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Thoracic Outlet Syndrome

Definition


Disease: Thoracic Outlet Syndrome Thoracic Outlet Syndrome
Category: Respiratory diseases

Disease Definition:

This disease occurs when the blood vessels or the nerves passing through the thoracic outlet, which is the space between the collarbone (clavicle) and the first rib, become compressed, resulting in a group of disorders characterized by numbness of fingers and pain in the shoulders and neck.

 

Sometimes it is not possible to identify the exact cause of thoracic outlet syndrome, but it can by repetitive injuries as result of practicing certain sport or professions, or it can be caused by physical trauma like a car crash. Sometimes, the symptoms of this syndrome appear long after the date of injury. While surgery is needed in some cases, but most cases are treated with physical therapy and pain relief measures.
 

Work Group:


Symptoms, Causes

Symptoms:

The three types of thoracic outlet symptoms are defined as follows:

 

Neurogenic (neurological) thoracic outlet syndrome:

In this case, the brachial plexus, which is the neural network that controls muscle movement and sensations in the shoulder, arm and hand, is compressed. Most of the symptoms of thoracic outlet syndrome are neurogenic.

 

Vascular thoracic outlet syndrome:

This is the case when a compression occurs to one or more of the arteries and veins under the clavicle (subclavian vessels).

 

Nonspecific-type thoracic outlet syndrome:

This condition is also called common thoracic outlet syndrome or disputed thoracic outlet syndrome, which is a controversial case between physicians since some doubt its existence. This type is characterized by chronic pain in the area of the thoracic outlet, with no apparent cause.

 

The signs and symptoms of thoracic outlet syndrome may vary according to the type of tissues that are being compressed. The following are a summary of symptoms when neural structures are involved:

 

  • Numbness or tingling in the fingers
  • Neck, shoulder, arm and hand pain
  • Weakening grip

 

When vascular structures are subject to compression, the following symptoms may appear:

 

  • Hand discoloration (with bluish shade)
  • Subclavian vein thrombosis
  • Arm pain and swelling, possibly due to blood clots
  • Throbbing lump near the collarbone
  • Lack of color (pallor) in one or more fingers or even the entire hand
  • Tiny black spots (infarcts) on the fingers

 

Consulting a physician is necessary when the above mentioned symptoms are experienced constantly.
 

Causes:

The symptoms of the thoracic outlet syndrome are caused by the compression of either verves or blood vessels or both of them. But the cause of this compression may be:

 

Anatomical defects:

Congenital defects might include an extra rib right above the first rib (cervical rib) or an abnormal connection between the spine and the rib by a tight fibrous band.

 

Poor posture:

Certain relative positions of the head and shoulders (loosening shoulders or holding the head forward) can cause thoracic outlet syndrome.

 

Trauma:

A physical impact such as a car accident may cause the compression of nerves and blood vessels in the thoracic outlet. In this case, a delay may occur from the incident date to the date of the symptom appearance.

 

Repetitive activity:

This occurs in people whose jobs or practiced sports require the performance of the same movements or postures repeatedly for extended periods of time, such as typing on a computer, working in an assembly line and repetitive lifting of objects above the head level or below the abdomen level. Swimmers and baseball pitchers may also experience signs and symptoms of thoracic outlet syndrome.

 

Pressure on the joints:

This happens in obese people, since it overloads the joints with unnecessary extra weight.

 

Pregnancy:

A woman may experience the symptoms of thoracic outlet syndrome while pregnant due to the loosening of joints.
 

Complications

Complications:

Surgery is a risky procedure, since it involves making an incision in one of the neck muscles and removing some of the first rib or repairing the brachial plexus nerves. Thus, physicians initially opt for conservative treatment approach. Untreated cases may lead to permanent nerve damage.
 

Treatments:

Early diagnosis can increase the probability of a successful conservative treatment, which includes:

 

Physical therapy:

The pressure applied over the nerves and blood vessels is diminished by strengthening the shoulder muscles, which opens the thoracic outlet through exercises, and improves motion range and posture.

 

Relaxation:

This involves relieving tension from the shoulders and maintaining good posture via relaxation techniques such as deep breathing.

 

Medications:

They include muscle relaxants and anti-inflammatory medications like aspirin or ibuprofen.

 

Surgery may be needed when a patient does not respond to conservative treatment or his condition deteriorates, with neural damage, muscle weakness or severe pain, or in the case of being diagnosed with true neurogenic thoracic outlet syndrome where surgery is the only solution.

 

SURGICAL OPTIONS:

Surgery has proved its efficiency in relieving the pain but not the weakness of muscles, especially when thoracic outlet syndrome is left untreated for a long time. The brachial plexus is at risk of injury regardless of the surgical options, which has to be done by a surgeon specialized in thoracic surgery or vascular surgery. The following are the common options of surgical treatment methods:

 

Anterior supraclavicular approach:

In this method, the compressed blood vessels are repaired by making an incision under the neck to be able to inspect the plexus region, looking for trauma or the fibrous bands near the uppermost rib that affect the blood vessels.

 

Transaxillary approach:

In this method, an incision to the chest is carried out to remove a portion of the first rib, relieving the compression. The advantage of this method is the ease of access to the first rib in a safe distance from nerves and blood vessels, and the drawback is the difficulty of access to the fibrous bands and cervical ribs that may be the reason behind the compression, which are hidden behind the nerves and blood vessels, that limit the surgeon’s access.
 

Prognosis:

Not available

Expert's opinion

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Dr. Samer Al-Jneidy

Dr. Samer Al-Jneidy Pediatrician

Dr. Tahsin Martini

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