Thoracic outlet syndrome is produced by compression of the nerves and vessels in the area behind the collarbone. Pain and swelling of the neck, shoulder and arm are common symptoms.
Presentation depends on the structure that is mainly affected by the compression. Patients can present with neurogenic, venous or arterial compression.
This condition can affect patients of any age. It is common among people who perform over-the-head activities where repetitive motions of the arm and shoulder are carried out. Also, compression can occur from trauma in the area, the presence of an extra rib, obesity, or anatomical variation of the first rib.
- tingling of arm and hands
- muscle wasting
- weak grip
- swelling and heaviness of arm and hand
- bluish discoloration
- dilation of veins of the arm and chest
- Cold feeling of arm and hand.
- pain and numbness
- loss of pulses
Diagnosis of thoracic outlet syndrome requires a good interview with the patient followed by a detailed physical exam. During the physical exam, the goal is to replicate the maneuvers that elicit those symptoms.
Additionally, X-rays of the neck and chest can evidence the presence of an anatomical variation or the existence of an extra rib. In cases of venous or arterial compression, venograms and arteriograms help us identify the area impinged and plan the appropriate treatment. Treating the clot only with medications to dissolve it and blood thinners most of the time results in recurrence. If there is vein compression, surgery is recommended to relieve the impingement.
The surgery involves removing the first rib and the muscles that are attached to it. The procedure requires a small incision (4-5 cm) above the collarbone allowing visualization of not only the nerves in charge of moving the arm and hand but also the vein and artery that supply and drain blood from the arm. With this approach, we are able to perform a complete decompression of all the structures involved in the thoracic outlet syndrome. Patients usually stay in the hospital for 2-3 days.