Thoracic outlet syndrome

  • Definition
    • Thoracic outlet syndrome is a rare condition that involves:

      The thoracic outlet is the area between the ribcage and collarbone.

  • Causes
    • Nerves coming from the spine and major blood vessels of the body pass through a narrow space near your shoulder and collarbone on the way to the arms. Sometimes, there is not enough space for the nerves to pass by through the collarbone and upper ribs.

      Pressure (compression) on these blood vessels or nerves can cause symptoms in the arms or hands. Problems with the nerves cause almost all cases of thoracic outlet syndrome.

      Pressure may happen if you have:

      • An extra rib above the first one
      • An abnormal tight band connecting the spine to the ribs.

      People with this syndrome often have injured the area in the past or overused the shoulder.

      People with long necks and droopy shoulders may be more likely to develop this condition because of extra pressure on the nerves and blood vessels.

  • Symptoms
    • Symptoms of thoracic outlet syndrome may include:

      • Pain, numbness, and tingling in the pinky and ring fingers, and the inner forearm
      • Pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse)
      • Signs of poor circulation in the hand or forearm (a bluish color, cold hands, or a swollen arm)
      • Weakness of the muscles in the hand
  • Exams and Tests
    • Your health care provider will examine you and ask questions about your medical history and symptoms. When you lift something, your arm may turn pale. Sometimes the following tests are done to confirm the diagnosis:

      Tests are also done to rule out other problems, such as carpal tunnel syndrome or a damaged nerve due to problems in the neck.

  • Treatment
    • Physical therapy is often used to treat thoracic outlet syndrome. It helps:

      • Make your shoulder muscles stronger
      • Improve your range of motion in the shoulder
      • Promote better posture

      Your health care provider may prescribe pain medicine.

      If there is pressure on a vein, your provider may give you a blood thinner to prevent a blood clot.

      You may need surgery if physical therapy and changes in activity do not improve your symptoms. The surgeon may make a cut either under your armpit or just above your collarbone.

      During surgery, the following may be done:

      • An extra rib is removed and certain muscles are cut.
      • A section of the first rib is removed to release pressure in the area.
      • Bypass surgery is done to reroute blood around the compression or remove the area that is causing the symptoms.

      Your doctor may also suggest other alternatives, including angioplasty, if the artery is narrowed.

  • Outlook (Prognosis)
    • Surgery to remove the extra rib and break up tight fiber bands may ease symptoms in some patients. Surgery can be successful in more than half of patients. A few patients have symptoms that return after surgery.

  • Possible Complications
    • Complications can occur with any surgery, and depend on the type of procedure and anesthesia.

      Risks related to this surgery include:

      • Damage to nerves or blood vessels, causing muscle weakness
      • Lung collapse
  • References
    • Posner MA, Roach CJ, Owens BD. Vascular problems and thoracic outlet syndrome. In: Miller MD, Thompson SR, eds. DeLee and Drez's Orthopaedic Sports Medicine. 4th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 59.

      Putnam JB. Lung, chest wall, pleura, and mediastinum. In: Townsend CM, ed. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 58.

      Thoracic outlet syndrome. In: Alvero R, Ferri FF, Fort GG, et al, eds. Ferri's Clinical Advisor 2015. 1st ed. Philadelphia, PA: Elsevier Mosby; 2014:section I.