Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a condition caused by compression of nerves or blood vessels in the thoracic outlet, the area between the base of the neck and the armpit, including the front of the shoulders and chest.

There are three types of TOS:

1. Vascular. This can be a compression of the artery and vein.
2. Neurogenic. The nerves become compromised from an extra cervical rib, present at birth.
3. Disputed or painful form. There is no neurological deficit but patients experience neurological symptoms and pain. Typically these patients’ electrodiagnostic studies (EMG; to study nerve conduction within your hands and wrists) are normal, but they complain of pain.

The trusted experience and surgical expertise of the neurosurgeons at The Johns Hopkins Peripheral Nerve Surgery Center make us the best choice for treatment of this condition.

Symptoms
Thoracic outlet syndrome may include the following symptoms:

• Neck, shoulder, and arm pain
• Numbness in the arm, hand or fingers
• Impaired circulation to the extremities (causing discoloration)
• Weakness in the shoulders, arm and hands

Causes
Thoracic outlet syndrome is caused by an enlargement or change of the tissues in or near the thoracic outlet. Causes of enlargement of the tissues may include:

• Trauma or injury
• Weight lifting
• Cervical rib (an extra rib extending from the neck present at birth)
• Weight gain
• Growth of a tumor

Often, there is no direct cause found in patients suffering from TOS.

Diagnosis
Proper diagnosis of thoracic outlet syndrome requires the expert attention of experienced neurologists and nerve specialists. Diagnosis will include:

• A comprehensive clinical exam, including neurological exams
• Complete medical history
• Imaging studies such as X-rays and/or MRI (magnetic resonance imaging)
• Electrodiagnostic studies (EMG)

Diagnosis is necessary to determine the cause of TOS, so the appropriate treatment plan, including a surgical option is considered.

Treatment
There are several forms of treatment for patients with TOS. These may include:

• Physical therapy with careful nerve stretching movements performed by a qualified and experienced physical therapist with experience treating TOS.
• Injections with nerve blocking agents to suppress pain and reduce swelling and compression.
• Acupuncture. Some patients with TOS have found relief using acupuncture.

Surgical Intervention
There are two types or approaches to TOS surgery.

1. Supraclavicular Approach
   (above the clavicle approach)
   In this approach, your surgeon will attempt to decompress the nerves in the brachial plexus. The anterior scalene muscle is usually divided and any bands constricting the nerves are cut or removed.
2. Transaxiallary Approach
   In this approach, your surgeon will access the nerves in the brachial plexus through the armpit. The nerves are decompressed and the first rib is removed.

Factors in Surgical Intervention
When physical therapy and other forms of non-surgical treatment fail, surgery is the best option to restore function and alleviate pain.

Recovery
Patients who have surgery for TOS should expect to stay one night in the hospital. Most patients recover within six weeks.