Thoracic Outlet Syndrome

What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed. This can cause pain in your shoulders and neck and numbness in your fingers.

What are the causes?

In general, the cause of thoracic outlet syndrome is compression of the nerves or blood vessels in the thoracic outlet, just under your collarbone (clavicle). The cause of the compression varies and can include:

  • Anatomical defects. Inherited defects that are present at birth (congenital) may include an extra rib located above the first rib (cervical rib) or an abnormally tight fibrous band connecting your spine to your rib.
  • Poor posture. Drooping your shoulders or holding your head in a forward position can cause compression in the thoracic outlet area.
  • Trauma. A traumatic event, such as a car accident, can cause internal changes that then compress the nerves in the thoracic outlet. The onset of symptoms related to a traumatic accident often is delayed.
  • Repetitive activity. Doing the same thing repeatedly can, over time, wear on your body’s tissue. You may notice symptoms of thoracic outlet syndrome if your job requires you to repeat a movement continuously, such as typing on a computer, working on an assembly line or lifting things above your head, as you would if you were stocking shelves. Athletes, such as baseball pitchers and swimmers, also can develop thoracic outlet syndrome from years of repetitive movements.
  • Pressure on your joints. Obesity can put an undue amount of stress on your joints, as can carrying around an oversized bag or backpack.
  • Pregnancy. Because joints loosen during pregnancy, signs of thoracic outlet syndrome may first appear while you’re pregnant.

What are the symptoms?

There are a number of types of thoracic outlet syndrome, including:

  • Neurogenic (neurological) thoracic outlet syndrome. This form of thoracic outlet syndrome is characterized by compression of the brachial plexus. The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensation in your shoulder, arm and hand. In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic.
  • Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome occurs when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) under the collarbone (clavicle) are compressed.
  • Nonspecific-type thoracic outlet syndrome. This type is also called disputed thoracic outlet syndrome. Some doctors don’t believe it exists, while others say it’s a common disorder. People with nonspecific-type thoracic outlet syndrome have chronic pain in the area of the thoracic outlet that worsens with activity, but a specific cause of the pain can’t be determined.

Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed. When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome include:

  • Muscle wasting in the fleshy base of your thumb (Gilliatt-Sumner hand)
  • Numbness or tingling in your arm or fingers
  • Pain or aches in your neck, shoulder or hand
  • Weakening grip

Signs and symptoms of vascular thoracic outlet syndrome can include:

  • Discoloration of your hand (bluish color)
  • Arm pain and swelling, possibly due to blood clots
  • Blood clot in veins or arteries in the upper area of your body
  • Lack of color (pallor) in one or more of your fingers or your entire hand
  • Weak or no pulse in the affected arm
  • Cold fingers, hands or arms
  • Arm fatigue with activity
  • Numbness or tingling in your fingers
  • Weakness of arm or neck
  • Throbbing lump near your collarbone

When to see a doctor

See your doctor if you consistently experience any of the signs and symptoms of thoracic outlet syndrome.

What are the treatments?

In most cases, a conservative approach to treatment is effective, especially if your condition is diagnosed early. Treatment may include:

  • Physical therapy. If you have neurogenic thoracic outlet syndrome, physical therapy is the first line of treatment. You’ll learn how to do exercises that strengthen and stretch your shoulder muscles to open the thoracic outlet, improve your range of motion and improve your posture. These exercises, done over time, may take the pressure off your blood vessels and nerves in the thoracic outlet.
  • Medications. Your doctor may prescribe anti-inflammatory medications, pain medications or muscle relaxants to decrease inflammation, reduce pain and encourage muscle relaxation.
  • Clot-dissolving medications. If you have venous or arterial thoracic outlet syndrome and have blood clots, your doctor may administer clot-dissolving medications (thrombolytics) into your veins or arteries to dissolve blood clots. After you’re given thrombolytics, your doctor may prescribe medications to prevent blood clots (anticoagulants).

Surgical options

Your doctor may recommend surgery if other treatment hasn’t been effective, if you’re experiencing ongoing symptoms or if you have progressive neurological problems.

A surgeon trained in chest (thoracic) surgery or blood vessel (vascular) surgery will perform the procedure.

Thoracic outlet syndrome surgery has risks of complications, such as injury to the brachial plexus. Also, surgery may not relieve your symptoms, and symptoms may recur.

Surgery to treat thoracic outlet syndrome, called thoracic outlet decompression, may be performed using several different approaches, including:

   Transaxillary approach. In this surgery, your surgeon makes 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. This approach gives your surgeon easy access to the first rib without disturbing the nerves or blood vessels. But, that only gives your surgeon limited access and makes it harder to see muscles and cervical ribs that may be contributing to compression behind the nerves and blood vessels.

   Supraclavicular approach. This approach repairs compressed blood vessels. Your surgeon makes an incision just under your neck to expose your brachial plexus region.

   Your surgeon then looks for signs of trauma or muscles contributing to compression near your first (uppermost) rib. Your surgeon may remove the muscles causing the compression and repair compressed blood vessels. Your first rib may be removed if necessary to relieve compression.

   Infraclavicular approach. In this approach, your surgeon makes an incision under your collarbone and across your chest. This procedure may be used to treat compressed veins that require extensive repair.

In venous or arterial thoracic outlet syndrome, your surgeon may deliver medications to dissolve blood clots prior to thoracic outlet compression. Also, in some cases, your surgeon may conduct a procedure to remove a clot from the vein or artery or repair the vein or artery prior to thoracic outlet decompression.
If you have arterial thoracic outlet syndrome, your surgeon may need to replace the damaged artery with a section of an artery from another part of your body (graft) or an artificial graft. This procedure may be done at the same time as your procedure to have the first rib removed.

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