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| Thoracic Outlet Syndrome (TOS) |
| Classification and external resources |
The right brachial plexus, viewed from in front. In thoracic outlet syndrome there is compression of the brachial plexus or subclavian vessels in their passage from the cervical and upper thoracic area toward the axilla and proximal arm. The anterior supraclavicular neurosurgical procedure is used to treat certain refractory cases. |
| ICD-10 |
G54.0 |
| ICD-9 |
353.0 |
| DiseasesDB |
13039 |
| MedlinePlus |
001434 |
| eMedicine |
pmr/136 |
| MeSH |
D013901 |
Thoracic outlet syndrome (TOS) is a syndrome involving compression at the superior thoracic outlet[1] wherein excess pressure placed on a neurovascular bundle passing between the anterior scalene and middle scalene muscles.[2] It can affect one or more of the nerves that innervate the upper limb and/or blood vessels as they pass between the chest and upper extremity; specifically in the brachial plexus, the subclavian artery, and - rarely - the subclavian vein, which does not normally pass through the scalene hiatus.
TOS may occur due to a positional cause - for example, by abnormal compression from the clavicle (collarbone) and shoulder girdle on arm movement. There are also several static forms, caused by abnormalities, enlargement, or spasm of the various muscles surrounding the arteries, veins, and/or brachial plexus, a fixation of a first rib, or a cervical rib. A Pancoast tumor (a rare form of lung cancer in the apex of the lung) can lead to thoracic outlet syndrome in the progressive stages of the disease. The most common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive strain injury from a job such as frequent non-ergonomic use of a keyboard, sports-related activities, anatomical defects such as having an extra rib, and pregnancy.[3]
Common orthopaedic tests used are the Adson's test, the Costoclavicular Manoeuvre, and the "Hands-Up" test or "EAST" test. Careful examination and X-ray are required to differentially diagnose between the positional and static aetiologies, first rib fixations, scalene muscle spasm, and a cervical rib or fibrous band.
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Contents
- 1 Classification
- 1.1 By structures affected and symptomatology
- 1.2 By event
- 1.3 By structure causing constriction
- 2 Symptoms and consequences
- 3 Diagnosis
- 4 Treatment
- 4.1 Noninvasive
- 4.2 Invasive
- 5 Notable TOS sufferers
- 6 See also
- 7 References
- 8 External links
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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), 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 protean.[4] http://www.tos-syndrome.com/old1/newpage12.htm[5]
- 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.[6]
- Arterial TOS is due to compression of the subclavian artery.[6]
- Venous TOS is due to compression of the subclavian vein.[6]
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). TOS is also found in certain occupations involving lots of lifting of the arms and repetitive use of the wrists and arms.
One cause of arterial compression is trauma, and a recent case involving fracture of the clavicle has been reported[7]
The two groups of people most likely to develop TOS are those suffering from neck injuries due to traffic accidents and those who use computers in non-ergonomic postures for extended periods of time[citation needed]. TOS is frequently a repetitive stress injury (RSI) caused by certain types of work environments. Other groups which may develop TOS are athletes who frequently raise their arms above the head (such as swimmers, volleyball players, shuttlecock players, baseball pitchers, and weightlifters), rock climbers, electricians who work long hours with their hands above their heads, and some musicians.
By structure causing constriction
It is also possible to classify TOS by the location of the obstruction:
- Scalenus anticus syndrome (compression on brachial plexus and/or subclavian artery caused by muscle growth) – diagnosed by using Adson's sign with patient's head turned outward.
- Cervical rib syndrome (compression on brachial plexus and/or subclavian artery caused by bone growth) – diagnosed by using Adson's sign with patient's head turned inward.
- Costoclavicular syndrome (narrowing between the clavicle and the first rib) – diagnosed with the 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 7th 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.
Symptoms and consequences
TOS affects mainly the upper limbs, with signs and symptoms manifesting in the arms and hands. Pain is almost always present, and can be sharp, burning, or aching. It can involve only part of the hand (as in the 4th and 5th finger only), 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). Decoloration of the hands, one hand colder than the other hand, weakness of the hand and arm muscles, and tingling are commonly present.
TOS is often the underlying cause of refractory upper limb conditions like frozen shoulder and carpal tunnel syndrome that frequently defy standard treatment protocols.
TOS can be related to Cerebrovascular arterial insufficiency when affecting the subclavian artery.[8] It also can affect the vertebral artery, case in which it could produce transient blindness,[9] and embolic cerebral infarction.[10]
A painful, swollen and blue arm, particularly when occurring after strenuous physical activity, could be a sign of a venous compression or subclavian vein thrombosis called Paget-Schroetter Syndrome.
Diagnosis
Adson's sign and the Costoclavicular maneuver lack specificity and sensitivity, and should comprise only a small part of the mandatory comprehensive history and physical examination undertaken with a patient suspected of having TOS. There is currently no single clinical sign that makes the diagnosis of TOS with any degree of certainty.
However, while there is no "gold standard" to diagnosis TOS Dr. Sheldon E. Jordan and Dr. Herbert I. Machleder published the "Diagnosis of Thoracic Outlet Syndrome Using Electrophysiologically Guided Anterior Scalene Blocks" in 1998. Previously anesthetic blocks of the anterior scalene muscle (AMS) had been used as a means of predicting which patients may benefit from surgical decompression. However the standard technique of using surface landmarks often resulted in inadvertent somatic block and sympathetic block because there is no reliable verification of needle tip localization. Their study was undertaken to determine if needle tip localization could be improved by using electrophysiological guidance. They determined that electrophysiological guidance facilitated accurate needle tip placement in the performance of ASM blocks; the result of these blocks appear to correlate with surgical outcomes. (Ann Vasc Surg 1998;12:260-246.) [11] This method of guidance for selective muscle blocks is rarely used today, for two major reasons. First, the accuracy of placement of the needle tip with EMG is controversial; ultrasound, CT or MRI are likely much more accurate. Second, there is no control over the spread of injectate. Any medication or other injectate could leak out of a confined structure such as a muscle and flow to adjoining structures, such as the brachial plexus. Should this occur, direct anesthesia of the brachial plexus could result in decreased symptoms, but without any clinical significance regarding the role of the muscle into which the injection was attempted. Making a judgement about correlation with surgical success is, thus, somewhat perilous. There are a number of publications from the same center as the paper quoted above, and from other centers, regarding selective muscle injections using Botox or other agents in which the subjects had various adverse outcomes, such as long-term paralysis of a vocal cord, that prove the limited control over where injectate flows. For these reasons and others, the quoted paper does not support this method as a "gold standard" for the diagnosis of TOS.
Additional maneuvers that may be abnormal in TOS include the "stick em up hand raise" for up to 3–5 minutes, which involves holding both hands at right angles over the head bent at the elbows, with or without opening and closing of the fingers (a positive test occurs when the affected hand quickly becomes paler than the unaffected because of compromised blood supply), and the "compression test", when exerting pressure between the clavicle and medial humeral head causes radiation of pain and/or numbness into the affected arm.[12]
Doppler Arteriography, with probes at the fingertips and arms, tests the force and "smoothness" of the arterial flow through the radial arteries, with and without having the patient perform various arm maneuvers (which causes compression of the subclavian artery at the thoracic outlet). The movements can elicit symptoms of pain and numbness and produce graphs with diminished arterial blood flow to the fingertips, providing strong evidence of impingement of the subclavian artery at the thoracic outlet.[13] It should be noted that Doppler arteriography does not utilize probes at the fingertips and arms, and in this case is likely being confused with plethysmography, which is a different method that utilizes ultrasound without direct visualization of the affected vessels. It should also be noted that Doppler ultrasound (not really 'arteriography') would not be used at the radial artery in order to make the diagnosis of TOS. Finally, even if a Doppler study of the appropriate artery were to be positive, it would not diagnose neurogenic TOS, by far the most common subtype of TOS. There is plenty of evidence in the medical literature to show that arterial compression does not equate to brachial plexus compression, although they may occur together, in varying degrees. Additionally, arterial compression by itself does not make the diagnosis of arterial TOS (the rarest form of TOS). Lesser degrees of arterial compression have been shown in normal individuals in various arm positions, and is thought to be of little significance without the other criteria for arterial TOS.
Some physicians advocate the injection of a short-acting anesthetic such as xylocaine or marcaine into the anterior scalene, subclavius, or pectoralis minor muscles as a provocative test to assist in the diagnosis of thoracic outlet syndrome. This is referred to as a 'scalene block' when employing the use of a local anesthetic. This is not considered a "treatment", however, as the relief is expected to wear off within an hour or two at most. Active clinical research continues into the specificity, sensitivity, risks and benefits of this provocative test and other types of neuromuscular blocks, particularly at Johns Hopkins Hospital in Baltimore, Maryland (US).[citation needed].
High resolution MRI/MRA of the Brachial Plexus[citation needed].
Treatment
Most patients respond to conservative measures such as medications, rest, chiropractic or physical therapy, and stretching. Only a minority of patients with signs and symptoms of TOS ultimately proceed to surgery.[citation needed]
Noninvasive
Stretching and Physical Therapy
The goal of stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, and/or tendons that are causing the problem.
- 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.
- Physical therapy can include passive or active range of motion exercises, working up to weighted or restricted sets (as tolerated).
- Chiropractic therapy usually consists of manipulation of any or all of the articulations of the shoulder girdle, including the 1st rib. Additional myofascial release (MFR) or Active Release Technique (ART) to the connected musculature and use of passive or active range of motion exercises.
Cases of TOS often involve compression of a large cluster of nerves, typically resulting in motor and/or sensory impairment throughout the arm. "Nerve gliding exercises" can stretch and mobilize affected nerve fibers and decrease symptomatology and function. Chronic and intermittent nerve compression has been studied in animal models, and has a well-described pathophysiology, as described by Susan Mackinnon, MDv (currently at Washington University in St. Louis).[citation needed] Nerve gliding exercises have been studied by several authorities, including David Butler in Australia.[citation needed].
- Nerve gliding can be performed by extending the injured arm with fingers directly outwards to the side and tilting the head to both sides. A gentle pulling feeling is generally felt throughout the injured side. Initially, only do this and repeat. Once this exercise has been mastered and no extreme pain is felt, begin stretching your fingers back. Repeat with different variations, tilting your hand up, backwards, or downwards.
- Posture
TOS is rapidly aggravated by poor posture. Active breathing exercises and ergonomic desk setup and motion practices can help maintain active posture. Often the muscles in the back become weak due to prolonged (years of) "hunching" and other poor postures.
- Ice/Heat
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).
Acupuncture is also an effective method of treatment for TOS. Patients may feel significantly less pain within 3-4 acupuncture treatment sessions.[citation needed]
Invasive
- Cortisone
Injected into a joint or muscle, cortisone can help lower inflammation and provide relief.[dubious – discuss]
- Botox injections
Botox - short for Botulinum Toxin Av - binds nerve endings and prevents the release of neurotransmitters that activate muscles. A small amount of Botox injected into the tight or spastic muscles (usually one or all three scalenes) found in TOS sufferers often provides months of relief while the muscle is temporarily paralyzed. This noncosmetic treatment is not covered by most medical insurance plans and costs upwards of $400. The relief of symptoms from a Botox injection generally lasts 3–4 months, at which point the Botox toxin is degraded by the affected muscles. Serious side effects have been reported, and are similarly long-lasting, so improved understanding of the mechanism this form of 'scalene block' is vital to determining iks risk-vs.benefit profile. Additionally, many patients in a study done at Johns Hopkins Hospital in Baltimore report no relief of symptoms from Botox or scalene injections, which may indicate that the pain does not stem from the scalene muscle, and may not be TOS. Botox can be a effective treatment for neurogenic TOS.[14] It may eliminate pain, or reduce it enough for the victim to undergo physical therapy, and hopefully be able to properly stretch and reduce compression in the affected area.
Surgical Approaches Surgical approaches have also been used successfully in TOS.[15] In cases where the first rib is compressing a vein, artery, or the nerve bundle, the first rib and scalene muscles and any compressive fibrous tissue can be removed. This procedure is called a first rib resection and scalenectomy and involves going through the underarm area or back of the neck area and removing the first rib, scalene muscles, and any compressive fibrous tissue to open the area to allow increased blood flow and/or reduce nerve compression. 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. However, no surgical option should be considered until all non-invasive approaches have been exhausted.
Physical therapy is often used before and after the operation to decrease recovery time and improve outcomes. Potential complications include pneumothorax, infection, loss of sensation, motor problems, and as in all surgeries, a very small risk of permanent serious injury or death.
Notable TOS sufferers
Major League Baseball players Phillies RP Mike Adams, Rangers SP Matt Harrison, former All-Star 3B Hank Blalock, Cardinals SP Chris Carpenter,[16] former Rangers SPJohn Rheinecker, former Tigers SP Jeremy Bonderman, Rays SP Alex Cobb, former All-Star Kenny Rogers, Red Sox Cather Jarrod Saltalamacchia, and former Giants SP Noah Lowry[17] have recently been diagnosed with thoracic outlet syndrome. Kenny Rogers was diagnosed several years earlier with TOS in the other upper extremity (coincidentally, six of these ten players have played for the Texas Rangers). All-Star pitcher J. R. Richard suffered a career-ending stroke from an undiagnosed case of TOS. Pitcher David Cone had an unusual "variant" case of TOS, with an arterial aneurysm of the upper aspect of his pitching arm. Craig Carton of WFAN had Thoracic outlet syndrome and underwent successful microsurgery to cure it.
Athletes who repetitively raise their arms above their heads - such as swimmers, track and field runners, and volleyball players - are known to be predisposed to the development of TOS.
Musician Isaac Hanson suffered a potentially life-threatening pulmonary embolism as a complication of thoracic outlet syndrome.[18]
Professional Baseball scout for the New York Mets Bryn Alderson underwent successful surgery to cure it in September of 2012.
Professional Darts player Denis Ovens suffers from the condition and says that it affects the grip he has on his darts.
Professional Hockey Player Adam McQuaid from the Boston Bruins received surgery for this condition in October 2012 following an injury while practicing earlier that month.
See also
- Paget-Schroetter disease
- May-Thurner syndrome - A similar compressive pathology involving the left common iliac vein.
References
- ^ Thoracic+outlet+syndrome at the US National Library of Medicine Medical Subject Headings (MeSH)
- ^ Jay Allan Liveson (25 September 2000). Peripheral neurology: case studies. Oxford University Press US. pp. 255–. ISBN 978-0-19-513563-3. http://books.google.com/books?id=nARrfwZPVH8C&pg=PA255. Retrieved 4 August 2010.
- ^ Mayo Clinic staff (November 6, 2010). "Thoracic outlet syndrome". mayoclinic.com. Rochester, MN, USA: Mayo Clinic. http://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800. Retrieved August 11, 2012.
- ^ Ambrad-Chalela, Esteban; Thomas, George I.; Johansen, Kaj H. (2004). "Recurrent neurogenic thoracic outlet syndrome". The American Journal of Surgery 187 (4): 505–10. doi:10.1016/j.amjsurg.2003.12.050.
- ^ Selmonosky, M.D., Carlos. "TOS-Syndrome; Symptoms". http://www.tos-syndrome.com. Retrieved 2011-03-20.
- ^ a b c Fugate, Mark W.; Rotellini-Coltvet, Lisa; Freischlag, Julie A. (2009). "Current management of thoracic outlet syndrome". Current Treatment Options in Cardiovascular Medicine 11 (2): 176–83. doi:10.1007/s11936-009-0018-4. PMID 19289030.
- ^ Burnand, K. M.; Lagocki, S.; Lahiri, R. P.; Tang, T. Y.; Patel, A. D.; Clarke, J. M. F. (2010). "Persistent subclavian artery stenosis following surgical repair of non-union of a fractured clavicle". Grand Rounds 10: 55–8. doi:10.1102/1470-5206.2010.0012. http://www.grandrounds-e-med.com/articles/gr100012.pdf.
- ^ Thetter, O; Van Dongen, RJ; Barwegen, MG (1985). "The thoracic outlet compression syndrome and its vascular complications". Zentralblatt fur Chirurgie 110 (8): 449–56. PMID 4002908.
- ^ Sell, James J.; Rael, Jesse R.; Orrison, William W. (1994). "Rotational vertebrobasilar insufficiency as a component of thoracic outlet syndrome resulting in transient blindness". Journal of Neurosurgery 81 (4): 617–9. doi:10.3171/jns.1994.81.4.0617. PMID 7931599.
- ^ Nishibe, T; Kunihara, T; Kudo, FA; Adachi, A; Shiiya, N; Murashita, T; Matusi, Y; Yasuda, K (2000). "Arterial thoracic outlet syndrome with embolic cerebral infarction. Report of a case". Panminerva medica 42 (4): 295–7. PMID 11294095.
- ^ http://www.ncbi.nlm.nih.gov/pubmed/9588513
- ^ http://www.nismat.org/ptcor/thoracic_outlet
- ^ Thoracic outlet syndrome Mount Sinai Hospital, New York
- ^ Christo, Paul J; Dana K Christo; Adam J Carinci; Julie A Freischlag (April 2010). "Single CT-Guided Chemodenervation of the Anterior Scalene Muscle with Botulinum Toxin for Neurogenic Thoracic Outlet Syndrome". Pain Medicine 11 (4): 504–511.
- ^ Rochkind, S; Shemesh, M; Patish, H; Graif, M; Segev, Y; Salame, K; Shifrin, E; Alon, M (2007). "Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection". Acta neurochirurgica. Supplement 100: 145–7. doi:10.1007/978-3-211-72958-8_31. PMID 17985565.
- ^ Carpenter's throwing session canceled, MLB.com (July 2, 2012)
- ^ San Francisco Chronicle: Lowry's agent lashes out
- ^ "People Magazine". Archived from the original on October 18, 2007. http://web.archive.org/web/20071018005700/http://www.hanson.net/site/hanson/blog_entry/1?entry_id=5832. Retrieved 2008-01-01.
External links
- thoracic at NINDS
- Thoracic Outlet Syndrome PART I: A clinical review, Journal of American Chiropractic Association
- Physical Therapy Corner - Thoracic Outlet Syndrome
- Society for Vascular Surgery (U.S.)
- Thoracic Outlet Syndrome Patient Information
- Thoracic Outlet Syndrome, Musculoskeletal Consumer Review
- Dr. Sheldon E. Jordan, of Neurological Associates of West Los Angeles, website.
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Nervous system pathology, PNS, somatic (G50–G64, 350–357)
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Nerve, nerve root, plexus
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Cranial nerve
disease
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V (Trigeminal neuralgia, Anesthesia dolorosa) · VII (Facial nerve paralysis, Bell's palsy, Melkersson–Rosenthal syndrome, Parry–Romberg syndrome, Central seven) · XI (Accessory nerve disorder)
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Radiculopathy,
plexopathy
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brachial plexus (Brachial plexus lesion, Thoracic outlet syndrome) · Phantom limb
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Mono-
neuropathy
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Upper limb
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median nerve (Carpal tunnel syndrome, Ape hand deformity)
ulnar nerve (Ulnar nerve entrapment, Froment's sign, Guyon's canal syndrome, Ulnar claw)
radial nerve (Radial neuropathy, Wrist drop, Cheiralgia paresthetica)
long thoracic nerve (Winged scapula)
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Lower limb
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lateral cutaneous nerve of thigh (Meralgia paraesthetica)
tibial nerve (Tarsal tunnel syndrome)
plantar nerve (Morton's neuroma)
superior gluteal nerve (Trendelenburg's sign)
sciatic nerve (Piriformis syndrome)
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General
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Causalgia · Mononeuritis multiplex · Neuropathy (Neuralgia/Neuritis) · Nerve compression syndrome
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Polyneuropathies/Polyradiculoneuropathy
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HMSN
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Charcot–Marie–Tooth disease · Dejerine–Sottas disease · Refsum's disease · Hereditary spastic paraplegia
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Autoimmune/demyelinating
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Guillain–Barré syndrome · Chronic inflammatory demyelinating polyneuropathy
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Other
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Alcoholic polyneuropathy
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anat (h/r/t/c/b/l/s/a)/phys (r)/devp/prot/nttr/nttm/ntrp
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noco/auto/cong/tumr, sysi/epon, injr
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