jargon.
There are three types of Thoracic Outlet Syndrome:
- Neurogenic T.O.S: Occurs when the nerves leading from the neck to the arm (the brachial plexus) is compressed. More than 90 percent of cases are neurogenic
- Vascular T.O.S: Occurs when a vein is compressed, leading to upper body thrombosis. Five percent of cases are venous
- Arterial T.O.S: Occurs when an artery is compressed This is the least common, but most serious.
Who is more likely to develop Thoracic Outlet Syndrome?
According to the Cleveland Clinic, people of all ages and gender can be affected by T.O.S. Athletes are at a higher risk for developing T.O.S. In a recent study, it it more common in women than in men. If someone has poor posture, or weak muscle development they are highly more likely to develop it.
The statistics of T.O.S according to, The National Center of Advancing Translational Sciences, accumulated that there are, 3 to 80 cases per 1000 people.
National Center of Advancing Translational Sciences
What are the symptoms of Thoracic Outlet Syndrome?
The symptoms you develop can mimic many other illnesses and diseases. The symptoms can range anywhere between numbness, weakness and tingling in your arms and hands. Pain can radiate in your shoulders, neck, head and your back. Some patients report having severe pain during activities with their extremities above their head (like lifting something overhead, brushing your hair, or striking a yoga pose). Patients can also develop a lowered temperature change in their arms/hands. Some experience severe symptoms of constant headaches and migraines.
How do you develop Thoracic Outlet Syndrome?
Many things can cause T.O.S. Some people are born with an extra rib, called a “cervical rib”. Having this narrows the opening in the Thoracic region. More commonly, symptoms can develop from injury, or accident, or after repetitive movements such as computer work, or sports (baseball or soccer). In addition, stress, sleep disorders and poor posture. There are some activities that can cause enlargement of the scalene muscle, for example, weightlifting. The enlargement puts pressure on nerves, or and blood vessels in the thoracic region.
How do you diagnose Thoracic Outlet Syndrome?
Diagnosing Thoracic Outlet Syndrome can be very hard. Not all doctors are familiar with T.O.S. Depending on the doctor, the first step in determining if someone has T.O.S is testing your pulse. The pulse will be tested with your arm at rest, and then tested with your arm raised above your head. The doctor measures your pulse readings. If your pulse diminishes when your arm is in the air that is one sign you have compression, and could indicate towards T.O.S. Once your doctor has run a series of tests ruling out cervical spine disease, cubital tunnel syndrome, or carpal tunnel syndrome the next step is to get a T.O.S MRI study done.
A T.O.S MRI is best described as a 3D MRI. This is an MRI of the brachial plexus (looking for evidence of compression of nerves) this MRI includes a contrast injection to show a presence of compression on the subclavian artery, or vein. This MRI can take about 1-3 hours depending on the patient. A chest x-ray, or cervical spine x-ray will also be performed to look for the presence of a cervical rib. This test can be a diagnosis of T.O.S.
A second test that can be performed is a T.O.S specific Nerve Conduction Test. This is called a Somato-Sensory Evoked Potential (SSEP). This is specialized to evaluate possible compression at the base of the neck, over the thoracic outlet. MAC SNP (Median Antebrachial Cutaneous Nerve Sensory Potential) test is a newer test that can also evaluate specifically for T.O.S.
To help determine if a patient needs a surgical procedure for TOS an Anterior Scalene Muscle block will be performed. It’s a nerve block that creates a spasm of the scalene muscle (part of the thoracic area). It will help the doctor have further evidence of a patient with T.O.S. The scalene block consists of injecting the anterior scalene muscle with a local anesthetic. This anesthetic allows the muscle to relax. When this happens it drops the first rib, the space in the thoracic outlet becomes larger and relieves the compression of the nerves. If symptoms improve with the scalene block this is a diagnosis of T.O.S.
What happens once you’re diagnosed?
First, recommended by UCLA medical center, the patient would ideally participate in physical therapy, specialized in Thoracic Outlet Syndrome. Depending on the severity of the chronic pain it is recommended to also work with a Pain Management doctor.
A second stage of treatment used is Lidocaine blocks. These blocks are to treat flare ups and reduce muscle spasms. Some patients opt for Botox injections in the scalene muscles. Botox injections are very controversial.
The final stage for thoracic outlet decompression is surgery.
Ok, so we’ve tried everything and now we have to opt for surgery. What happens in surgery?
The concept of surgery is to remove the anatomical elements that are compressing the nerves of the brachial plexus. There are two primary sources of compression: the scalene muscles and the first rib. The two scalene muscles (anterior and middle scalene) attach onto the first rib. There are two operations for T.O.S. Scalenectomy, and or rib resection. Depending on your MRI results, and clinical symptoms they will determine which operation you will have.
The Scalenectomy operation removes the anterior scalene muscle which may relieve compression on the brachial plexus nerves. An incision above the clavicle (collar bone) is made. This operation takes about 1-2 hours.
The Rib Resection is the more invasive procedure. This incision is done above the clavicle or under the arm. This operation has a higher success rate in eliminating T.O.S symptoms. A resection, a partial removal of the first rib. In some cases the entire first rib will need to be removed. The length of the surgery is about 1 1/2 hours to 2 1/2 hours.
Occasionally, both surgeries may be performed depending on the surgeon and the severity of your case. Recovery time varies (6 months – 1 year).
-Courtney