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Thoracic outlet syndrome (TOS) is a group of disorders that cause pain and other symptoms in the upper body. TOS occurs when nerves or blood vessels are compressed by the rib, collarbone, or neck muscles. While TOS can cause pain in the neck, upper chest, shoulder, and arm, it is unclear whether this pain is always indicative of muscle spasms. However, it is known that TOS can be caused by a trapezius muscle deficiency, which causes the shoulder to depress and the outlet to narrow, increasing pressure. Furthermore, in the case of neurogenic TOS, which accounts for over 90% of all cases, muscle relaxation induced by an ASM/PM anesthetic block can temporarily decompress the brachial plexus nerve roots passing through the thoracic outlet, suggesting that muscle spasms may be a factor in this type of TOS.
| Characteristics | Values |
|---|---|
| Definition | Thoracic outlet syndrome (TOS) is a group of disorders that cause pain and other symptoms in the upper body. |
| Cause | Compression of nerves or blood vessels in the lower neck and upper chest. |
| Types | Neurogenic TOS, Venous TOS, Arterial TOS, Vascular TOS. |
| Symptoms | Pain, abnormal sensations (paresthesia), muscle spasms, swelling, venous distension, dull ache, numbness, weakness, tingling, atrophy of the intrinsic muscles of the hand, hand pain, colour changes in the upper extremity, diminished pulses, blood clots, pulmonary embolism. |
| Risk Factors | Congenital abnormality, injury, bodybuilding, whiplash, weight gain, anatomical abnormalities, fibrous muscular bands from overuse, poor muscle development, poor posture, repetitive overhead arm movements, cervical rib, abnormal first rib formation, abnormal clavicle formation, tumour in the neck, trapezius muscle deficiency, clavicle fracture. |
| Treatment | Conservative treatments like physical therapy, pain medications, surgery (decompression surgery, transaxillary first rib resection, supraclavicular decompression). |
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What You'll Learn
Thoracic outlet syndrome is caused by nerve or blood vessel compression
Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed by the rib, collarbone, or neck muscles at the top of the thoracic outlet. The thoracic outlet is the ring formed by the top ribs, just below the collarbone. It is an anatomical term that refers to the opening between the neck and chest, which is usually wide enough to allow nerves and blood vessels to pass through easily.
There are three types of TOS: neurogenic, venous, and arterial. Neurogenic TOS, which accounts for more than 90% of cases, occurs when nerves leading from the neck to the arm (the brachial plexus) are compressed. Venous TOS, which accounts for about 5% of cases, occurs when a vein is compressed, leading to upper body thrombosis. Arterial TOS, which accounts for about 1% of cases, occurs when an artery is compressed. Sometimes, venous and arterial TOS are referred to together as vascular thoracic outlet syndrome.
TOS can be caused by various factors, including congenital abnormalities, injuries, and muscle buildup in the neck. Certain activities that require repeated overhead motions can also contribute to TOS. Symptoms of TOS include pain, tingling, numbness, and abnormal sensations (paresthesia) in the upper body, particularly in the neck, chest, shoulder, arm, or hand. These symptoms can vary depending on the type of TOS and the specific structures being compressed.
While TOS can cause a variety of symptoms, it is important to note that it shares some symptoms with more serious conditions such as heart attack and stroke. Therefore, a thorough evaluation and diagnosis are crucial to distinguish TOS from other conditions and determine the most appropriate treatment options.
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Compression can be caused by anatomical abnormalities
Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed by the rib, collarbone, or neck muscles. Compression can be caused by anatomical abnormalities, such as:
Cervical Rib
A cervical rib is an extra rib that grows from the cervical spine, or the neck part of the spine. Between 1 and 3 percent of the population has a cervical rib, which may grow on one side or both. Having a cervical rib increases the chance of nerve or blood vessel compression between the rib or its muscles and ligamentous connections sharing this small space. A small percentage of people with a cervical rib develop thoracic outlet syndrome.
Abnormal Muscle or First Rib Formation
Some people may have an extra or aberrant scalene muscle (an inner muscle of the neck) or an abnormal first rib or clavicle (collarbone). The first rib, scalene muscles, and the clavicle comprise the thoracic outlet.
Trapezius Muscle Deficiency
Trapezius muscle deficiency can cause the shoulder to depress, which can cause the outlet to diminish, thus increasing the pressure.
Fibrous Muscular Bands
Fibrous muscular bands from overuse or in muscular athletes can cause increased pressure in anatomically normal individuals.
Weight Gain
Extra fat in the neck may compress nerves or subclavian vessels.
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Compression can also be caused by injuries or overuse
Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed by the rib, collarbone, or neck muscles at the top of the outlet. TOS can cause pain in the neck, upper chest, shoulder, and arm. This pain may worsen when moving the arms. The thoracic outlet is the ring formed by the top ribs, just below the collarbone.
Repetitive overhead arm movements, such as those required in swimming, baseball, painting, hairstyling, or auto mechanics, can cause swelling or growth in muscle size, leading to compression in the thoracic outlet. Bodybuilding can also lead to TOS, as built-up muscles in the neck may grow too large and compress nerves or subclavian vessels.
Fibrous muscular bands from overuse or muscle build-up in muscular athletes can cause increased pressure in anatomically normal individuals, leading to TOS. Additionally, weight gain can result in extra fat in the neck, which may compress nerves or subclavian vessels.
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Symptoms include pain, numbness, and weakness
Thoracic outlet syndrome (TOS) is a group of disorders that cause pain and other symptoms in the upper body. TOS occurs when nerves or blood vessels are compressed by the rib, collarbone, or neck muscles at the top of the outlet. The compression of these nerves, veins, or arteries impairs their ability to work properly and gives rise to a range of symptoms, including pain, numbness, and weakness.
The symptoms of TOS depend on the type of TOS, which can be classified according to what is compressed: neurogenic TOS, venous TOS, or arterial TOS. Neurogenic TOS occurs when the nerves leading from the neck to the arm (the brachial plexus) are compressed. This is the most common type of TOS, accounting for more than 90% of cases. Symptoms of neurogenic TOS include pain, numbness, and tingling in the arm and/or hand, as well as weakness in the hand and neurological sensory deficits. The pain may feel like a dull ache and may worsen when moving the arms.
Venous TOS occurs when a vein is compressed, leading to symptoms such as arm swelling, pain, and numbness. Arterial TOS occurs when an artery is compressed, resulting in reduced blood flow to the arm and causing symptoms such as arm and hand pain, numbness, and colour changes in the upper extremity.
In some cases, TOS can cause muscle spasms, particularly in the neck, shoulder, and back. These muscle spasms are thought to be caused by excessive stretch and inadvertent alterations in posture that patients may subconsciously make to minimize positions that worsen their symptoms. Palpable spasm in the anterior scalene muscle is not uncommon in neurogenic TOS.
The symptoms of TOS can vary widely, from minor complaints to debilitating manifestations. They may come and go, but they are often made worse when the arms are held up, with symptoms worsening the longer the arms are raised. The vague nature of TOS symptoms can make diagnosis challenging and delay treatment.
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Treatment options include physical therapy, medication, and surgery
Treatment options for thoracic outlet syndrome (TOS) depend on the specific type of TOS and the severity of the symptoms. Physical therapy, medication, and surgery are all possible treatment options that can help manage symptoms and improve quality of life.
Physical therapy plays a crucial role in managing TOS-related symptoms and can be an effective way to alleviate compression and restore function without resorting to surgery. This includes patient education, posture correction, and strengthening and stretching exercises. Postural re-education is particularly important, as it can help patients become more aware of their body mechanics and make the necessary adjustments to reduce nerve compression.
Medications can also be prescribed to help with pain and inflammation caused by compressed nerves. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen, can be effective in reducing pain and inflammation. Doctors may also prescribe muscle relaxants to reduce muscle tension and improve mobility, although these can have side effects such as drowsiness and dry mouth. In some cases, thrombolytic medications may be used to dissolve blood clots, especially in patients with venous or arterial thoracic outlet syndrome.
Surgery is typically considered a last resort after conservative treatments have proven ineffective. However, in cases of severe compression or limb-threatening complications, surgery may be necessary to alleviate symptoms and restore function. There are several surgical approaches, including conventional rib resection, which involves making an incision to access and remove the extra rib. This procedure may also include the removal of scalene muscles, which can reduce compression on adjacent nerves, arteries, and veins. Minimally invasive procedures, such as balloon angioplasty or balloon venoplasty, are also options. These procedures use a catheter with an inflatable balloon to open narrowed arteries or veins without the need for large incisions. Robotic-assisted rib resection is another innovative procedure that uses small incisions and robotic assistance to widen the thoracic outlet and remove any obstructions, such as scar tissue or muscles.
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Frequently asked questions
Thoracic outlet syndrome is a group of disorders that cause pain and other symptoms in the upper body. It occurs when nerves or blood vessels in the lower neck and upper chest are compressed.
Yes, thoracic outlet syndrome can cause muscle spasms. In particular, neurogenic TOS, which accounts for over 90% of all cases, can lead to excessive stretch and muscle spasm in the neck, shoulder, and back.
Symptoms of thoracic outlet syndrome include pain in the neck, chest, shoulder, and arm. Other symptoms include numbness, a "pins-and-needles" feeling, swelling, and weakness in the affected areas.
