Thoracic Outlet Syndrome

The thoracic outlet is the area between your neck and upper chest, formed by your top ribs and framed by your collarbone. Thoracic outlet syndrome happens when structures at the top of the outlet press on nerves or blood vessels that pass through. These structures can include the top rib, the collarbone or neck muscles.

The condition usually affects only one side of the body but can sometimes occur on both sides. If untreated, thoracic outlet syndrome can lead to permanent nerve damage, blood clots or gangrene (tissue death) from reduced blood flow.

Pressure on the nerves or blood vessels in the thoracic outlet can result from several causes, including:

• Congenital (present since birth) defects such as an:
  • Extra rib at the top
  • Abnormality in the collarbone or first rib
  • Unusually tight muscle connecting your first rib and spine
• Poor posture such as slumped shoulders or forward-tilting head
• Pressure on the neck and shoulders from obesity, heavy shoulder loads or extra muscle from weightlifting
• Repetitive arm or shoulder motions, such as lifting objects above your head, pitching a baseball or swimming
• Trauma such as whiplash
• Tumors or other growths in the area

Signs and symptoms of thoracic outlet syndrome vary and depend on the form you have:

Neurogenic (neurological) thoracic outlet syndrome

Most of these cases affect the brachial plexus, a network of nerves leading from your spinal cord. The brachial plexus controls muscle movements and sensation in your shoulder, arm and hand. Neurogenic symptoms include:

• Atrophy (muscle wasting) in the fleshy base of your thumb, in rare cases
• Numbness or tingling in your fingers
• Pain or aches in your neck, shoulder or hand
• Weakened grip

Venous thoracic outlet syndrome

When one or more veins are compressed, you may experience signs and symptoms such as:

• Bluish skin color on your hand and arm
• Swelling (edema) in your arm, hand or fingers
• Swollen veins in your shoulder, neck and hand
• Tingling in your hand and arm
• Weakness in your neck and arms

Arterial thoracic outlet syndrome

Pressure on arteries is the least common form of the condition. Signs and symptoms can include:

• Cold fingers or hands
• Numbness or pain in your hand and arm, especially with overhead motion
• Pale fingers or entire hand
• Slow-healing sores on your hand or fingers

Symptoms of thoracic outlet syndrome vary among people who have the condition, as does the severity of warning signs. Because of that variation, thoracic outlet syndrome is sometimes difficult to diagnose. It’s important that you see a specialist with advanced training and experience in thoracic outlet syndrome.

Henry Ford’s vascular surgeons and neurosurgeons are experts in distinguishing between thoracic outlet syndrome types and ruling out other conditions. We conduct a thorough evaluation that includes:

• Questions about your symptoms, work and physical activities
• Review of your personal and family medical history
• Physical exam, including looking for signs such as arm swelling or discolored skin
• Stress maneuver testing, which tries to reproduce symptoms with certain movements

Our doctors can usually determine whether you have thoracic outlet syndrome, and the type, during your office visit. Sometimes, we order additional imaging or other testing to rule out other conditions and confirm a diagnosis.

Depending on your specific symptoms, you may have testing in our nationally accredited vascular labs or our radiology centers. Our experienced imaging technologists and radiologists use the latest equipment and sophisticated techniques for precise results.

If you need additional testing, we often use these types:

Vascular studies

We use vascular imaging to create pictures of the inside of arteries and veins:

• Angiography/arteriography: We make a small incision to access an artery, then insert a catheter (thin, flexible tube) and guide it to the affected area. After injecting a substance called a contrast agent that highlights arteries, we take X-rays.
• Venography: This test is similar to angiography but is used to look at veins. We can provide the contrast agent with an injection or a catheter procedure to check for blockages or damage.

Imaging

Our radiologists use the latest imaging technologies to help make a diagnosis or rule out other causes:

• Computed tomography (CT): Specialized X-ray equipment produces 3D images of the chest to identify any blood vessel compression. We can also look at the cervical spine to rule out cervical spine impingement, which has similar symptoms.
• CT angiography/venography: This noninvasive procedure is similar to angiography or venography but uses CT scans to produce images of blockages in arteries or veins. These noninvasive tests also don’t require a catheter-based procedure.
• Doppler ultrasound: Sound waves create imaging that measures blood flow through vessels.
• Duplex ultrasound: Traditional ultrasound (still images) with Doppler ultrasound can assess blood flow and measure any narrowing or blockages in blood vessels.
• Magnetic resonance imaging (MRI): Radio waves and a large magnet produce cross-sectional images of the chest to identify any blood vessel compression. We can also take scans of the cervical spine to rule out cervical spine impingement.
• MR angiography/venography: This version of angiography and venography uses magnetic resonance to produce pictures of blockages in arteries or veins. MRA and MRV don’t require a catheter-based procedure, so are considered noninvasive.
• X-rays: This noninvasive procedure uses high-energy radiation to image bones. We take X-rays of the chest to check for an abnormal first rib. We also X-ray the cervical spine to check for an extra rib or for spine abnormalities.

Neurological testing

If your doctor suspects the neurogenic form of thoracic outlet syndrome, these tests can evaluate nerve and muscle function:

• Brachial plexus block: We inject a local anesthetic into muscles on the sides of your neck. If your symptoms go away, it means that you have the neurogenic form.
• Electromyography (EMG): This test inserts needle electrodes into muscles to evaluate their function and the nerves that control them.
• Nerve conduction velocity study: Similar to EMG, this study uses surface (sticker) electrodes to measure muscle and nerve response to stimulation. A nerve conduction velocity study evaluates motor and sensory nerve function.

Henry Ford’s experienced vascular surgeons and neurosurgeons offer the latest treatments for all forms of thoracic outlet syndrome. As your care partner, we work closely with you to customize a treatment plan to relieve your symptoms and prevent serious complications. Your treatment options depend on the form of thoracic outlet syndrome you have.

Initial treatment for all forms of thoracic outlet syndrome

In the early stages of thoracic outlet syndrome, you may experience mild symptoms. We can manage your care with conservative therapies. For all forms, we typically begin with one or more of these options:

• Pain medications: Over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs) may be all you need for pain. We can also prescribe muscle relaxants as needed.
• Physical therapy: You’ll work with our licensed physical therapists on exercises to increase your range of motion and improve your posture. These exercises can strengthen and stretch neck and shoulder muscles enough to open the thoracic outlet, avoiding the need for surgery.

Surgery for neurogenic thoracic outlet syndrome

If conservative treatment isn’t effective or your symptoms get worse, thoracic outlet decompression surgery can provide an option. If you have the neurogenic form, you might see our vascular surgeons or our neurosurgeons.

Our surgeons operate to relieve pressure on motor and sensory nerves to the hand and arm. We use an open procedure to removing the source of pressure, which could be:

• Extra rib
• All or part of the first rib
• Abnormal muscles or connective tissue

Additional treatment for venous thoracic outlet syndrome

Our vascular surgeons oversee your care if you have the venous form. Depending on your specific symptoms, you may need a minimally invasive procedure from our interventional radiologists. If you need surgery to remove the source of the compression, our vascular surgeons have expertise in thoracic outlet decompression surgery.

Your treatment options include:

• Anticoagulant medications: Blood thinners help prevent blood clots from forming.
• Catheter-directed thrombolysis: If you have a blood clot in the compressed vein, our interventional radiology team performs a minimally invasive procedure to dissolve the clot. Your doctor inserts a catheter (thin, flexible tube) through a tiny incision in a vein and guides it to the clot. Using the catheter, the doctor delivers clot-dissolving medication directly to the clot.
• Thoracic outlet decompression surgery: Your vascular surgeon performs open surgery to remove all or part of the first rib and certain muscles in the neck and collarbone area.

Additional treatment for arterial thoracic outlet syndrome

If you have arterial thoracic outlet syndrome, our vascular surgeons oversee your care.

Some people need a minimally invasive procedure from our interventional radiologists. But most people require surgery to relieve pressure on the affected arteries. Surgery to treat arterial thoracic outlet syndrome is highly effective, relieving symptoms about 95 percent of the time . Relieving pressure restores blood flow to your arm and avoids the risk of gangrene (tissue death) and limb loss.

Treatment options for arterial thoracic outlet syndrome include:

• Anticoagulant medications: Blood thinners help prevent blood clots.
• Catheter-directed thrombolysis: If you have a blood clot in the compressed artery, our interventional radiology team performs a minimally invasive procedure to dissolve the clot.
• Thoracic outlet decompression surgery: Your vascular surgeon performs an open procedure to remove:
  • The extra rib, if present
  • All or part of the first rib
  • Certain muscles in the neck
• Artery reconstruction: If the compressed artery is damaged or has a bulge (aneurysm), your surgeon can replace the damaged section. We typically reconstruct arteries during the same procedure as decompression surgery. We replace the damaged section with an artificial graft or a section of artery from elsewhere in your body.

Henry Ford vascular medicine specialists manage your care after you receive treatment for thoracic outlet syndrome. We provide ongoing care to keep you healthy and prevent complications.