eMedicine Specialties > Emergency Medicine > Cardiovascular

Thoracic Outlet Syndrome: Differential Diagnoses & Workup

Author: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s): J Stephen Bohan, MD, FACP, FACEP, Director, Observation Medicine, Department of Emergency Medicine, Clinical Director, Harvard Medical School, Brigham and Women's Hospital
Contributor Information and Disclosures

Updated: Oct 30, 2009

Differential Diagnoses

Acute Coronary Syndrome
Spinal Cord Injuries
Carpal Tunnel Syndrome
Thrombophlebitis, Superficial
Multiple Sclerosis
Neoplasms, Spinal Cord
Rotator Cuff Injuries

Other Problems to Be Considered

Cervical spondylitis
Mediastinal venous obstruction (eg, Pancoast tumor)
Brachial plexitis
Fibromyalgia
Postural palsy
Raynaud disease
Trauma
Ulnar nerve compression at the elbow
Vasculitis
Vasospastic disorder

Workup

Laboratory Studies

  • With the rare exception of a vascular cause, the vast majority of ED presentations of thoracic outlet syndrome are not emergent. Screening tests may be appropriate if indicated and to rule out other causes. Once the clinical diagnosis is made, most of the imaging studies and other tests should be reserved for the outpatient setting.

Imaging Studies

  • Cervical radiography - May demonstrate a skeletal abnormality3
  • Chest radiography
    • Cervical or first rib: This is usually associated with the arterial form of TOS but also can be a predisposition to developing the neurologic form following neck trauma.
    • Clavicle deformity
    • Pulmonary disease
    • Pancoast tumor
  • Color flow duplex scanning for suspected vascular thoracic outlet syndrome (TOS)
  • Arteriography (indications)
    • Evidence of peripheral emboli in the upper extremity
    • Suspected subclavian stenosis or aneurysm (eg, bruit or abnormal supraclavicular pulsation)
    • Blood pressure differential greater than 20 mm Hg
    • Obliteration of radial pulse during EAST
  • Venography (indications)
    • Persistent or intermittent edema of the hand or arm
    • Peripheral unilateral cyanosis
    • Prominent venous pattern over the arm, shoulder, or chest

Other Tests

  • The following special studies are generally appropriate in the outpatient setting. They should be arranged by the primary care physician once the patient has been discharged from the ED.
    • Nerve conduction evaluation via root stimulation and F wave is the best direct approach to evaluation of neurologic TOS.
    • Electromyography (EMG) is unreliable and does not provide objective evidence of TOS.
    • Cervical myelogram, CT scan, or MRI may be appropriate for patients suspected of having cervical disk disease or spinal cord disease.

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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References

  1. Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. Apr 2009;11(2):176-83. [Medline].

  2. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. Sep 2007;46(3):601-4. [Medline].

  3. Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. Nov-Dec 2006;26(6):1735-50. [Medline].

  4. Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. Oct 2004;55(4):897-902; discussion 902-3. [Medline].

  5. Barkhordarian S. First rib resection in thoracic outlet syndrome. J Hand Surg [Am]. Apr 2007;32(4):565-70. [Medline].

  6. Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet syndrome in Washington state workers' compensation. Neurology. Mar 28 2000;54(6):1252-7. [Medline].

  7. Aufderheide TP. Peripheral arteriovascular disease. Emerg Med: Concepts and Clinical Practice. 1998;2:1844-7.

  8. Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. Oct 1997;63(10):913-7. [Medline].

  9. Oates SD, Daley RA. Thoracic outlet syndrome. Hand Clin. Nov 1996;12(4):705-18. [Medline].

  10. Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med. Apr 1998;5(4):337-42. [Medline].

  11. Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. Neurologist. Nov 2008;14(6):365-73. [Medline].

  12. Weber RJ, Lebduskin S. Rehabilitation issues in plexopathies. Phys Med Rehabil. 1988;996-8.

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Further Reading

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Keywords

thoracic outlet syndrome, nerve compression syndrome, thoracic outlet syndrome causes, thoracic outlet syndrome symptoms, TOS, vascular thoracic outlet syndrome, neurologic thoracic outlet syndrome, arterial thoracic outlet syndrome, venous thoracic outlet syndrome, compression of neurovascular structures, neurovascular entrapment

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Contributor Information and Disclosures

Author

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

J Stephen Bohan, MD, FACP, FACEP, Director, Observation Medicine, Department of Emergency Medicine, Clinical Director, Harvard Medical School, Brigham and Women's Hospital
J Stephen Bohan, MD, FACP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Eitel, MD, MBA, Associate Professor, Department of Emergency Medicine, York Hospital
David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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