Thoracic Outlet Syndrome (TOS) refers to a group of conditions that occur when the blood
vessels or nerves just below the neck are compressed.
Neurological Thoracic Outlet Syndrome (NTOS), the most common type, specifically involves the compression of the brachial plexus, a network of
nerves that come from the spinal cord and control muscle movements and sensation in the shoulder, arm, and hand.
The causes of NTOS are varied, including physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects such as having an extra rib at birth, and sometimes pregnancy, due to changes in the body’s structure. Risk factors for developing NTOS include professions or sports that involve repetitive arm or shoulder movements, like baseball pitching or jobs that require prolonged overhead lifting.
Understanding NTOS is important for those who might be at risk or are currently experiencing symptoms. Early diagnosis and management can significantly improve the quality of life and prevent complications such as permanent nerve damage. If you suspect you may have symptoms of NTOS, a consultation with a healthcare provider is a crucial step.
Arterial Thoracic Outlet Syndrome (ATOS) is a rare condition, affecting less than 1% of all Thoracic Outlet Syndrome cases. It occurs when the
subclavian artery, one of the main blood vessels that supply blood to the arm, is compressed as it passes through the thoracic outlet – an area at the lower neck and upper chest.
The compression of the subclavian artery in ATOS is most commonly caused by repetitive arm movement or trauma, which may result in either an extra cervical rib (a congenital condition where there is an additional rib above the first rib) or a
developed anomaly such as a fibrous band connecting the spine to the rib. Risk factors include activities that involve repetitive overhead arm motions, like baseball or swimming, or professions that require prolonged arm extension above the head, such as electricians or painters.
ATOS can lead to serious complications if left untreated, including blood clots or even gangrene, so its crucial for anyone with persistent symptoms to seek medical advice. Early intervention can often lead to a full recovery and prevent long-term damage.
People with ATOS might experience a variety of symptoms. The most common sign is pain in the hand, arm, or shoulder. As the condition progresses, individuals may notice cold sensitivity in the hands and fingers, numbness or tingling in the arm, and possibly a weakening of the pulse in the affected arm. In severe cases,
there may be noticeable muscle wasting in the hand or fingers, discoloration of the hand, or even sores or ulcers on the fingers due to poor blood circulation.
Investigating ATOS often involves a combination of a thorough physical examination and imaging studies. During the physical exam, the doctor may feel for a weakened pulse in the affected arm or look for a difference in blood pressure between arms.
Various manoeuvres may also be performed to replicate the symptoms. Imaging studies, such as Doppler ultrasound, can assess blood flow and identify any vessel narrowing or blockages. Further, an angiogram, which uses X-ray imaging with a contrast dye to view blood flow, can be conducted to pinpoint the specific location and cause of the compression.
If ATOS is suspected or diagnosed, the treatment may involve a combination of therapeutic and surgical approaches. Therapeutic measures typically include physical therapy and exercises to improve range of motion and posture, while surgical intervention may be needed to relieve the arterial compression and restore blood flow, particularly in cases where there is a risk of arterial damage or where symptoms are severe and persistent.
Venous Thoracic Outlet Syndrome (VTOS) is a condition where the veins under the collarbone (subclavian veins) are compressed, leading to restricted blood flow from the arm back to the heart. This type of thoracic outlet syndrome is less common than its neurological counterpart but more frequent than arterial thoracic outlet syndrome.
The root cause of VTOS is often related to repetitive arm activity or injury, leading to compression between the collarbone and first rib, which can cause blood clots in the veins (venous thrombosis). Risk factors include activities that require repetitive lifting of the arms, such as weightlifting or working overhead, and can also be seen in people with anatomical variations like an extra rib above the first
rib, called a cervical rib, which narrows the space through which the subclavian vein passes.
Understanding and recognising the signs of VTOS is crucial as early treatment can prevent serious complications and improve outcomes. If you have persistent pain, swelling, or discoloration in the arms, particularly with arm use, consult a healthcare professional for evaluation.
Individuals with VTOS may experience swelling, a feeling of heaviness, aching pain, and bluish discoloration in the affected arm. These symptoms are often exacerbated by activity, especially lifting the arms. The affected arm may feel fatigued, and veins on the surface of the body may become more visible, a condition referred to as collateral circulation, where blood reroutes through smaller channels to get around the blockage.
To diagnose VTOS, a clinician will conduct a thorough physical examination and may order imaging tests. An ultrasound is often the first step, as its a non- invasive way to assess blood flow and can help to visualize a clot. A venogram, where dye is injected into the blood vessels making them visible on X-ray images, is a more specific test that can confirm the diagnosis and determine the exact location and extent of the compression or clot.
Treatment of VTOS often starts with anticoagulation therapy to dissolve blood clots and prevent new ones from forming. Thrombolytic drugs (Clot Busters) may also be used to rapidly break down clots in more severe cases. If non-surgical treatments are not effective, surgical options may be explored. These can include removing the first rib or the cervical rib to relieve the compression or repairing the damaged vein. After surgery, physical therapy is vital to restore function and prevent future compression.
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