The thoracic outlet comprises three triangular passages that travel from the upper neck, through the collarbone region and down into the arm. Bundles of nerves and blood vessels travel through this area to supply the arm with blood flow and feeling. However, if this area is compressed or injured, it can result in nerve damage or obstruction of blood flow. When this occurs, it is known as thoracic outlet syndrome (TOS). The most common symptoms of TOS include numbness, pain, tingling or weakness in the affected arm and hand.
There are a number of possible causes of TOS, including injury (e.g., whiplash), poor posture, carrying heavy backpacks, and aging and weakened musculature that results in drooping. This may be caused by obesity , repetitive stress injuries or lack of exercise. However, TOS may have other causes as well, including minor skeletal defects that are present at birth.
Symptoms may vary depending on the location of the pressure and whether nerves or blood vessels are being compressed. In most cases, there are symptoms related to both vascular obstruction and nerve compression. It is very unusual that somebody would be affected with only one or the other. In some cases, TOS can cause angina-like chest pain or arm pain. Other symptoms may include cold hands, headaches and dizziness.
There are five categories of TOS - true neurologic TOS, disputed TOS, arterial TOS, venous TOS and traumatic TOS. Medical professionals do not agree on how common TOS is in the general population. Because symptoms can vary so widely (and in some cases are absent) estimates run from 3 to 80 per 1,000 people. Physicians dispute whether some types of TOS actually exist.
Tests that can aid in diagnosis include physical examination, nerve and muscle studies, x-ray, MRI and ultrasound. Treatment may include physical therapy, exercise, anti-inflammatory pain medication or surgery. In general, many people benefit from physician-prescribed stretching and physical therapy. As with diagnosis, there is no standard treatment option.
About thoracic outlet syndrome (TOS)
Thoracic outlet syndrome (TOS) is the general term for a group of disorders that affect the nerves running from neck to the arms (called the brachial plexus) and the nerves and blood vessels running between the base of the neck and the armpit (called the axilla).
TOS is a controversial condition, and some physicians doubt whether some or all types of TOS actually exist. In many cases, TOS cannot be definitively confirmed by laboratory tests. Because of this, it is not known if the condition is underdiagnosed or overdiagnosed. Recent data indicate that it occurs in 3 to 80 people out of every 1,000.
TOS is described as neurogenic (affecting the nerves) or vascular (affecting the blood vessels). However, it is rare that someone would be affected with either one or the other. In most cases, the condition is caused by external factors, such as aging, poor musculature or injury, that affect both the blood vessels and the nerves in the region.
TOS is divided into five general categories by the National Institute of Neurological Disorders and Stroke : -
Traumatic TOS. This is the most common type of TOS. It is often caused by hyperextension neck injuries (e.g., whiplash) and repetitive stress injuries, in which pressure is exerted on the nerves. Symptoms include pain, tenderness and paresthesias (abnormal burning or prickling sensation in the hands, arms, legs or feet). Other symptoms may include numbness, fatigue and weakness.
True neurologic TOS. A rare, usually painless, condition caused by the compression of nerves by an abnormal bony growth in the neck. This type of TOS generally occurs in middle-aged women and almost always on one side of the body. Symptoms include weakness and numbness in the hands, and a wasting of the hand muscles.
Arterial TOS. Like true neurologic TOS, this type is rare, occurring in about 2 to 3 percent of cases, and is often related to a congenital defect. Symptoms may include sensitivity to cold in the hands and fingers, numbness or pain in the fingers, finger ulcers, or inadequate blood circulation in the fingers (severe limb ischemia).
Venous TOS. This is the rarest type of TOS, affecting only 1 to 2 percent of people with TOS. Venous TOS (also called Paget-Schroetter syndrome) can develop suddenly and usually results from the compression of the subclavian vein (located under the collar bone, or clavicle) by the surrounding muscles and ligaments. Symptoms include pain and arm swelling.
Disputed TOS. Also called common or nonspecific TOS, disputed TOS is highly controversial. The exact cause in unknown. Some physicians do not believe it exists, and others believe it is very common. Symptoms include numbness or tingling in the fingers; pain in the arm, shoulder or neck; headaches; and weakness in the arm or hand.
Although both are rare, prolonged arterial and venous TOS have been linked to potentially dangerous cardiovascular conditions. Arterial TOS may cause aneurysm within the subclavian artery. Pulmonary embolism has been reported in some patients with venous TOS.
Potential causes of TOS
The most common form of thoracic outlet syndrome (TOS) involves the nerves and appears to be caused by hyperextension (excessive backward bending) of the neck, a type of injury usually referred to as "whiplash." Swollen and scarred neck muscles can compress or irritate the brachial plexus nerves (running between the neck and the shoulder). This type of injury is also common in contact sports such as football.
TOS may also be caused by weak musculature related to aging, obesity, large breasts and/or lack of exercise. In this case, the muscles that normally support the shoulder become weak (e.g., droopy shoulder syndrome), allowing the thoracic outlet to become compressed.
Although external trauma and weakened musculature are the most common types of TOS, congenital abnormalities play a part as well. A patient may have an abnormal bony growth in the neck that, undisturbed, may not produce any symptoms. Trauma or certain repetitive arm motions (e.g., typing, assembly line work) may cause the abnormal bone to press against the nerves, resulting in symptoms.
An extra rib, called the cervical rib in the neck, appears in less than 1 percent of the population. People born with a cervical rib are 10 times more likely to develop TOS, and some type of injury usually triggers symptoms.
It should be noted that other injuries related to repetitive motion can be caused by other conditions, such as carpal tunnel syndrome and tendinitis. These conditions can coexist with TOS, but are considered separate and are treated separately.
Other risk factors include : -
Age and gender. Women between the ages of 30 and 50 are more likely to develop neurogenic TOS. Men are more likely to develop venous TOS.
Posture. People with poor, slouching postures are more likely to develop TOS.
Weight. Overweight and obese people are more likely to develop TOS, although this may be related to posture.
Stress and depression. Psychological factors can cause chronic muscle spasms, which may play a role in developing TOS. In addition, stress and depression may be related to weight and posture.
The risk of developing thoracic outlet syndrome (TOS) can be diminished by : -
Regular exercise and stretching to build the neck and shoulder muscles
Maintaining a correct posture when sitting or standing
Maintaining a healthy weight
People at risk for developing TOS should avoid carrying heavy bags over the shoulder, which can compress the collar bone and increase pressure on the thoracic outlet.
Signs and symptoms of TOS
The most frequently reported symptoms are those caused by neurogenic thoracic outlet syndrome (TOS).
They include : -
Numbness and tingling in the fingers
Aching pain in the arm, shoulder and neck
Headaches in the back of the neck
Weakness in the arm
Cold feeling and blue or pale hand color
In more severe, forms, neurogenic TOS can make it difficult to raise the arms or hold onto even light objects. Angina-like pain may radiate to the chest.
Symptoms of vascular TOS, which affects the subclavian artery or vein, include many of the same symptoms as neurogenic TOS (e.g., numbness, paleness, coldness, tingling, pain in arm, shoulder, neck, fatigue). Ulcers and finger ischemia may develop in more severe cases of arterial TOS.
Diagnosis methods for TOS
A definitive diagnosis of thoracic outlet syndrome (TOS) is often not possible. Many TOS cases are diagnosed by ruling out other causes (e.g., herniated disc, carpal tunnel syndrome , acute coronary syndrome). The physician will take a medical history of the patient that includes when the symptoms began and whether the patient has had any accidents or trauma in the past. Before seeing the physician, it is helpful to write down at what times and during which activities the symptoms appear.
A physical examination will be performed, in which the physician will try to reproduce the symptoms of TOS by examining the patient's range of motion (e.g., rolling or tilting the patient's head to one side and/or holding the patient's arms up to reproduce the symptoms). The physician will look for swelling or discoloration in the arm or a depression in the shoulder.
Other diagnostic tests include : -
X-ray. A painless test in which an image is created of part of the body by using low doses of radiation reflected on film paper or fluorescent screens. This test may show structural abnormalities, including rib malformations, that may contribute to TOS.
Nerve conduction studies (NCS). A test of nerve function in which a nerve is stimulated with electric current after placement of electrodes on the skin. Patients may find the sensation unusual but generally not painful. This test is generally used to rule out other nerve-related conditions.
Electromyography (EMG). A test of electrical activity in muscle. EMG involves insertion of thin needles in the muscle and can cause discomfort and bruising.
Magnetic resonance imaging (MRI). A safe and painless test that produces very clear cross-sectional or three-dimensional images of the body's tissues, even through bone and other obstructions. An MRI may be used to rule out other causes.
Duplex ultrasound. Similar to an echocardiogram, Duplex ultrasound is a non-invasive vascular test that uses sound waves to visualize circulation within blood vessels. This test is useful to determine if an artery or vein is being compressed, which may help diagnose arterial or venous TOS.
Treatment
Physical therapy helps strengthen the shoulder muscles, improve range of motion, and promote better posture. Treatment may also include pain medication.
Surgery is used as a last step. Your doctor may use bypass surgery to reroute blood around the compression or remove the structure that is causing the symptoms. Your doctor may also suggest other alternatives, including angioplasty.
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