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Thoracic Outlet Syndrome

Ashley Koontz Sturts, DO
Morgan Lee Chambers, MD, MEd
Huong N. Nguyen, DO, MS

BASICS

DESCRIPTION

  • Constellation of symptoms affecting upper extremities caused by compression of neurovascular structures (brachial plexus and subclavian vessels) at the thoracic outlet

  • Three forms of TOS:

    • Neurogenic (nTOS)

    • Venous (vTOS)

    • Arterial (aTOS)

  • Synonyms: scalenus anticus syndrome, cervical rib syndrome, costoclavicular syndrome

EPIDEMIOLOGY

  • No universal diagnostic criteria

  • nTOS: ~90–95% of all cases; predominant in 20–50 year old females

  • vTOS: ~5–10%; predominant in 20–35 year old physically active males

  • aTOS: ~1%; no gender preference

ETIOLOGY AND PATHOPHYSIOLOGY

  • TOS impacts three anatomic spaces:

    • Scalene triangle: bounded by anterior/middle scalene; contains trunks of brachial plexus, subclavian artery

    • Costoclavicular space: bounded by clavicle; contains divisions of brachial plexus, subclavian artery/vein

    • Subcoracoid space: bounded by pectoralis muscle, ribs 2–4, coracoid; contains cords of brachial plexus

  • Proposed etiologies:

    • Congenital: cervical rib

    • Traumatic: MVA

    • Functional: overuse (shoulder abduction/extension)

RISK FACTORS

  • Trauma to shoulder girdle

  • Cervical rib (1% of population)

  • Exostosis of clavicle/1st rib

  • Postural abnormalities (drooping shoulders, scoliosis)

  • Occupational exposure (repetitive activity: computer users, musicians, overhead athletes)

GENERAL PREVENTION

  • Workplace evaluation for ergonomics and proper posture

COMMONLY ASSOCIATED CONDITIONS

  • Paget-von Schrötter syndrome

  • Gilliatt-Sumner hand: neurogenic atrophy of abductor pollicis brevis

  • Pancoast tumor

DIAGNOSIS

HISTORY

  • nTOS: neck trauma/repetitive overhead activity, upper extremity pain and paresthesias

    • Occipital/orbital headache

    • Muscle atrophy (UE)

    • Raynaud phenomenon

  • vTOS: symptoms worsen with shoulder abduction; unilateral arm claudication, cyanosis, swelling, pain, venous enlargement

  • aTOS: 85% related to cervical rib; highest morbidity (risk of limb ischemia)

    • Unilateral arm weakness, pallor, paresthesia, pain, weak/absent pulse, BP asymmetry

PHYSICAL EXAM

  • Posture, cervical alignment, scapular stability

  • Inspection/palpation of thoracic outlet

  • Neurologic exam (UE, cranial nerves)

  • Specialized testing:

    • Adson maneuver (aTOS): head rotation; positive if paresthesias or radial pulse not palpable

    • Morley test (vTOS): compress brachial plexus in supraclavicular area; positive if aching/paresthesia

    • Hyperabduction test (aTOS): arm elevation above head; positive if radial pulse diminishes

    • Military (costoclavicular) maneuver: chin up, shoulders back; positive if symptoms

    • 1-min Roos test: 90° abducted/externally rotated arms, clench/relax fists; positive if symptoms

DIFFERENTIAL DIAGNOSIS

  • Cervical disc disease, carpal tunnel

  • Orthopedic shoulder problems

  • Cervical spondylitis

  • Ulnar nerve compression

  • Multiple sclerosis, spinal cord tumor

  • Angina pectoris, migraine

  • Complex regional pain syndrome

  • Radiculopathies (C3–C5, C8)

  • Pancoast tumor

DIAGNOSTIC TESTS & INTERPRETATION

  • History/physical exam = most important

  • Imaging:

    • Chest x-ray: initial modality (all subtypes)

    • nTOS: chest MRI

    • aTOS: chest CTA/MRA, duplex US (subclavian vessels)

    • vTOS: chest CT w/ contrast, catheter venography, duplex US (subclavian)

  • EMG: may help

  • Labs: typically not done in initial workup

TREATMENT

GENERAL MEASURES

  • Conservative management: reduce/redistribute pressure/traction on thoracic outlet

  • Physical therapy: mainstay (unless alarm symptoms)

  • Adjuncts: taping, elastic bandages, moist heat, TENS, US (do not substitute active exercise/posture correction)

MEDICATION

  • NSAIDs (e.g., ibuprofen): adult 400–800 mg PO q8h (max 3200 mg/day)

  • Neuropathic pain: TCAs, carbamazepine, gabapentin, phenytoin, pregabalin

  • Muscle relaxants: baclofen, metaxalone, tizanidine

ISSUES FOR REFERRAL

  • Vascular TOS: immediate vascular surgery referral

  • Sports medicine/PM&R: for diagnostic/therapeutic injections

  • Surgical evaluation: vascular surgery (aTOS/vTOS), ortho/neurosurgery (nTOS)

SURGERY/OTHER PROCEDURES

  • Botulinum toxin A injection

    • Relief in 64–69% (up to 3 months)

  • Other injections: trigger point, corticosteroid, local anesthetic

  • Surgical: 1st rib resection & anterior scalenectomy (common for all subtypes)

  • vTOS: thrombolytics for acute, possible venoplasty

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Conservative/outpatient: unless vascular phenomena, acute ischemia, chronic occlusion, stenosis, arterial dilation, or progressive neurologic deficit

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Monitor symptoms, physical therapy compliance

PATIENT EDUCATION

  • Physical therapy, postural exercises, ergonomic modifications

PROGNOSIS

  • Durable functional outcomes possible with selective surgical management

  • Most operated patients do not need chronic narcotics/adjunctive procedures

COMPLICATIONS

  • Post-op shoulder/arm/hand pain, paresthesia: 10%

  • Recurrence (1 mo–7 yrs, usually <3 mo): 1.5–2%

  • Brachial plexus injury (intraop traction): 0.5–1%

  • Venous obstruction/arterial emboli: responds to thrombolytics

  • Reoperation: for symptomatic recurrence (posterior 1st rib remnant/fibrous adhesions)

REFERENCES

  1. Cavanna AC, Giovanis A, Daley A, et al. Thoracic outlet syndrome: a review for the primary care provider. J Osteopath Med. 2022;122(11):587-599.

  2. Garraud T, Pomares G, Daley P, et al. Thoracic outlet syndrome in sport: a systematic review. Front Physiol. 2022;13:838014.

  3. Zurkiya O, Ganguli S, Kalva SP, et al; for Expert Panels on Vascular Imaging, Thoracic Imaging, and Neurological Imaging. ACR Appropriateness Criteria® thoracic outlet syndrome. J Am Coll Radiol. 2020;17(5S):S323-S334.

  4. Povlsen S, Povlsen B. Diagnosing thoracic outlet syndrome: current approaches and future directions. Diagnostics (Basel). 2018;8(1):21.

  5. Vanti C, Natalini L, Romeo A, et al. Conservative treatment of thoracic outlet syndrome. A review of the literature. Eura Medicophys. 2007;43(1):55-70.

  6. Li N, Dierks G, Vervaeke HE, et al. Thoracic outlet syndrome: a narrative review. J Clin Med. 2021;10(5):962.

  7. Balderman J, Abuirqeba AA, Eichaker L, et al. Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2019;70(3):832-841.

  8. Christo PJ, Christo DK, Carinci AJ, et al. Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med. 2010;11(4):504-511.

  9. Scali S, Stone D, Bjerke A, et al. Long-term functional results for the surgical management of neurogenic thoracic outlet syndrome. Vasc Endovascular Surg. 2010;44(7):550-555.

Additional Reading:

  • Dengler NF, Ferraresi S, Rochkind S, et al. Thoracic outlet syndrome part I: systematic review and consensus. Neurosurgery. 2022;90(6):653-667.

  • Hock G, Johnson A, Barber P, et al. Current clinical concepts: rehabilitation of thoracic outlet syndrome. J Athl Train. doi:10.4085/1062-6050-138-22.

Codes:

  • ICD10: G54.0 Brachial plexus disorders

Clinical Pearls

  • TOS = compression of neurovascular structures at thoracic outlet

  • Three subtypes: neurogenic, arterial, venous

  • Physical therapy and activity modification are primary interventions

  • Immediate vascular surgery referral for vascular TOS (risk of limb ischemia)

End of note