Thoracic Outlet Syndrome (TOS)

Thoracic outlet syndrome is a group of conditions that develop when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) become compressed. The increased pressure on the blood vessels and nerves may cause pain in your shoulders, neck and arms. It also can cause numbness or tingling in your fingers.

The initial treatment for TOS typically consists of physical therapy, pain relief measures including medication and occasionally blood thinning medications in case a clot is detected.

There are currently three types of Thoracic Outlet Syndrome.

• Neurogenic thoracic outlet syndrome represents more than 90% of all cases and is more commonly found in women.  Symptoms are produced by compression or entrapment of the nerves (brachial plexus) at the thoracic outlet.
• Arterial thoracic outlet syndrome symptoms are produced by the compression of the subclavian artery.
• Venous thoracic outlet syndrome symptoms are produced by the persistent compression and injury to the subclavian vein at the thoracic outlet.   

Surgery may be needed and recommended if a blood is diagnosed and if the symptoms do not improve with initial treatment, ongoing symptoms persist or if you have progressive problems.

What are the signs and symptoms of Thoracic Outlet Syndrome?

Symptoms can vary, depending on whether nerves or blood vessels are compressed. When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome include:

• Numbness or tingling in your forearm and fingers
• Pain or aches in your neck, shoulder, arm or hand
• Weakness in your hand or a weakening grip

When blood vessels become compressed, signs and symptoms of arterial or vascular thoracic outlet syndrome can include:

• Discoloration of your hand (bluish color)
• Arm pain and swelling including redness of the arm
• Blood clot in veins or arteries in the upper area of your body
• Lack of color in one or more of your fingers or your entire hand
• Weak or no pulse in your arm
• Cold fingers, hands or arms
• Hands or arm that become easily fatigued with activity
• Numbness or tingling in your fingers
• Weakness of arm or neck
• Throbbing lump near your collarbone

What are some of the common cause of Thoracic Outlet Syndrome?

• Injuries or physical trauma from a car accident or other traumatic event can cause compression of the thoracic outlet and nerves and blood vessels in the surrounding area.
• Repetitive injuries from job- or sports-related activities such as heavy lifting of objects or repetitive activities can cause damage to the tissues of the thoracic outlet.  Over time this may shrink the size of the thoracic outlet and place pressure on nerves and blood vessels.
• An extra rib (some people are born with an extra rib above their first rib) reduces the size of your thoracic outlet and compresses nerves and blood vessels.
• Poor posture and obesity has been known to increase pressure on your joints and lead to a narrowing of the thoracic outlet.

Surgical options

Your doctor may recommend surgery if your symptoms are severe and persistent and do not improve with physical therapy and medication.  At UNC Medical Center, our blood vessel (vascular) surgeon will perform the surgery to treat thoracic outlet syndrome, called thoracic outlet decompression. 

There are several different approaches to the procedure, including:

• Transaxillary approach. In this surgery, your UNC vascular surgeon makes an incision at the base of the armpit to access and remove a portion of the first rib to relieve compression.
• Supraclavicular approach.  Your UNC vascular surgeon makes an incision just under your neck to expose the thoracic outlet region. This approach allows the repair compressed blood vessels. This approach allows also to free the brachial plexus from the surrounding scar tissue.

If a clot is detected (venous or arterial thoracic outlet syndrome), your UNC vascular surgeon may dissolve the clots with a clot bursting medication prior to the thoracic outlet decompression. This procedure is called a catheter directed thrombolysis.  After the clot is dissolve, the thoracic outlet decompression is performed.

In the neurogenic form, as no blood clot is detected, the thoracic outlet decompression is promptly performed in order to free the nerves that go into the arms.

Ask your physician if you are a candidate for surgery if you are experiencing persistent signs and symptoms of Thoracic Outlet Syndrome.