Thoracic outlet syndrome
Thoracic outlet syndrome | |
---|---|
Nerve conduction studies, medical imaging[1] | |
Differential diagnosis | Rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome,[1] pectoralis minor syndrome[3] |
Treatment | Pain medication, surgery[1][2] |
Frequency | ~1%[4] |
Thoracic outlet syndrome (TOS) is a condition in which there is compression of the
TOS may result from
Initial treatment for the neurogenic type is with
Signs and symptoms
TOS affects mainly the upper limbs, with signs and symptoms manifesting in the shoulders, neck, arms and hands. Pain can be present on an intermittent or permanent basis. It can be sharp/stabbing, burning, or aching. TOS can involve only part of the hand (as in the pinky and adjacent half of the ring finger), all of the hand, or the inner aspect of the forearm and upper arm. Pain can also be in the side of the neck, the pectoral area below the clavicle, the armpit/axillary area, and the upper back (i.e., the trapezius and rhomboid area). Discoloration of the hands, one hand colder than the other hand, weakness of the hand and arm muscles, and tingling are commonly present.[citation needed]
Only 1% of people with carpal tunnel syndrome have concomitant TOS.[7]
Repetitive motions can cause enlargement of muscles which causes compression of veins. Besides, overuse injury of the upper limbs causes swellings, small bleeding, and subsequent fibrosis which would cause the thrombosis of the subclavian vein, leading to Paget–Schroetter disease or effort-induced thrombosis.[7]
TOS can be related to
TOS can also lead to eye problems and vision loss as a circumstance of vertebral artery compression. Although very rare, if compression of the brain stem is also involved in an individual presentation of TOS, transient blindness may occur while the head is held in certain positions.[9] If left untreated, TOS can lead to neurological deficits as a result of the hypoperfusion and hypometabolism of certain areas of the brain and cerebellum.[11]
TOS has similar symptoms to pectoralis minor syndrome (PMS), which usually results from compression of the braxial plexus beneath the pectoralis minor muscle (while neurogenic TOS is caused by compression of the same nerves above the clavicle).[12] Unlike TOS there is typically few headaches or neck pain in patients with PMS only, instead with pain in the chest area.[13] Initially, it was believed that 95 percent of patients with TOS had nerve compression in the scalene area, but in the twenty-first century it is now recognized that the majority have nerve compression under the pectoralis minor, either by itself or in addition to the scalene area.[14] One study of 100 patients diagnosed with neurogenic TOS found that 75 percent had neurogenic PMS and 30 percent in fact had PMS without TOS.[3][14]
Causes
TOS can be attributed to one or more of the following factors:[15]
- scalenus medius) or fibrous connective tissue anomalies.[15]
- Trauma (e.g., whiplash injuries) or repetitive strain is frequently implicated.[15]
- Rarer acquired causes include
Diagnosis
Additional maneuvers that may be abnormal in TOS include
MRI scan can show the anatomy of the thoracic outlet, the soft tissues causing compression, and can show directly the brachial plexus compression.[7]
Classification
By structures affected and symptomatology
There are three main types of TOS, named according to the cause of the symptoms; however, these three classifications have been coming into disfavor because TOS can involve all three types of compression to various degrees. The compression can occur in three anatomical structures (arteries, veins and nerves), it can be isolated, or, more commonly, two or three of the structures are compressed to greater or lesser degrees. In addition, the compressive forces can be of different magnitude in each affected structure. Therefore, symptoms can be variable.[18]
- Neurogenic TOS includes disorders produced by compression of components of the brachial plexus nerves. The neurogenic form of TOS accounts for 95% of all cases of TOS.[19]
- Arterial TOS is due to compression of the subclavian artery.[19] This is less than one percent of cases.[2]
- Venous TOS is due to compression of the subclavian vein.[19] This makes up about 4% of cases.[2]
By event
There are many causes of TOS. The most frequent cause is trauma, either sudden (as in a clavicle fracture caused by a car accident), or repetitive (as in a legal secretary who works with his/her hands, wrists, and arms at a fast-paced desk station with non-ergonomic posture for many years)[citation needed]. TOS is also found in certain occupations involving much lifting of the arms and repetitive use of the wrists and arms [citation needed].
One cause of arterial compression is
The two groups of people most likely to develop TOS are those with neck injuries due to traffic accidents and those who use computers in non-
By structure causing constriction
It is also possible to classify TOS by the location of the obstruction:[citation needed]
- Anterior scalene syndrome (compression on brachial plexus and/or subclavian arterycaused by muscle growth).
- Cervical rib syndrome (compression on brachial plexus and/or subclavian artery caused by bone growth).
- costoclavicular maneuver.
Some people are born with an extra incomplete and very small rib above their first rib, which protrudes out into the superior thoracic outlet space. This rudimentary rib causes fibrous changes around the brachial plexus nerves, inducing compression and causing the symptoms and signs of TOS. This is called a "cervical rib" because of its attachment to C-7 (the seventh cervical vertebra), and its surgical removal is almost always recommended. The symptoms of TOS can first appear in the early teen years as a child is becoming more athletic.[citation needed]
Treatment
Evidence for the treatment of thoracic outlet syndrome as of 2014 is poor.[21]
Physical measures
Stretching, occupational and physical therapy are common non-invasive approaches used in the treatment of TOS. The goal of stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, or tendons that are causing the problem.[citation needed]
- One commonly prescribed set of stretches includes moving the shoulders anteriorly (forward – called "hunching"), then back to a neutral position, then extending them posteriorly (backward, called "arching"), then back to neutral, followed by lifting the shoulders up as high as possible, and then back down to neutral, repeated in cycles as tolerated.
- Another set of stretches involves tilting and extending the neck opposite to the side of the injury while keeping the injured arm down or wrapped around the back.
- Occupational or Physical therapy can include passive or active range of motion exercises, working up to weighted or restricted sets (as tolerated).
TOS is rapidly aggravated by poor posture.[
Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving blood circulation to them. While the whole arm generally feels painful in TOS, some relief can be seen when ice or heat is intermittently applied to the thoracic region (collar bone, armpit, or shoulder blades).[citation needed]
Medications
In a review, botox was compared to a placebo injected into the scalene muscles. No effect in terms of pain relief or improved movement was noted. However, in a six-months follow-up, paresthesia (abnormal sensations such as in pins and needles) was seen to be significantly improved.[21]
Surgery
Surgical approaches have also been used successfully in TOS. Microsurgery can be used approaching the area from above the collar bone (supraclavicular) followed by neurolysis of the brachial plexus, removal of the scalene muscle (scalenectomy), and the release of the underlying (subclavicular) blood vessels. This approach avoids the use of resection, and has been found to be an effective treatment.[22] In cases where the first rib (or a fibrous band extending from the first rib) is compressing a vein, artery, or the nerve bundle, part of the first rib and any compressive fibrous tissue, can be removed in a first rib resection and thoracic outlet decompression surgical procedure; scalene muscles may also need to be removed (scalenectomy). This allows increased blood flow and the reduction of nerve compression.[23] In some cases there may be a rudimentary rib or a cervical rib that can be causing the compression, which can be removed using the same technique.[citation needed]
Physical therapy is often used before and after the operation to improve recovery time and outcomes. Potential complications include pneumothorax, infection, loss of sensation, motor problems, subclavian vessel damage, and, as in all surgeries, a very small risk of permanent serious injury or death.[citation needed]
Notable cases
- Sports
Several
UFC fighter Matt Serra had a rib removed to alleviate TOS.[39]
- Music
Musician Isaac Hanson had a pulmonary embolism as a consequence of thoracic outlet syndrome.[40]
The Japanese band Maria disbanded in 2010 due to drummer Tattsu's TOS which made it impossible for her to continue playing.[41]
In 2015, singer
See also
- Pectoralis minor syndrome
- May–Thurner syndrome – a similar compressive pathology involving the left common iliac vein
- Backpack palsy– a similar compressive pathology involving the long thoracic nerve, or adjacent brachial plexus nerves
References
- ^ a b c d e f g h i j k l m n o p q r "NINDS Thoracic Outlet Syndrome Information Page". NINDS. December 28, 2011. Archived from the original on July 27, 2016. Retrieved August 19, 2016.
- ^ S2CID 23150937.
- ^ PMID 20471786.
- ^ ISBN 978-1-4557-5386-4.
- PMID 29558408.
- ISBN 978-1-4471-4366-6.
- ^ PMID 31037504.
- PMID 4002908.
- ^ PMID 7931599.
- PMID 11294095.
- PMID 10064369.
- PMID 25868762.
- ISBN 978-3-030-55073-8.
- ^ ISBN 978-3-030-55073-8.
- ^ PMID 21193950.
- ^ "Thoracic Outlet Syndrome". Nicholas Institute of Sports Medicine and Athletic Trauma. Archived from the original on May 17, 2013.
- Mount Sinai Hospital, New York. Archived from the originalon December 9, 2008.
- PMID 15041500.
- ^ S2CID 23667734.
- doi:10.1102/1470-5206.2010.0012 (inactive January 31, 2024). Archived (PDF) from the original on July 11, 2011.)
{{cite journal}}
: CS1 maint: DOI inactive as of January 2024 (link - ^ PMID 25427003.
- )
- PMID 15977087.
- ^ DiComo A (February 13, 2017). "Harvey determined to regain dominant form". MLB News.
- ^ Langosch J, Still M (July 2, 2012). "Carpenter's throwing session canceled". MLB.com. Archived from the original on October 29, 2013.
- ^ Halsted A (July 5, 2014). "Garcia to have season-ending surgery for nerve issue". MLB.com. Archived from the original on July 14, 2014.
- ^ "Marcum needs thoracic outlet syndrome surgery". Rotoworld.com. July 9, 2013. Archived from the original on July 12, 2013.
- ^ Fort Worth Star-Telegram (September 7, 2013). "Foul Territory: Rangers' Matt Harrison facing surgery for thoracic outlet syndrome on right shoulder". Sportsblogs.star-telegram.com. Archived from the original on October 29, 2013. Retrieved October 26, 2013.
- ^ "Clayton Richard's Story". Center for Thoracic Outlet Syndrome. Washington University School of Medicine in St Louis. Archived from the original on April 16, 2016. Retrieved April 9, 2016.
- ^ Jul 15, A. P.; ET, 2017 at 6:21p (July 15, 2017). "Nate Karns out for season due to thoracic outlet surgery". FOX Sports. Retrieved October 12, 2020.
{{cite web}}
: CS1 maint: numeric names: authors list (link) - ^ Shea J, Schulman H (May 20, 2009). "San Francisco Chronicle: Lowry's agent lashes out". Sfgate.com. Archived from the original on May 23, 2009. Retrieved October 26, 2013.
- ^ Wagner J (March 12, 2014). "Nationals Journal: Back from injury, Chris Young hopes to be part of the Nationals". The Washington Post. Retrieved October 19, 2014.
- ^ Stecker B (August 18, 2014). "Mariners' Chris Young has strong case for Comeback award". 710Sports.com. Archived from the original on August 22, 2014. Retrieved October 19, 2014.
- ISBN 0-7867-1335-6.
- ^ Marrapese-Burrell N. "McQuaid a Masterton Trophy Finalist". Boston Globe. Archived from the original on June 8, 2013. Retrieved June 8, 2013.
- ^ Kaplan E (August 2, 2018). "Inside Chris Kreider's journey back to the ice". ESPN.
- ^ "Markelle Fultz diagnosed with nerve condition". NBA.com.
- ^ Wojnarowski A. "76ers' Markelle Fultz expected to miss 3-6 weeks for shoulder rehabilitation". ESPN. Retrieved December 4, 2018.
- ^ Burke T (May 22, 2013). "Health scare leads to former UFC champion Matt Serra probably walking away from MMA". Bloody Elbow. Archived from the original on October 29, 2013. Retrieved October 26, 2013.
- ^ Dyball R, Schneider KS (October 22, 2007). "Anson Brother's Health Scare 'I Could Have Silently Died'". People. 68 (17). New York: 96. Archived from the original on October 18, 2007. Retrieved January 1, 2008.
Isaac hanson talks about surviving a life-threatening blood clot--and how his family is helping him cope.
- ^ "MARIA今後の活動に関するお知らせ" (in Japanese). MARIA6. Archived from the original on February 11, 2010. Retrieved February 16, 2010.
- ^ "Tamar Braxton Opens up About Health Crisis, Rib Removal". ABC News. December 17, 2015.