Thoracic Outlet Syndrome

Introduction:

In 1956 Peet introduces the term thoracic outlet syndrome (TOS) which consists of several
disorders that cause neurovascular constriction across the thoracic outlet region. The first rib
and anterior scalene muscle are typically suffer leaving a local effect on the branchial plexus
and subclavian vessels.1 We can differentiate TOS in three different forms, the diagnosis of
each form is depending on the structure that is affected. There are three different forms of
TOS that is neurogenic form, venous form and the arterial form. In rare cases, more than one
form may appear in a same clinical context. Neurological TOS is the most common form
which consists of 95% of cases. Venous TOS consists of 3-5% of cases and arterial TOS
consists about 1-2%.2 TOS is a rare disorder, which is commonly found in women's than
men's, with a men-women 1:4 which affects 20 to 40 years old adults. The pathophysiology
of TOS is likely a combination of a structural predisposition to pressure on the brachial
plexus and injury of scalene muscle. This predisposition may be linked to congenital factors
such as narrow scalene triangle caused by bands, ligaments, or cervical ribs or variations in
anatomy that cause the brachial plexus cord to emerge at high location where the anterior and
middle scalene muscles are close together. Injury to the scalene muscles leads to fibrosis and
mild compression of the plexus due to spasticity in the muscle fibrosis. 3 Arterial TOS include
Paller, coldness, digital ischemia, claudication, paraesthesia and pain in the hand but rarely in
shoulder or neck are the symptoms of the arterial TOS. These symptoms are caused due to
the arterial emboli arising from the thrombus forming just distal to subclavian artery stenosis
or from the mural thrombus in a subclavian artery aneurysm. 4The symptoms of venous TOS

2
Jones, M.R., Prabhakar, A., Viswanath, O. et al. Thoracic Outlet Syndrome: A
Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain Ther 8, 5–18
(2019). https://doi.org/10.1007/s40122-019-0124-2
3
Sanders, Richard J.; Pearce, William H. (1989). The treatment of thoracic outlet syndrome:
A comparison of different operations. , 10(6), 626–634. doi:10.1016/0741-5214(89)90005-0

4
Sanders, Richard J.; Hammond, Sharon L.; Rao, Neal M. (2007). Diagnosis of
thoracic outlet syndrome. Journal of Vascular Surgery, 46(3), 601–604.
doi:10.1016/j.jvs.2007.04.050
that can differentiate from the arterial and neurogenic TOS by inflammation in the whole
arm, forearm, and hand. This is commonly linked with cyanosis of the extremity. Some
patient feels tightness in the arm while other just feel pain in the arm. Paresthesias can appear
in the in the hand with moderate or severe swelling, but this symptom is not usually present. 5
The primary cause of the neurological TOS is neck traumas which is caused due to the
brachial plexus compression from scarred scalene muscles. Patients experience symptoms in
nTOS are extremity paraesthesia, pain, and weakness as well as whiplash pain and occipital
headache. NTOS is the most common type of the thoracic outlet syndrome6

5
Sanders, Richard J; Hammond, Sharon L (2004). Venous thoracic outlet syndrome. , 20(1),
113–118. doi:10.1016/S0749-0712(03)00094-5

6
Sanders, Richard J.; Hammond, Sharon L.; Rao, Neal M. (2007). Diagnosis of
thoracic outlet syndrome. Journal of Vascular Surgery, 46(3), 601–604.
doi:10.1016/j.jvs.2007.04.050
The treatment of TOS is Determined by the underlying cause of TOS. In neurogenic TOS
non-surgical treatment should be considered first. Surgery is recommended for arterial and
venous as well as those with neurogenic TOS who have chronic symptoms like progressive
impairment or muscular atrophy. Neurogenic TOS is initially treated with non-surgical care,
which has shown promising results. Nonsurgical management consists physical therapy,
activity modifications and pain control tactics include anti-inflammatory medications, muscle
relaxants, transcutaneous electric nerve stimulation, and injections. Patients with vascular
compression or neurogenic TOS that has not responded to nonsurgical treatment, surgical
intervention is recommended. Three basic surgical methods for thoracic outlet decompression
are transaxillary, supraclavicular, and posterior, with various variants and preferences that
vary by surgeon7. The treatment for arterial TOS is determined by characteristics and severity
of the arterial complications. If subclavian artery compression is present in asymptomatic
patients without signs of arterial degeneration a non-surgical approach may be taken due to
the minimal risk of complications. Patients who exhibit sighs of arterial problems such as
embolization, poststenotic dilatation, intimal damage, mural thrombus, must require surgery.
The optimal surgical approach is determined by three fundamental principles which are
decompression, arterial resection, and distal revascularization8.

7
Kuhn, J. E.; Lebus V, G. F.; Bible, J. E. (2015). Thoracic Outlet Syndrome. Journal of the
American Academy of Orthopaedic Surgeons, 23(4), 222–232. doi:10.5435/JAAOS-D-13-
00215

8
Hussain, Mohamad Anas; Aljabri, Badr; Al-Omran, Mohammed (2015). Vascular
Thoracic Outlet Syndrome. Seminars in Thoracic and Cardiovascular Surgery, (),
S1043067915001677–. doi:10.1053/j.semtcvs.2015.10.008
PATHOGENESIS:
The cause of TOS is a variation in anatomy or muscle that compresses the brachial plexus or
the subclavian axillary arteries in the area thoracic outlet. The intercostal-scalene triangle, the
costoclavicular region, and the retrocoraco-pectoral space are the three main locations where
compression happens. These spaces are traversed by the vascular and neural regions, and
because of their small size, any deformity of the bone or muscle may exert compression and
result in neurogenic or vascular clinical complaints. A combination of developmental
abnormalities, traumas, and physical activities that contribute to local compression might
cause the compression of the neurovascular bundle when it crosses the thoracic outlet.
Traumatic events often occur in high-velocity scenarios, such as motor vehicle accidents. A
hematoma, haemorrhage, or displaced fracture might compress the nerves and vessels.
Variations in thoracic outlet anatomy whether congenital or acquired are mainly include
changes in the structure of the bones and muscles. TOS causes can be categorized into soft
and bone tissue. 70% of TOS cases are associated with soft tissue, whereas bone
abnormalities make up the remaining 30%.9

9
SYMPTOMS:
There are three categories into which symptoms of TOS can be categorized: pain, paresis, and
paresias. Patients report experiencing intense or sporadic pain that varies in severity, radiating
down the upper extremities, across the top, front, or back of the shoulder, and in the side or
back of the neck. It always gets worse when using one's limbs, particularly when elevating
the hand, and it gets better when at rest. Although they nearly always occur, intermittent
paresthesias cause the patient less distress than pain. Numbness, tingling, and coldness result
from the neuropathy of brachial plexus irritation rather than arterial insufficiency. They may
involve the entire hand or may be localized to a specific neurologic area, most commonly the
ulnar side of the hand, the region innervated by the C-8 and T-1 roots of the brachial plexus.
These are the roots most affected by the anomalous muscle bands. Paresis in the form of early
fatigability, progressive weakness, and dyscoordination are later manifestations of the outlet
syndrome and indicate a more advanced stage.10.

 NEUROGENIC TOS: When there is insufficient space for the brachial plexus as it
travels from the neck to the axilla, symptoms such as pain, paresthesia, and weakness
may develop. Mild symptoms can merely be positional and resolve with repositioning
of the arm. Two subtypes of neurogenic TOS exist. Upper TOS involves the superior
aspect of the brachial plexus (C5 through C7), with symptoms felt mostly in the arm
and forearm, sparing the hand. Additionally, the patient can experience neck pain on
the affected side that radiates to the ear, face, and occiput, causing headaches. The
pain can also radiate across the rhomboids, clavicle, and trapezius/deltoid area. It can
mimic a C5-C6 nerve root compression by a herniated nucleus pulposus. Causes of
upper TOS include hypertrophied scalene, passage of the brachial plexus through the
anterior scalene, anterior pressure on the middle scalene by an elongated C7
transverse process, or the presence of a cervical rib. Lower TOS involves the C8-T1
components of the brachial plexus. In these patients, the hand is affected, but the arm
and forearm are spared. However, these patients can have neck and shoulder pain as

10
Roos, D. B. (1979). New Concepts of Thoracic Outlet Syndrome that Explain
Etiology, Symptoms, Diagnosis, and Treatment. Vascular and Endovascular Surgery,
13(5), 313–321. doi:10.1177/153857447901300503
 well, with a variable intensity that can radiate down the medial brachial area of the
arm into the forearm and hand. Paresthesias are usually felt in the 4th and 5th digits.
Most patients with NTOS experience paresthesias in the fingers and sometimes the
entire hand, usually in the median or ulnar distribution as described above. Also, if the
arm is held overhead for a length of time, weakness may develop in the specific arm,
and this fatiguing of the arm in overhead positions is often the presenting symptom.
Furthermore, when carrying objects with the arm by the side (e.g. shopping bags) the
arm may become numb, and a loss of grip may occur. In more advanced cases, muscle
atrophy can be seen, along with loss of fine motor movement. Sleeplessness and
irritability are likely. Most symptoms manifest after exercise, which helps to
distinguish it from orthopedic injuries, which usually occur during exercise. In
addition, TOS is not limited to a specific dermatome, in comparison to a cervical disc
problem which is usually dermatomal in nature11. Pain, paresthesia, and weakness in
the hand, arm, and shoulder, plus neck pain and occipital headaches, are the classical
symptoms of NTOS. Raynaud’s phenomenon, hand coldness and colour changes, is
also frequently seen in NTOS. It is the latter symptoms that can lead to an erroneous
diagnosis of ATO

11
Boezaart, AndréP; Haller, Allison; Laduzenski, Sarah; Koyyalamudi, VeerandraB;
Ihnatsenka, Barys; Wright, Thomas (2010). Neurogenic thoracic outlet syndrome: A case
report and review of the literature. International Journal of Shoulder Surgery, 4(2), 27–.
doi:10.4103/0973-6042.70817