The thoracic outlet is a small area between your collarbone, first rib and vertebra. This is a rigid space where many important structures are crowded together including blood vessels, nerves and muscles. Because they are in such a narrow space, compression of the nerves or vessels can occur, causing pain in the neck and shoulder, numbness and tingling of the fingers, and a weak grip. This group of symptoms is known as thoracic outlet syndrome (TOS).
Thoracic outlet syndrome can be difficult to diagnose because a number of disorders have similar symptoms. It is important that you choose an experienced medical team to treat your TOS. The Lung Center at Brigham and Women’s Hospital (the Brigham) provides specialized diagnostic services for thoracic outlet syndrome, as well as proven techniques to relieve symptoms.
What are the types of thoracic outlet syndrome?
There are two common types of Thoracic Outlet Syndrome:
Neurogenic/Neurological Thoracic Outlet Syndrome
- Compression of the nerves that come from your spinal cord and control your shoulders, arms and hands
- Comprises the majority of thoracic outlet syndrome cases
Vascular Thoracic Outlet Syndrome
Compression of one or more of the veins or arteries under the collarbone
Risk Factors for Thoracic Outlet Syndrome:
- Trauma from a car accident (the symptoms can often be delayed)
- Repetitive injuries (related to sports or job activities)
- Anatomical defects (such as having an extra rib, usually a cervical rib)
- Poor posture
- Tumors that press on nerves
- Pregnancy
- Obesity
What are the symptoms of thoracic outlet syndrome?
The symptoms of thoracic outlet syndrome can vary, depending on the compressed structure (artery, nerve, or vein). Signs and symptoms of neurogenic/neurological thoracic outlet syndrome are:
- Numbness or tingling in your arm or fingers
- Pain in your neck, shoulders, or hands
- Weak grip
- Gilliatt-Sumner hand (severe wasting in the fleshy base of the thumb)
Signs and symptoms of vascular thoracic outlet syndrome are:
- Bluish color to your hand
- Swelling and pain in your arm
- Blood clots in veins or arteries in the upper body
- Lack of color in one or more fingers, or in hand
- Weak or no pulse in affected arm
- Cold fingers, hands or arms
- Fatigue in arm after activity
- Numbness or tingling in fingers
- Weakness of arm or neck
- Throbbing lump near your collarbone
- Padgett-Schroeder Syndrome – effort thrombosis of axillary vein
How is thoracic outlet syndrome diagnosed?
Your medical team at The Lung Center will collaborate with a neurologist to evaluate your symptoms. Your medical team will perform a complete physical examination in order to find any outward signs of thoracic outlet syndrome, such as swelling or discoloration. In addition, your team may perform the following tests:
- Elevated arm stress test
- Imaging tests, including X-ray, CT scan or ultrasound
- Thoracic outlet specific MRI of the chest
- Nerve conduction study (NCS) can determine nerve damage and destruction
- Electromyography (EMG) measures electrical activity in muscles
- Arteriography and venography, tests which can see if a vein or artery is compressed or has a clot
What is the treatment for thoracic outlet syndrome?
- Physical therapy
- Pain medications, such as ibuprofen, stronger pain medications or muscle relaxants
- Lifestyle changes
- Maintain good posture
- Avoid strenuous activities
- Avoid repetitious activities, such as sitting at a computer for too long
- Weight loss, if you are overweight
- Clot-dissolving medications, if you have vascular thoracic outlet syndrome
Surgery
Surgery for patients who have an indication for surgery, the first rib or a part of the first rib is resected through a small incision in the armpit. This is done under general anesthesia:
- An extra rib is removed and certain muscles are cut.
- A section of the first rib is removed to release pressure in the area.
- Patients with vascular TOS may require repair of veins and arteries.
Bypass surgery may be done to reroute blood around the compression or remove the area that is causing the symptoms. Your doctor may also suggest other alternatives, including angioplasty, if the artery is narrowed.
What can I expect?
When you become a patient of The Lung Center you will meet many members of the team who will carefully review your medical history and studies. You will receive a thorough diagnostic evaluation and receive clinically proven treatment by a BWH board-certified thoracic surgeon who specializes in thoracic outlet syndrome. This may include specialized physiologic tests, as well as imaging to examine the trapped vessel or nerve. Additionally, a psychological evaluation may be indicated.
Team-based care
Thoracic outlet syndrome patients benefit from the wide range of specialists at The Lung Center. Any surgery recommended will be performed by an experienced, board-certified thoracic surgeon, in collaboration with a treatment team that includes pulmonologists and neurologists, as well as nurses and physician assistants, all of whom specialize in caring for patients with thoracic outlet syndrome.
Where are you located, and how do I book an appointment?
Do you have additional resources on thoracic outlet syndrome?
Go to our online health library to learn more about thoracic diseases and tests.
Visit the Kessler Health Education Library in the Bretholtz Center for Patients and Families to access computers and knowledgeable staff.
Access a complete directory of patient and family services.
