Thoracic Outlet Syndrome
Thoracic Outlet Syndrome |
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The C5, C6, C7, C8 and T1 spinal nerves emerging from the foramina recombine to form the 3 trunks of the brachial plexus (BP). These elements pass between the anterior and middle scalenes which, along with the first rib to which they attach, form the interscalenic triangle. The second portion of the subclavian artery accompanies the BP while the subclavian vein is located in front of the anterior scalene. The trunks of the BP divide into anterior and posterior divisions which travel under the clavicle, in the costoclavicular space. The divisions recombine into 3 cords which enter the axilla by passing beneath the pectoralis minor insertion on the coracoid process of the scapula. The neurovascular bundle can be compressed or irritated by repetitive movements in one or other of these 3 locations-the interscalenic triangle, the costoclavicular space and/or the subcoracoid tunnel. |
Thoracic outlet syndrome consists of symptoms caused by compression of the nerves in the brachial plexus (nerves that pass into the arms from the neck) or blood vessels. Patients may have pain in the shoulder, arm, or hand, or in all three locations. The hand pain is often most severe in the fourth and fifth fingers. The pain is aggravated by the use of the arm, and "fatigue" of the arm is often prominent.
The goals of treatment are twofold: to correct postural abnormalities that might contribute to the compression, and to establish an exercise program to strengthen the shoulder muscles. Most often a conservative course of treatment is followed. If vascular or major neurological impairment is present, surgical decompression may be considered. However, only a small number of patients require surgery.
The predisposing factors responsive for the development of thoracic outlet syndrome are fibromuscular bands, bony protuberances and long or larger transverse processes, this together with the tendinous or cartilaginous muscular insertions are responsible for the compression of the neurovascular structures at the thoracic outlet. These abnormalities or variations of the anatomy of this area produce symptoms of thoracic outlet syndrome that have been triggered by trauma or repetitive work.
The symptoms may spontaneously occur because there are patients who have symptoms of thoracic outlet syndrome without a history of trauma or repetitive work. The compression occurs in three anatomical structures, arteries, veins and nerves; isolated, or more commonly two or three of the structures are compressed. Compression can be of different magnitude in each of these structures. Therefore symptoms can be protean. For example, the subclavian vein can be the only compressed structure and this patient might have a thrombosis of the vein that was called in the past effort thrombosis, or a swelling of the fingers. The subclavian artery can also be compressed with symptoms of temporary, arterial, positional insufficiency of the upper extremity. When they are present for a long time, aneurysm and thrombosis of the subclavian artery may develop with distal embolization. Nerve compression of the brachial plexus is very common and is or not associated with venous or arterial compression. Neurocompression can exist without vascular compression. The intermingling of all this compressions, the degree, and which of the three anatomical structure is the most compressed, might produce protean manifestations of the symptoms in these patients. They are difficult to interpret unless the health provider is aware of the symptoms and the physical examination of thoracic outlet syndrome.
If any individual who has a predisposition for thoracic outlet syndrome performs repetitive work with the upper extremity, it is very likely that he will begin to have symptoms in the first few months after he or she starts to work. On the other hand, some people who may have predisposition may take a longer time and it would take years of repetitive work to show the symptoms of thoracic outlet syndrome. They may have had symptoms for a long time, without being aware of them, and at one point in time the symptoms become worse and this is when they are first noticed. The individual is affected because he feels tinglingness and weakness and heaviness of the hands and arms, pains in the chest, pain in the upper back and in the neck. It is difficult now to perform the same type of work that before was easy to do. Also the weakness of the hands, sometimes dropping of objects, make it difficult to perform repetitive work. What symptoms does the patient have? The patient may have few or many symptoms. You can see in the web page the origin of the symptoms, the name of the symptoms, and how they can be classified; they can be together, separate, or isolated and can have a venous, arterial, or neurologic origin. The symptoms also refer to the structure that is compressed and the degree and the association with the others. Some of the manifestations are protean, like anterior chest pains, and if the doctors are unaware of this manifestations, the diagnosis is difficult to make.
The diagnosis is therapy, because these patients may go to numerous doctors but the diagnosis is not entertained. The patient becomes disappointed because of the lack of diagnosis, they also continue to have the pains and frequently they feel that they are judged to be malingering. This puts honest patients in a very difficult position. They may think that they are having mental problems because they know that they have the pains and they are frequently being told that they are exaggerating the symptoms or the doctor can't find anything wrong with them. Many of these patients are depressed, the posture is slouchy.
It is well known that one of the most effective ways to detect depression is to ask the patient. The person who is trying to substantiate the claims of the patient or client should know that when a doctor sees a patient with thoracic outlet syndrome, the physician cannot differentiate what has been the triggering factor in the development of the symptoms. If I examine a patient who has thoracic outlet syndrome I am not being told if it was spontaneous, secondary to an accident or trauma, or secondary to repetitive work; I cannot differentiate the causative triggering factor. I can make a diagnosis of thoracic outlet syndrome but the etiological factor can escape at the present time unless there is a severe case of a large cervical rib. Otherwise I cannot possibly decide or make a statement about the etiological diagnosis. The etiological diagnosis cannot be made just with the history and physical examination. Part of the treatment is physical therapy, but with somebody who is aware of thoracic syndrome manifestations and has a special training in the treatment. Some exercises are also very important, correction of the posture, checking that the patient is not depressed. Surgery is the last of the treatment choices and only has to be performed when there is no improvement in the condition. The patient has to be screened by a psychiatrist or a psychotherapist and the patient should know the pros and cons of the procedure and the possibility of failure and damage to the nerves and vessels, and he/she has to be well motivated. There has been evidence in the medical literature that employment in an upper extremity repetitive work has a higher incidence of upper extremity and shoulder problems that include thoracic outlet syndrome.
1. No treatment can be successful unless a proper diagnosis is made.
2. The patient has to find a health provider who understands and is knowledgeable in thoracic outlet syndrome.
3. The diagnosis of cervical spondylosis (pinching of nerves at the spinal level) should be ruled out or ruled in, thoracic outlet syndrome is at times associated with cervical spondylosis.
4. The presence of depression has to be ruled out (depression may result in a slouching posture).
5. Posture. Posture. Posture!!! The realization by the patient of the importance of a proper posture is paramount to the treatment of thoracic outlet syndrome.
6. Physical therapy, but by a professional who can apply the proper techniques and exercises to the treatment.
7. Analgesics (pain medicines). Try to avoid taking narcotics (opiolds). Tylenol, Advil, Motrin, Naprosyn, Relafen and other non-steroid analgesics should be used. Discuss with your own health provider the possible side effects.
8. Perseverance is needed, don't expect to be free of symptoms very quickly. The nonsurgical treatment may take months.
9. Stop any repetitive motion activity or work; or arrange for a light schedule for four to eight weeks to let healing take place.
10. Surgical treatment is the last resort.
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