Scripps Health in San Diego provides expert diagnosis and treatment for an uncommon group of disorders known as thoracic outlet syndrome (TOS). Because TOS can’t be effectively treated without a precise diagnosis, it’s important to seek care from physicians who not only have experience identifying the various forms of the disorder, but can prescribe the right combination of medical or surgical treatment options.
Scripps vascular surgeons are proud to offer comprehensive care for patients with all forms of TOS, whether it’s caused by a structural abnormality in the body or due to an overuse injury. Our doctors will work closely with you to determine a course of treatment that can reduce or eliminate symptoms, preserve your active lifestyle and prevent serious long-term side effects.
Each of us has a small space underneath and behind our collarbone called the thoracic outlet. Within this space are the nerves, veins and arteries that supply our arms. When these nerves or blood vessels become compressed, irritated or injured, it causes a condition called thoracic outlet syndrome (TOS).
TOS can be caused by many different things, including:
- Back or neck injury, including whiplash
- Frequent heavy lifting that strains the shoulder or arms
- Fractured collarbone
- Bone or soft tissue abnormalities in the lower neck or cervical rib area
- Participating in sports that require constant repetitive motion in the arms or shoulders, including baseball and swimming
- Having an extra first rib present at birth, which reduces the amount of space available within the thoracic outlet
There are three different types of TOS. Each type affects one of the three different structures found within the thoracic outlet (nerves, veins and arteries):
- Neurogenic thoracic outlet syndrome is the most common kind of TOS, and is caused when a bundle of nerves called the brachial plexus is compressed or irritated. These nerves are responsible for movement and feeling in the arms and hands.
- Venous thoracic outlet syndrome is caused by damage or obstruction of major veins that lead to the arms. One variant of venous TOS is a condition called effort thrombosis, also known as Paget-Schroetter syndrome, which occurs when a blood clot forms in one of the deep veins in an arm muscle. Effort thrombosis is often associated with frequent and repetitive arm motions, especially among people who play sports.
- Arterial thoracic outlet syndrome, while rare, is the most serious form of TOS. It’s caused by damage to the artery that runs from the thoracic outlet into the arm, and is usually found in someone who was born with an extra rib.
Symptoms vary, depending on which of the three types of TOS a person has:
- In neurogenic TOS, symptoms include pain, numbness, tingling, or weakness in an arm, hand or fingers. The affected arm may also feel tired, which worsens if the arm is raised over the head. Neck pain is also common.
- Venous TOS usually causes swelling of the hand and arm along with pain, weakness or bluish discoloration. Someone with venous TOS may also appear to have swollen veins in the chest.
- Arterial TOS causes, pain, coldness and a pale hand. Someone with arterial TOS may also develop sores on their fingers due to poor blood circulation.
The most important first step in treating TOS is getting a proper diagnosis by vascular surgeons who are familiar with the disorders and can properly distinguish TOS from other medical conditions that cause similar symptoms.
Scripps physicians can diagnose thoracic outlet syndrome using one or more of the following tests:
- Scalene muscle blocks are often used to determine whether a patient has TOS and, if so, whether he or she would respond well to surgery. During the procedure an anesthetic is injected into the scalene muscle, which connects to the first rib. When the muscle relaxes, allowing the first rib to drop, it opens up the space within the thoracic outlet. If the patient’s symptoms improve once the anesthetic has taken effect (meaning the nerves and blood vessels are no longer compressed), he or she is likely to be diagnosed with TOS.
- Conventional angiography
- Computed tomography angiography (CTA)
- Magnetic resonance angiography (MRA)
- Intravascular ultrasound (IVUS), an imaging procedure that uses catheters to see inside of an artery
- Doppler ultrasound, an imaging study that allows doctors to assess how blood is flowing through a blood vessel
While many symptoms of thoracic outlet syndrome seem more aggravating than serious, if left untreated TOS can lead to chronic sores on the fingers, gangrene, permanent nerve damage, or life-threatening blood clots.
Fortunately, Scripps vascular surgeons have experience treating even rare and hard-to-diagnose forms of TOS. While many patients, particularly with neurogenic TOS, will start with conservative treatments such as physical therapy and anti-inflammatory pain medications, others will need more aggressive treatment that includes one or more of the following procedures:
- First rib resection, sometimes referred to as decompression surgery, is a surgical procedure that removes a portion of the first rib, which is located directly under the collarbone. This frees up space within the thoracic outlet, allowing more room for the blood vessels and nerves that reside there. A first rib resection is often paired with a procedure called a scalenectomy, in which some or all of the scalene muscle is removed from the neck. First rib resection with or without scalenectomy can treat all three varieties of TOS.
- Angioplasty and stenting is a minimally-invasive procedure that uses a balloon-tipped catheter to first inflate the problem vein, then insert a tiny cylinder called a stent that keeps the vein propped open. Angioplasty with or without stenting can be used to treat venous TOS.
- Thrombolysis, also known as thrombolytic therapy, is used to dissolve a blood clot with medication injected directly into the vein. This procedure is usually used to treat venous TOS, and is sometimes paired with first rib resection or angioplasty and stenting.