Chapter 41 - Thoracic Outlet Syndrome

Synonyms
Scalenus anticus syndrome
Cervical rib syndrome
First thoracic rib syndrome
Costoclavicular syndrome
Subcoracoid-pectoralis minor syndrome
Hyperabduction syndrome[1]
ICD-9 Code
353.0
Brachial plexus lesions (cervical rib syndrome, costoclavicular syndrome,
scalenus anticus syndrome, thoracic outlet syndrome)
Definition
Thoracic outlet syndrome (TOS) remains a contentious area in medicine. The term is
used to describe a number of conditions attributed to a compromise of the
brachial plexus (typically the lower trunk), subclavian/axillary artery or vein, or both at
one or more points between the base of the neck and the axilla. Because of the
controversy and confusion surrounding this entity it is helpful to further subclassify the
condition based on the neurovascular structure that is compromised: neurologic
(axonal) TOS, vascular TOS, and disputed/symptomatic TOS.[2]
Vascular TOS refers to compromise of the subclavian/axillary artery or vein. Both are
very rare and usually affect young to middle-aged persons. Vascular
compromise may develop from trauma, thrombi, or congenital anomalies, such as a
fully formed cervical rib or abnormal first thoracic rib. Traumatic causes such as
midclavicular fractures may present acutely or as a late effect secondary to non-union
or excessive callus formation. Repetitive trauma has also been implicated, such
as that seen in throwing sports. Intimal damage to vascular structures may lead to
thrombus or aneurysm formation.
Neurologic (axonal) TOS refers to true compression of the brachial plexus with
resultant axonal damage, particularly to the lower trunk. This condition is also very
rare, affecting young to middle-aged women more than men. Although many
conditions may contribute to brachial plexus injuries (e.g., trauma, tumor, infections),
the

term "neurologic TOS" is used to describe a condition believed to be caused by the

compression of the distal T1 and, to a lesser extent, the distal C8 anterior primary
rami, by a taut band that extends from a rudimentary cervical rib or elongated C7
transverse process to the first thoracic rib.
"Disputed," or "symptomatic," TOS refers to a condition that occurs more commonly
than both the vascular and true neurologic types. It is defined more as a symptom
complex rather than a true anatomic pathologic process. Because of the difficulties in
defining this condition, accurate etiologic data is not available, although it
appears to affect women more than men. It is a diagnosis of exclusion, and therefore
other conditions must be excluded prior to making the diagnosis. Physical
examination should reveal normal neurologic and vascular findings.
219
Figure 41-1 Areas of compression of the neurovascular bundle. A, Hypertrophy of
scalene muscles. B, Presence of cervical rib. C, Presence of a fibrous band. D,
Compression
by pectoralis minor during hyperabduc tion. (From DePalma AF: Surgery of the
Shoulder, 2nd ed. Philadelphia, J.B. Lippincott, 1973, pp 511520, with permission.)
Symptoms
Patients typically report pain along the distal and ulnar aspects of their forearm and
hand as well as sensory symptoms such as numbness, tingling, and burning.
These symptoms are often aggravated by certain positions or activities, especially
those involving overhead work. Subjective complaints of weakness or of dropping
objects should be verified by physical examination. Those with vascular compromise
may present with swelling, cyanosis, coldness, or even Raynaud's type
symptoms.
220
Physical Examination
Physical examination should include an extensive evaluation of the patient's neck,
shoulders, and upper extremities, with particular attention to the neurologic and
vascular examinations. The patient should be undressed in order to assess any
postural abnormalities or side-to-side atrophy.
Careful attention to the neck range of motion and a positive Spurling's test may reveal
a cervical root lesion. Abnormal reflexes, weakness, and atrophy are consistent
with a true neurologic deficit. Neurologic TOS, affecting primarily the lower trunk of the
brachial plexus, may reveal atrophy of the thenar greater than hypothenar

eminence in the hand, weakness of the hand intrinsic muscles, and sensory
abnormalities of the medial forearm and hand.
Patients with vascular compromise to their upper extremity may have upper extremity
swelling, discoloration, prominent dilated veins, subungual hemorrhages, and
ulcerations of the fingertips.[3] These patients may also have a diminished radial
pulse, especially after exercise.
Patients with disputed/symptomatic TOS, as discussed earlier, have normal neurologic
and vascular examinations. This, however, may be difficult to establish,
especially if a patient reports nonspecific decreased sensation or weakness associated
with pain or "give-way" effort. These patients often present with a "droopy
shoulder" posture, characterized by a long thin neck, and sloping, rounded, and often
protracted shoulders, with horizontal clavicles. [4] Some patients may have
tenderness in the supraclavicular fossa overlying the anterior/middle scalenes.
Careful palpation to the scalene, trapezius, levator scapulae, or supraspinatus muscles
may reveal identifiable trigger points, reproducing the patient's symptoms.
This finding would be more consistent with a diagnosis of myofascial pain syndrome.
Special tests, such as a Tinel's sign at the elbow or wrist and a positive Phalen's
maneuver, may be helpful when considering the diagnosis of cubital or carpal tunnel
syndrome. Other special tests advocated in evaluating TOS, such as Adson's, Allen's,
hyperabduction, and costoclavicular tests, have disputed results.
Functional Limitations
Patients with all forms of TOS typically have difficulty with upper extremity function,
particularly when their arms are in the overhead or abducted positions. In addition,
the patient may report difficulty carrying heavy objects, such as groceries, when a
downward load is applied to the upper extremities causing additional stretch to the
plexus and vessels.
Patients with more advanced disease may have significant weakness and numbness of
the hands, impairing their ability to perform fine motor activities such as
writing, typing, buttoning a shirt, and working a cash register.
TOS has been reported in a subsection of patients who are instrumental musicians.
Patients most affected were reported to play the violin or viola, followed by
keyboard instrumentalists and flutists. [5]
Diagnostic Studies
Cervical spine x-rays are helpful to identify an elongated C7 transverse process or a
rudimentary cervical rib. In addition, oblique films of the cervical spine are helpful

to evaluate for significant neuroforaminal stenosis, which may be more consistent with
a cervical radiculopathy. If the clinician has a high suspicion of cervical
radiculopathy, even in the face of normal cervical spine x-rays, magnetic resonance
imaging (MRI) should be performed to rule out a possible herniated nucleus
pulposus.
Chest x-rays or clavicular films may reveal a possible pancoast tumor or an
undiagnosed clavicular fracture.
221
Electrodiagnostic testing (e.g., EMG and nerve conduction studies) may be extremely
helpful in determining the presence of true neurologic insult as well as localizing
the injury to the root, plexus, or peripheral nerve (median or ulnar). Hallmark findings
of neurologic (axonal) TOS include abnormal needle EMG activity in the C8/T1
myotomes as well as decreased amplitudes of the median greater than ulnar
compound motor action potential (CMAP) and ulnar sensory nerve action potential
(SNAP) with preservation of the median SNAP.[6] Abnormal ulnar motor conduction
velocity studies across the "thoracic outlet" should be interpreted with skepticism,
as these recordings have been shown to be of no use. [7] Normal electrodiagnostic
testing is expected in both vascular and disputed/symptomatic TOS.
An MRI of the brachial plexus may be particularly helpful in identifying a possible soft
tissue lesion, such as a tumor or hematoma, which may be compromising the
plexus.
Arteriography and venography are indicated for further evaluation of possible vascular
compromise; however, given the risk of potential complications from these
more invasive procedures, they are typically done at the discretion of a vascular
surgeon.
Differential Diagnosis
Cervical radiculopathy
Carpal tunnel syndrome
Traction plexopathy
Thrombophlebitis
Vasculitis
Myofascial pain syndrome
Neuralgic amyotrophy

Ulnar neuropathy
Mass lesion (tumor, hematoma)
Arteriosclerosis
Multiple sclerosis
Syringomyelia
Treatment
Initial
Initial treatment starts with an accurate diagnosis. Vascular compromises warrant
immediate consultation with a vascular surgeon. True neurologic compromise to the
brachial plexus, where structural lesions can be identified, warrant further evaluation
by a neurosurgeon or a thoracic surgeon.
The vast majority of patients with disputed/symptomatic TOS, where no identifiable
structural lesion can be identified, should be treated conservatively. Initial
treatment involves activity modification and pain management. Medications that may
be helpful include nonsteroidal anti-inflammatory drugs (NSAIDs), including
cyclooxygenase-2 (COX-2) inhibitors, tricyclic antidepressants (e.g., amytryptiline,
nortriptyline) as well as anticonvulsant medications (e.g., gabapentin,
carbamezepine), especially when there is a large component of neuropathic pain.
Significant sleep disturbances should be addressed and treated appropriately. Patients
may benefit by utilizing a cervical roll or wearing a soft cervical collar when
sleeping. Symptoms of sleep apnea should be addressed. Poor sleep secondary to soft
tissue pain or depression may greatly improve with the use of a low-dose
antidepressant medication.
Rehabilitation
Rehabilitation regimens attempt to normalize the neck and upper trunk relationships,
thereby helping to minimize any potential compression of the plexus or vascular
structures at the various sites between the neck and the axilla, including the
interscalene, costoclavicular, and subcoracoid areas. Some key components to this
treatment program include postural training and awareness, correction of muscle
imbalances through appropriate stretching and strengthening, weight reduction, and
aerobic conditioning.[8] [9] Some important points listed in Table 1 .
222
TABLE 41-1 -- Rehabilitation Considerations

1. Postures that tend to exacerbate symptoms of TOS include when the head and
cervical spine are anterior to the thorax and protraction of the scapulae. A
figure-of-eight harness may be used to help correct this posture; however, it is
typically poorly tolerated by most patients. Patients should be made aware of their
posture, using visual aides such as mirrors, and should remind themselves during the
day to avoid "slouching." In addition, an exercise program emphasizing
stretching of the anterior muscles, such as the serratus anterior and pectoralis major
and minor, coupled with strengthening of the lower scapular stabilizers and
thoracic extensors may offer significant benefit.
2. Women with breast hypertrophy may benefit from a more supportive brassier with
wider straps across the back.
3. Patients who perform most of their activities at a desk, especially those who use a
keyboard, have a tendency to slide forward in their chair, thereby reducing
lumbar lordosis, increasing thoracic kyphosis, and increasing cervical lordosis and
head forward postures. Having the patient lower the keyboard may be an effective
way to improve posture and decrease muscle effort in the upper extremity and
minimize irritation of the cervicoscapular region. [9] Further ergonomic assessments of
patients' work or home environments may be warranted by an occupational therapist
or other skilled provider.
4. Obesity may be a contributing factor to TOS symptoms; therefore, overweight
patients should be referred to a nutritionist, who can assist with establishing an
appropriate weight loss program.
5. Aerobic conditioning may be helpful in managing patients' chronic pain symptoms.
In addition, patients with decreased respiratory efficiency tend to utilize their
accessory respiratory muscles more, including the scalenes, upper trapezius, and
sternocleidomastoid, which may contribute to TOS symptoms. Improving
respiratory efficiency may be achieved by introducing aerobic conditioning and chest
expansion exercises.
Procedures
Patients with neurologic symptoms attributed to other causes such as radiculopathy or
peripheral nerve entrapment should be treated in the appropriate manner for
such conditions.
Patients with identifiable trigger points, consistent with myofascial pain syndrome,
may benefit greatly from local trigger point injections, spray and stretch treatments,
or other myofascial release techniques.

Surgery
Prompt surgical evaluation and treatment is indicated for patients with vascular TOS.
This may involve thrombolytic therapy, aneurysm repair, cervical rib removal, or
bypass grafting, depending on the extent of damage.
Patients with true neurologic TOS often benefit from surgical sectioning of the
congenital band between the tip of the cervical rib or elongated C7 transverse process
and the first thoracic rib via a supraclavicular approach. Patients undergoing this
procedure typically experience improved sensory symptoms and some improved
hand strength, although one should not expect significant improvement of hand
intrinsic muscle atrophy. [10]
Because of the potential risk of serious complications and inconsistent results, surgery
should be considered as a last resort for patients in whom no structural lesion
is identified on imaging and/or no objective abnormalities are noted on physical
examination or electrodiagnostic testing.
Potential Disease Complications
Potential complications from unrecognized or undiagnosed vascular or neurologic TOS
include progressive and irreversible loss of limb function by either ischemia or
nerve damage. In cases of thrombus formation, proximal embolization into the carotids
and brain is unlikely but has been reported. [11]
223
Potential Treatment Complications
Analgesics, NSAIDs, and COX-2 inhibitors have well-known side effects that most
commonly affect the gasdtric, hepatic, and renal systems.
Occasionally the use of medications such as tricyclic antidepressants (TCAs) and
anticonvulsants for neuropathic pain is limited by their side effects. Most common
side effects include drowsiness, constipation, dry mouth, and urinary retention.
Patients with known cardiac disease should not be prescribed TCAs without a
cardiologist's approval. Patients who are prescribed carbamezipine should receive liver
function and complete blood count tests, per Federal Drug Administration
(FDA) recommendations.
Surgery should be reserved for patients with identifiable structural lesions or patients
with intractable pain and/or significant functional impairment unimproved by
conservative treatment. Great care must be advocated with any surgical intervention
because of the potential for grave harm to the patient. Potential complications

from TOS surgery include exsanguinations, phrenic nerve laceration, long thoracic
nerve palsy, wound infection, pleural effusion, pneumothorax, and severe
permanent brachial plexus injuries.[12] [13]
References
1. Peet RM, Henriksen JD, Anderson TP, Martin GM: Thoracic-outlet syndrome:
Evaluation of a therapeutic exercise program. Mayo Clin Proc 1956;31:281287.
2. Dawson DM, Hallett M, Wilbourn AJ: Thoracic outlet syndromes. In Terrano AL,
Dawson DM, Hallet M, et al (eds): Entrapment neuropathies, 3rd ed. Philadelphia,
Lippincott-Raven, 1999, pp
227250.
3. Judy KL, Heymann RI: Vascular complications of thoracic outlet syndrome. Am J Surg
1972;123:521531.
4. Swift TR, Nichols FT: The droopy shoulder syndrome. Neurology 1984;34:212215.
5. Lederman RJ: AAEM Minimonograph #43: Neruomuscular problems in the
performing arts. Muscle Nerve 1994;17:569577.
6. Cuetter AC, Bartoszek DM: The thoracic outlet syndrome: Controversies,
overdiagnosis, overtreatment, and recommendations for management. Muscle Nerve
1989;12:410419.
7. Wilbourn AJ, Lederman RJ: Evidence for conduction delay in thoracic outlet
syndrome is challenged. N Engl J Med 1984;310:10521053.
8. Lindgren KA, Manninen H, Rytkonen H: Thoracic outlet syndromea functional
disturbance of the thoracic upper aperture? Muscle Nerve 1995;18:526530.
9. Novak CB, Mackinnnon SE: Thoracic outlet syndrome. Orthop Clin North Am
1996;27:747762.
10. Wilbourn AJ: Thoracic outlet syndromes. Neurol Clin 1999;17:477497.
11. Prior AL, Wilson LA, Gosling RG, et al: Retrograde cerebral embolism. Lancet
1979;2:10441047.
12. Moore WS, Machleder HI, Porter JM, Roos DB: Symposium: Thoracic outlet
syndrome. Contemp Surg 1994;45:99111.
13. Wilbourn AJ: Thoracic outlet surgery causing severe brachial plexopathy. Muscle
Nerve 1988;11:6674.