Thoracic outlet syndrome is a condition involving compression of the nerves and/or blood vessels in the region around
the neck and collarbone, called the thoracic outlet. Thoracic outlet syndrome is controversial in the medical literature.
The diagnosis and treatment of patients who have thoracic outlet syndrome have been varied, particularly in those with
complaints of tingling, numbness and pain in the arm and hand. Recently, surgeons have recognized that patients with
thoracic outlet syndrome can be divided into patients with compression of the blood vessels and those with nerve compression.
Symptoms related to nerve compression are more common than those involving compression of the blood vessels. However, most
of the controversy surrounds patients with compression of the nerves (brachial plexus).
In thoracic outlet syndrome, abnormalities in insertions of the scalenus anticus and scalenus medius
muscles â€” or simple enlargement of these muscles due to unhealthy postures â€” can create narrowing of
the triangular region through which the brachial plexus travels across the first rib and beneath the
clavicle. Illustration from Surgery of the Peripheral Nerve
by Mackinnon and Dellon, reprinted with
permission of Thieme Medical Publishers, Inc.
Patients with thoracic outlet syndrome related to compression of the brachial plexus usually complain of a feeling
of "pins and needles" and/or numbness in the arm, forearm or hand. Many patients also have complaints of pain and
aching in the shoulder, neck or shoulder blade region. These symptoms usually are made worse when the arms are positioned overhead.
Patients may describe headaches at the back of the head or around the eyes. Pressure on the blood vessels in the region
of the thoracic outlet may cause the hand to feel cooler or to be swollen, or the hand may appear white or blue. Early
symptoms may only occur with the arms in an overhead position and go away with the arms down by the side. As time goes
on, symptoms often occur more frequently and with less time in irritating positions.
What Causes Thoracic Outlet Syndrome?
In general, thoracic outlet syndrome is thought to be caused by a number of factors, including activities at home and
work, sleep postures, trauma, anatomical variations and other diseases.
Double Crush Syndrome
Patients with thoracic outlet syndrome usually have symptoms of tingling and numbness in the hand. These hand symptoms
are similar to those of carpal tunnel syndrome and cubital tunnel syndrome. The â€śdouble crushâ€ť mechanism may play a role
in the development of symptoms in patients with thoracic outlet syndrome. The nerve fiber begins in or near the spinal
cord and then goes all the way to the hand to give sensation and movement to the arm and hand. If the nerve is pinched
at one place, then it is less likely to tolerate any more pressure along the nerve. Therefore, other tight places, such
as at the wrist (carpal tunnel) or elbow (cubital tunnel), are more likely to produce symptoms with very little added pressure.
In the vast majority of patients, non-operative treatment is successful in relieving the symptoms of thoracic outlet syndrome.
This begins by modifying your activities to decrease the time that you spend in positions that are aggravating your symptoms.
Thoracic Outlet Surgery
Surgical management may involve release of the scalene muscles and/or removal of the first rib. This operation frequently
is done with an incision above the collarbone. However, your surgeon instead may recommend a surgical approach through the armpit.
Patient information on thoracic outlet syndrome