Thoracic Spine Series: New Treatment Option for Thoracic Outlet Syndrome
If you’ve had symptoms like numbness or tingling in your hands or arm, aches or pain in your shoulder or neck, a weakening grip, or the muscles in your hand shrinking, you may have been told you have thoracic outlet syndrome.
What Is the Thoracic Outlet?
The thoracic outlet is an area around the collar bone where the nerves that come from your neck meet up with the blood vessels from your heart and together supply the entire upper extremity (shoulder and arm). These blood vessels (subclavian artery and vein) and nerves (brachial plexus) travel from the base of your neck to your arm pit (axilla) and is considered the “thoracic outlet” (1). Now that you know what the thoracic outlet is, what is thoracic outlet syndrome?
What is Thoracic Outlet Syndrome (TOS)?
TOS symptoms are positional intermittent compression of the brachial plexus and/or subclavian blood vessels. There are 3 areas that can cause the compression (2).
1. Scalene triangle – Muscle spasms or chronically tight scalene muscles can compress the nerve plexus as the nerves travel through them.
2. Costoclavicular Space – this narrow space can compress the nerves or blood vessels in several ways
3. Pectoralis Minor Space – typically poor posture leads to chronic tightness of this muscle and muscle spasms that in turn compress the structures under the muscle.
Is TOS Serious?
Like most syndromes, there is a variety from very mild cases to life threatening. TOS is a group of symptoms in the chest, neck, shoulder and arms and can be broken into 3 different types:
1. Neurogenic thoracic outlet syndrome (nTOS).
This most common type 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. This is considered the most common type of TOS, making up 95% of all cases. This creates a numbness feeling in the arm. It can be isolated to single nerve or multiple nerves (3).
2. Vascular thoracic outlet syndrome (vTOS).
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. Which can lead to extremity swelling, cyanosis (blue discoloring of the skin), and possibly deep venous thrombosis (blood clot in arm) (4).
3. 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 (5).
· Muscle wasting (Gilliatt-Sumner hand)
· Numbness or tingling in your arm or fingers
· Pain or aches in your neck, shoulder or hand
· Weakening grip
How Do You Diagnose TOS?
Simply listening to a patient’s history and completing a physical examination is all that is needed to diagnose TOS. But more involved imaging such as xrays, diagnostic ultrasound, MRIs, EMG (nerve conduction test) are used to rule out the underlying issue (2).
How Long does It Take to Recover from TOS?
Recovery depends on the severity of the syndrome and response to treatment. Thoracic Outlet Syndrome can resolve in a matter of weeks to months or can become chronic and last many years before getting proper treatment.
Can Thoracic Outlet Syndrome Be Cured?
Conservative options for TOS include modification of behaviors by avoiding activities that aggravate symptoms, and arm positions, along with physical therapy programs that strengthen the muscles of the pectoral girdle and help to restore normal posture (6, 7). TOS can be treated successfully with simple physical therapy. A paper by Dobrusin comments on how dysfunctional area treatment can, “decrease muscular tone in the scalene muscles, allow the first rib to become more mobile, and open up the interscalene triangle” (8). Success can vary, as 50% to 90% of patients respond well to conservative care.
What Happens if Conservative Care Fails?
Some patients respond well to medications for this. Pharmacologic interventions often provide symptomatic relief, and primarily include analgesics (NSAIDs and/or opioids) for nerve pain, as well as muscle relaxants, anticonvulsants (anti-seizure drugs), and/or antidepressants (9). Downside, if these medications help then you may be on them for the rest of your life!
Additionally, injection of local anesthetic, steroids, or botulinum toxin type A into the anterior scalene and/or pectoralis muscle have demonstrated varying levels of success in observational studies (10). BUT failed to demonstrate any benefit in a larger randomized control trial (11).
If failed those and continues to be debilitating, patient will be referred to cardio-thoracic surgeons for a first rib resection with scalenectomy. Utilizing the “when in doubt, take it out” mentality by removing the rib and muscles that are creating the compression! But do you need your first rib and scalene muscles and are these surgeries safe?
There is limited research with long-term follow up outcomes for these patients. In the short term studies show 6.7% of patients have postoperative bleeding requiring thoracentesis (draining the bleeding from your lungs) or video-assisted thoracoscopic evacuation (small camera into the lung to find the bleeding) of hemothorax (12, 13). Other risks with this type of surgery are wound infection, lymph leak, brachial plexus injury, winged scapula (from injury to the long thoracic nerve), or paralyzed hemidiaphragm (from injury to the phrenic nerve). Hosseinian showed that nerve injuries to the nerves that are being decompressed can be as high as 9% (13, 14)!
NEW Percutaneous-Orthobiologic Approach
Combining the best of interventional orthopedic techniques with the most advanced ortho-biologics can help reduce the conversion of patients that are referred to surgery by significant number.
We have seen excellent results utilizing a SANS approach with a mulit-faceted treatment. Clinic on the link to get a better understanding of utilization of SANS approach to treat orthopedic conditions. SANS APPROACH
Here is ideal treatment for TOS:
While this treatment is an excellent alternatives to more invasive surgeries, these injections are not without risks and need to consider who is able to perform these injections safely and effectively. While many physicians still utilize a “feel and poke” (blind) method for injecting. Please be aware, the risk of complications from blind injections can increase complication rates drastically. The advent of musculoskeletal ultrasound and utilization of fluoroscopic guidance has made it possible to visualize soft tissue and boney structures allowing us to avoid the things we don’t want to inject (nerves, blood vessels) and directly inject the ligament or place injection around a nerve without damaging the nerve! These treatments are highly advanced injections that require advanced training to do these safely – here is a video done by Dr. Centeno explaining interventional orthopedics
There are thousands of patients that suffer from TOS and up to 50% may require surgery. We have created a treatment option that is far less invasive and involves far less risk of serious complications with the goal to improve symptoms and overall function without the need of surgery. If you have been diagnosed with TOS and considering alternatives to surgery, feel free to contact us. We’re happy to discuss and evaluate you further to see if you are a good candidate for this new treatment option!
1. Yuschak E, Haq F, Chase S. A Case of Venous Thoracic Outlet Syndrome: Primary Care Review of Physical Exam Provocative Tests and Osteopathic Manipulative Technique Considerations. Cureus. 2019;11(6):e4921.
2. Ciampi P, Scotti C, Gerevini S, et al. Surgical treatment of thoracic outlet syndrome in young adults: single centre experience with minimum three-year follow-up. Int Orthop. 2011;35(8):1179-86.
3. Teijink JAW, Pesser N, van Grinsven R, van Suijlekom H, van Sambeek MRHM, van Nuenen BFL. [Neurogenic thoracic outlet syndrome]. Ned Tijdschr Geneeskd. 2017;161:D1385.
4. Moore R, Wei Lum Y. Venous thoracic outlet syndrome. Vasc Med. 2015;20(2):182-9.
5. Köknel Talu G. Thoracic outlet syndrome. Agri. 2005;17(2):5-9.
6. Lindgren KA. Conservative treatment of thoracic outlet syndrome: a 2-year follow-up. Arch Phys Med Rehabil. 1997;78(4):373-8.
7. Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am. 1995;20(4):542-8.
8. Dobrusin R. An osteopathic approach to conservative management of thoracic outlet syndromes. J Am Osteopath Assoc. 1989;89(8):1046-50, 1053-7.
9.Brooke BS, Freischlag JA. Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol. 2010;25(6):535–540.
10. Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of botulinum toxin in the treatment of this syndrome. Toxins (Basel). 2012;4(11):1223–1235.
11. Finlayson HC, O’Connor RJ, Brasher PMA, Travlos A. Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial. Pain. 2011;152(9):2023–2028.
12. Hawkins AT, Schaumeier MJ, Smith AD, et al. Concurrent venography during first rib resection and scalenectomy for venous thoracic outlet syndrome is safe and efficient. J Vasc Surg Venous Lymphat Disord. 2015;3(3):290-4.
13. Hosseinian MA, Loron AG, Soleimanifard Y. Evaluation of complications after surgical treatment of thoracic outlet syndrome. Korean J Thorac Cardiovasc Surg. 2017
14. Jones MR, Prabhakar A, Viswanath O, et al. Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain Ther. 2019;8(1):5-18.