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Thoracic Outlet Syndrome

  1. Definitions: Thoracic outlet syndrome is a disease of extrinsic compression of the artery, vein, or nerve at the thoracic outlet.
  2. The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein. Q
  3. The compressing structures include the clavicle, the first rib, subclavian muscles, costoclavicular ligament and the anterior scalene.
  4. Sir Astley Cooper first described axillary-subclavian artery symptoms due to compression from a cervical rib.
  5. Thoracic outlet syndrome must be differentiated from symptomatic osteoarthritis of the cervical spine, tumors of the cervical spinal cord or nerve roots, periarthritis of the shoulder, and other cervicobrachial pain syndromes. Q
  6. The predisposing factors are fibromuscular bands, bony protuberances and long or larger transverse processes, this together with the tendinous or cartilaginous muscular insertions are responsible for the compression of the neurovascular structures at the thoracic outlet.







Upper Extremity


Numbness of arms and hands

Tingling of arms and hands

Positional weakness of arms and hands


Swelling of fingers and hands

Heaviness of the upper extremity


Upper extremity pain

Paresthesias of ulnar distribution

Weakness of the hands

Clumsiness of the hands

Coldness of the hands

Tiredness, heaviness and paresthesias on elevation of arms

Shoulder And Neck


Pain - tightness

Chest Wall


Anginal chest pain

Inter-para scapular pain




Funny feelings in face and ear

Vertebral Artery


Dizziness, lightheadness

Vertigo, syncope

Diplopia, dysarthria, dysphonia, dysphagia

Tinnitus, ear pain

  1. Compression can be of different magnitude in each of these structures.
  2. For example, the subclavian vein can be the only compressed structure and this patient might have a thrombosis of the vein that was called in the past effort thrombosis, or a swelling of the fingers.
  3. The subclavian artery can also be compressed with symptoms of temporary, arterial, positionalinsufficiency of the upper extremity.
  4. When they are present for a long time, aneurysm and thrombosis of the subclavian artery may develop with distal embolization.
  5. Nerve compression of the brachial plexus is very common and is or not associated with venous or arterial compression. Q

Paget Schroetter Syndrome: This is the name given to the subclavian vein thrombosis (beneath the clavicle) which results in pain, swelling, blue discoloration, and congestion of the arm. It is commonly caused by compression of the vein between the clavicle and the first rib, and is considered one of the venous manifestations of TOS.


Physical Examination:
  1. Posture
  2. The White Hand Sign
  3. C7-C8-T1 Testing
  4. Sweating, Swelling
    1. Tenderness in the supra clavicular area.
    2. Hand paleness and/or paresthesias on elevation.
    3. Adduction and abduction weakness of fingers 4 & 5. (C8 - T1 testing)
  6. The Adson sign is the loss of radial pulse by rotating the head to the ipsilateral side and inspiring. Q 
  1. Investigations: Imaging Studies:
    Chest x-ray:  Cervical ribs or rudimentary first ribs often can be identified with a CXR.
    CT scan:
    1. CT scans with 3-dimensional reconstruction have become popular for evaluating the thoracic outlet.
    2. CT scan angiography and venography.
      Standard MRI: Dynamic MRI with gadolinium infusion also provides detail of the thoracic outlet and may be helpful when evaluating for compression.
      Angiography with dynamic positioning.
      Venography with dynamic positioning. 
  2. Other Tests:
    Electromyography (EMG) and nerve conduction studies are useful in the workup of patients suspected of having neurogenic TOS. A reduction in nerve conduction velocity <85 m/s of either ulnar or median nerves across the thoracic outlet corroborates the diagnosis of neurogenic TOS. Q
    Indications: Failure of conservative treatment in a patient with severe disability.

  1. Treatment
    1. Physical therapy: Postural exercises, stretching, abdominal breathing, and medications used to relieve muscular tension and pain are beneficial.
    2. No satisfactory medical treatment for arterial TOS exists. Q 
  2. Surgical therapy:
    1. Arterial TOS requires prompt surgical intervention to treat or prevent acute thromboembolic events.
    2. Treatment for venous TOS-related effort thrombosis relies on anticoagulation and arm elevation leaves.  
  3. Venous thoracic outlet obstruction:
    1. Surgical treatment of venous TOS consists of releasing the extrinsic compression and restoring luminal patency.
    2. After thrombolysis, surgeons wait one month before decompressive treatment surgery is undertaken. Q
    3. Surgical decompression of veins within the scalene triangle is achieved by anterior rib resection, anterior scalene release and in some cases clavicular resection. 
  4. Neurogenic/arterial thoracic outlet obstruction
    1. Thoracic outlet decompression can be performed through an axillary, supraclavicular, or posterior approach. Q
    2. Thoracic outlet decompression may entail anterior and middle scalenectomy, first rib resection, or scalenectomy plus first rib resection. Q

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