eMedicine Specialties > Neurology > Headache and Pain

Thoracic Outlet Syndrome

Author: Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University hospital
Coauthor(s): Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Contributor Information and Disclosures

Updated: Nov 29, 2007

Introduction

Background

Thoracic outlet syndrome (TOS) is complex clinical entity characterized by various neurovascular signs and symptoms of the upper limb. It includes several different types of disorders, as follows:

  • Neurologic TOS
    • Classic (true) neurologic TOS
    • Common (disputed) neurologic TOS
  • Vascular TOS
    • Arterial TOS
    • Venous TOS
  • Combined neurovascular TOS

TOS can involve various components of the brachial plexus, the blood vessels, or both at different sites between the base of the neck and the axilla.

The arterial form is caused by compression of the subclavian artery, the venous form is caused by compression of the subclavian vein, and the neurologic form is caused by brachial plexus compression. Combined neurovascular TOS is usually traumatic.

Pathophysiology

Most authors suggest that nonspecific neurologic TOS results from injury to the brachial plexus, by either traction or compression, at some point within the cervicoaxillary canal.

True (classic) neurologic TOS, which is rare, is caused by congenital anomalies. Usually these anomalies include a taut fibrous band or rudimentary cervical rib.

Frequency

United States

The exact prevalence of TOS is difficult to assess. True neurogenic or vascular TOS is considered rare, but common (nonspecific/disputed) neurogenic TOS is more prevalent.

Sex

TOS is more common in women than in men. The sex ratio varies depending on the type of TOS.

  • The female-to-male ratio in neurologic-type TOS is approximately 3.5:1.
  • The venous type is more common in males than in females, and the arterial type has no sexual predilection.

Clinical

History

Because of complex etiology and absence of good diagnostic tests, patient history is important in TOS.

  • In common neurogenic TOS, pain is the most common and earliest complaint. Detailed history characterizing the patient's pain may lead to appropriate diagnostic and therapeutic plans.
    • The location of pain is an important part of the history.
      • Ask the patient to describe the pain location and type on a pain diagram (anterior/posterior and lateral view of human picture).
      • Pain, numbness, and/or tingling of the upper extremity are common presenting features of neurogenic TOS.
      • Sometimes the patient may report pain in the chest, neck, and/or face and even headache.1
    • Precipitating factors include repetitive or stressful activity, such as prolonged computer keyboard use or overhead work, which can provoke or intensify pain.
      • Most patients report a history of an automobile accident or work-related injury.
      • Alleviating factors may exist and may provide additional clues for possible etiologies.
    • Various terms can be used to describe quality of pain, but it is usually a dull aching type in neurogenic TOS.
    • Spreading or radiation of pain is also important in evaluation of neuropathic pain. If retrosternal pain (radiation from intercostobrachial nerve, a branch of T2 intercostal nerve) is noticed on the left side, it can be confused with pain of cardiac or pulmonary origin.2,3
    • Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more useful and reliable. The Visual Analog Scale (VAS) is a commonly used numerical scale.
  • Arterial TOS often is associated with aching, fatigue, weakness, and pallor due to brachial ischemia.
  • Cold temperature always worsens symptoms.

Physical

  • Hyperabduction and depression of the shoulder may provoke symptoms in patients with TOS.
  • Various stress tests or provocative maneuvers are used by the clinician to evaluate TOS. The sensitivity and specificity of these maneuvers have been reported to be low.
    • Roos maneuver: When in the surrender posture, the patient reports paresthesia and numbness in extremities within 1 minute. This maneuver usually provokes symptoms in lateral cord distribution.
    • Wright maneuver: This maneuver requires the patient to hold the arms next to the ears. Paresthesias usually are noted down the medial scapular border and into lower trunk distribution.
    • Elevated-arm stress test: In this test, the patient keeps arms abducted with flexed elbows for 3 minutes while flexing and extending the fingers. Results are considered positive if the patient cannot do this for 3 minutes.
    • Hyperabduction test: The radial pulse is diminished after elevating the involved arm above the head.
    • Adson maneuvers: While the patient is in a sitting position, ask the patient to inspire deeply, hold his breath, and extend his neck. Then, turn the patient's head passively as far as possible toward one side and then the other. When the head is turned toward the unaffected side, or sometimes the affected side, obliteration of the radial pulse with a drop in blood pressure in the arm is considered a positive result. While turning the head in either direction, the pulse may disappear on both sides, but, on the affected side, a longer lag occurs in its return. During this maneuver, a bruit may develop that is best heard in the supraclavicular space.4
    • Military maneuver (ie, costoclavicular bracing): This maneuver provokes symptoms when the patient elevates the chin and pulls the shoulder joint behind in an extreme "attention" position.5
  • In common neurogenic TOS, physical examination usually does not reveal appreciable sensory loss or motor atrophy in the limb.
    • Upper trunk involvement results in deltoid, upper arm, and medial scapular border pain.
    • Lower trunk involvement can cause dull ache in the medial forearm and paresthesias in the fourth and fifth fingers.
    • Tenderness to palpation over the brachial plexus and paresthesia on percussion may be observed (Tinel sign). Most patients demonstrate hypersensitivity to mechanical compression over the supraclavicular and infraclavicular fossae.
    • The Spurling sign (ie, pain during direct compression of the foraminal exit areas of cervical nerve roots) may help in making the diagnosis of cervical radiculopathy.
    • Vasomotor involvement caused by TOS must be differentiated from coexistent or other causes of vasomotor instability (eg, complex regional pain syndrome [reflex sympathetic dystrophy or causalgia]).
  • In classic neurologic TOS, wasting (especially intrinsic hand muscle atrophy) is a characteristic feature. Signs of decreased pain and temperature sensation may be present in the C8 through T1 distribution.
  • In arterial TOS, usual findings include cool and pale extremity. This finding depends on the extent of compression and injury to the subclavian artery.
  • In venous TOS, the affected limb may be swollen and tender. It may exhibit cyanosis (dusky coloration), venous distension, and ischemic changes in the upper extremity. Strenuous physical activities of extremity can evoke these symptoms and signs. Venous thrombosis can develop at the site of compression.

Causes

  • Most authors suggest that nonspecific neurologic TOS results from injury to the brachial plexus, by either traction or compression, at some point within the cervicoaxillary canal.
  • True (classic) neurologic TOS is caused by congenital anomalies and usually includes a taut fibrous band or rudimentary cervical rib. Other anatomic anomalies include elongated transverse process of C7.
  • Trauma or repetitive activities may produce TOS (eg, motor vehicle accident hyperextension injury, effort vein thrombosis).
  • Certain postures of the body may exacerbate or provoke the symptoms of TOS (eg, hyperabduction with external rotation of arm, depression of shoulder).

More on Thoracic Outlet Syndrome

Overview: Thoracic Outlet Syndrome
Differential Diagnoses & Workup: Thoracic Outlet Syndrome
Treatment & Medication: Thoracic Outlet Syndrome
Follow-up: Thoracic Outlet Syndrome
References
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Further Reading

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Keywords

TOS, thoracic outlet syndrome, brachial plexus, neurologic TOS, vascular TOS, compression of the subclavian artery, compression of the subclavian vein, brachial plexus compression, congenital anomaly, arterial TOS, venous TOS, combined neurovascular TOS

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Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University hospital
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Jashvant Patel, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Jorge E Mendizabal, MD, Consulting Staff, Corpus Christi Neurology
Jorge E Mendizabal, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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