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Thoracic Outlet Syndrome


What is Thoracic Outlet Syndrome?

TOS is an umbrella term that encompasses three related syndromes that cause pain in the arm, shoulder, and neck: neurogenic TOS (caused by compression of the brachial plexus), vascular TOS (caused by compression of the subclavian artery or vein) and nonspecific or disputed TOS (in which the pain is from unexplained causes). Occasionally, neurogenic TOS and vascular TOS co-exist in the same person. Most doctors agree that TOS is caused by compression of the brachial plexus or subclavian vessels as they pass through narrow passageways leading from the base of the neck to the armpit and arm, but there is considerable disagreement about its diagnosis and treatment.
Making the diagnosis of TOS even more difficult is that a number of disorders feature symptoms similar to those of TOS, including rotator cuff injuries, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome, and tumors of the syrinx or spinal cord. The disorder can sometimes be diagnosed in a physical exam by tenderness in the supraclavicular area, weakness and/or a "pins and needles" feeling when elevating the hands, weakness in the fifth ("little") finger, and paleness in the palm of one or both hands when the individual raises them above the shoulders, with the fingers pointing to the ceiling. Symptoms of TOS vary depending on the type.

Neurogenic TOS has a characteristic sign, called the Gilliatt-Sumner hand, in which there is severe wasting in the fleshy base of the thumb. There may be numbness along the underside of the hand and forearm, or dull aching pain in the neck, shoulder, and armpit.

Vascular TOS features pallor, a weak or absent pulse in the affected arm, which also may be cool to the touch and appear paler than the unaffected arm. Symptoms may include numbness, tingling, aching, and heaviness.

Non-specific TOS most prominently features a dull, aching pain in the neck, shoulder, and armpit that gets worse with activity. Non-specific TOS is frequently triggered by a traumatic event such as a car accident or a work related injury. It also occurs in athletes, including weight lifters, swimmers, tennis players, and baseball pitchers.

TOS is more common in women. The onset of symptoms usually occurs between 20 and 50 years of age. Doctors usually recommend nerve conduction studies, electromyography, or imaging studies to confirm or rule out a diagnosis of TOS.

Is there any treatment?

Treatment begins with exercise programs and physical therapy to strengthen chest muscles, restore normal posture, and relieve compression by increasing the space of the area the nerve passes through. Doctors will often prescribe non-steroidal anti-inflammatory drugs (such as naproxen or ibuprofen) for pain. If this doesn't relieve pain, a doctor may recommend thoracic outlet decompression surgery to release or remove the structures causing compression of the nerve or artery.

What is the prognosis?

The outcome for individuals with TOS varies according to type. The majority of individuals with TOS will improve with exercise and physical therapy. Vascular TOS, and true neurogenic TOS often require surgery to relieve pressure on the affected vessel or nerve.

What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes at the National Institutes of Health support research in TOS through grants to major medical institutions across the country. Much of this research focuses on finding better ways to diagnose and treat TOS.

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