The term thoracic-outlet syndrome is used to describe various compressions of the bundle of nerve vessels comprising the brachial plexus, subclavian artery, and subclavian vein. These syndromes belong to the neurovascular diseases and manifest themselves in neurological symptoms as well as those of the blood circulation. Therapeutically, the site of compression of the plexus can be permanently resolved.
What is thoracic outlet syndrome?
The neurovascular syndromes are a group of conditions that present simultaneously with neurologic symptoms and pathologic blood flow processes. Most of these syndromes are among the compression diseases and result from entrapment of nerve-vascular plexuses found in the body of every human being. One syndrome in this group is thoracic-outlet syndrome. This subgroup of neurovascular syndromes includes several phenomena that result in compression of the nerve-vascular plexus from the brachial plexus, subclavian artery, and subclavian vein. The main manifestations of the group are hyperabduction syndrome, pectoralis-minor syndrome, Paget-von-Schroetter syndrome, and costoclavicular syndrome. The vascular nerve bundle in thoracic-outlet syndrome can be both temporarily and permanently compressed. The strand travels down the neck toward the extremities and must negotiate various bottlenecks along the way. Most notably, the anterior and posterior scalenus gaps, the costoclavicular space between the rib and the clavicle, and the coracopectoral space between the coracoid process and the pectoralis muscle. At each of these narrowing points, the cord can become jammed. The symptoms depend on the location of the compression.
Causes
The vascular nerve cord of the arm can become entrapped at three narrowing sites. Compression of the structures at these sites is the primary cause of thoracic outlet syndrome. Jamming in the scalenus gap corresponds to scalenus syndrome. This subtype of the syndrome is favored by existing cervical ribs, by exostoses, or by the steepness of the upper ribs, as well as by hypertrophy of the scalenus muscles. With the latter cause, the syndrome is known as scalenus anterior syndrome. A thoracic-outlet syndrome due to a cervical rib is called cervical rib syndrome. When there is an obstruction in the costoclavicular space, the thoracic-outlet syndrome is in the form of costoclavicular syndrome. This phenomenon presents predominantly after clavicle fractures, which may cause excessive callus formation. In addition, compression in this area can occur with maximal abduction of the arm. When the cause of thoracic-outlet syndrome is entrapment of the vascular nerve bundle in the coracopectoral space, either hyperabduction syndrome or pectoralis-minor syndrome is present. The manifestations are usually due to hypertrophy of the pectoralis minor muscle. In some cases, thoracic-outlet syndrome is also associated with causative Pancoast tumors. When the vascular nerve bundle is jammed in constrictions of the subclavian vein, a special form of thoracic-outlet syndrome is present.
Symptoms, complaints, and signs
The clinical symptoms of thoracic-outlet syndrome vary with the location of the entrapment. As the vessels are entrapped, obstructions to blood flow occur. These impediments to blood flow may be evident, for example, by the arm becoming heavy and cold. The limb falls asleep, loses color or reddens in certain areas. The special form of thoracic outlet syndrome can also cause venous outflow disorders, resulting in thromboses such as those that characterize Paget-von-Schroetter syndrome. The neurological symptoms of the syndrome begin with mild sensory disturbances and end with paralysis of the entire arm. Both the sensitive and motor nerves of the arm may be jammed in the described constrictions. When only sensitive nerves are affected by compression, numbness sets in. In some circumstances, other sensory disturbances such as disturbed hot-cold sensation or abnormal pain sensation may also occur. If motor nerves are affected in addition to the sensitive nerves, this usually manifests itself in movement disorders. Muscles contract only weakly and muscle tremors may occur. Depth sensitivity may be disturbed, resulting in reduced coordination of movement and strength.Remittant symptoms and thus intermittent locking are present when the symptoms remit as soon as the patient changes posture.
Diagnosis and course of the disease
A tentative diagnosis of thoracic outlet syndrome can already be made ach the patient’s medical history. The physician can then trigger the symptomatology in a provocation test and thus confirm the suspected diagnosis. The most important tests in this context are the fist closure test and the Adson test. Diagnostics also include X-rays of the thoracic region and cervical spine. Imaging can be used to search for the exact cause of the sprain, and the condition can be assigned to a subtype. The physician uses electroneurography to detect damage to the nerve conductors in the affected area. To confirm the diagnosis, the vascular blood flow is shown in various postures of the arm as part of a duplex sonography. Patients with thoracic outlet syndrome generally have an excellent diagnosis. Complications such as thrombosis tend to be a special case.
Complications
First and foremost, those affected by thoracic outlet syndrome suffer from severe disturbances in blood flow. This can lead to disturbances in sensibility or even paralysis, which make the affected person’s everyday life much more difficult. Especially the extremities are affected by the disorders, so that they tingle or fall asleep. Furthermore, the color of the skin may also change. In most cases, the paralysis due to thoracic outlet syndrome is only temporary. Temperature perception may also be disturbed, so that the affected person can injure himself more easily or cannot assess dangers correctly. Furthermore, without treatment, there are disturbances in movement and muscle tremors. If no treatment of the thoracic outlet syndrome occurs, the paralyses may also be permanent in the worst case. Usually, the symptoms of thoracic outlet syndrome can be relieved relatively easily with repositioning of the body or the affected body region. However, in some cases, surgical procedures and various therapies are necessary to limit the discomfort. Complications do not usually occur. Life expectancy is also not limited or reduced in most cases.
When should you see a doctor?
Thoracic outlet syndrome should always be treated by a physician. In this case, self-healing cannot occur, so the affected person is always dependent on a medical examination with subsequent treatment. This is the only way to prevent further complications. The doctor should be consulted for thoracic outlet syndrome if the affected person suffers from disturbances in blood circulation. These disturbances can occur in various parts of the body and have a very negative effect on the quality of life of the affected person. Furthermore, severe paralysis symptoms may also indicate thoracic outlet syndrome. In this case, the affected person suffers from disturbances in movement and also from muscle complaints. There is trembling and severe pain in the muscles, which can occur even without exertion. If these complaints occur, the thoracic outlet syndrome must be examined by a doctor in any case. Thoracic-outlet syndrome can be detected by a general practitioner. Further treatment then depends on the exact nature and severity of the complaints and is carried out by a specialist.
Treatment and therapy
Thoracic outlet syndrome does not require further treatment in all cases. If the symptomatology is only intermittent and also subtle, there is no need for therapy. If the patient would still like to prevent the occurrence, he or she will receive tips on preventive positioning of the arms and body. In the case of more pronounced symptoms, either conservative or surgical therapy is performed. Intervention is particularly important in the case of permanent compression, since such phenomena can result in the death of nerve cells in addition to ischemia of the tissue. The conservative therapy path is usually suitable only for less pronounced manifestations of the disease and consists mainly of physiotherapeutic steps. In addition to manual grips, active exercises to strengthen the shoulder girdle and massages of the region, the conservative therapy path includes heat applications that condition a loosening of the muscles.In the case of a pronounced thoracic outlet syndrome, the surgical measures correspond to an invasive removal of the causative constriction. This removal may correspond, for example, to the removal of a cervical rib. Surgery is followed by physical therapy.
Prevention
Various forms of thoracic outlet syndrome can be prevented by postural training and relaxation techniques, which result in relaxation of the muscles and thus a reduction in any narrowing.
Aftercare
Aftercare for thoracic outlet syndrome depends on the type of treatment and any secondary conditions that have developed because of the thoracic outlet syndrome. Surgical treatment of thoracic outlet syndrome should always be followed by intensive rehabilitative physiotherapy. The focus is on remobilization of the shoulder and restoration of normal functioning of the shoulder and shoulder girdle muscles. Accordingly, physiotherapy should consist of heat treatments, massage applications, and muscle strengthening exercises. If thoracic outlet syndrome could be completely cured, no further follow-up treatment is required. If chronic pain remains after treatment of thoracic outlet syndrome, additional pain management may be considered. In addition to the administration of painkillers, this also includes physiotherapeutic measures that should reduce the pain in the muscles, arm and shoulder by increasing mobility. Primarily, however, pain relief for persistent pain after treatment of thoracic outlet syndrome must be medication. If necessary, the use of opioids (tilidine) can be considered here. In this case, the liver and kidney function values must also be checked regularly in the blood in order to be able to detect a reduction in organ activity resulting from the therapy with opioids at an early stage and to be able to take countermeasures. In addition, alcohol consumption must be avoided for life in this case, as it can cause additional damage to the liver and kidneys.
What you can do yourself
The therapy of thoracic outlet syndrome can be supported by some measures. Physiotherapy treatment is accompanied by appropriate gymnastics. The sports physician or physiotherapist can suggest appropriate exercises to strengthen the shoulder girdle muscles. Sports activity may be gradually prolonged, provided that the thoracic-outlet syndrome heals as desired. The use of massage is used to loosen the muscles. Patients may self-massage or seek professional massage to relieve discomfort. In addition, heat applications counteract the hardening. The physician must monitor the self-help measures. In the case of pronounced discomfort, surgical intervention is necessary. After surgical removal of the constriction, physiotherapeutic measures are also indicated. Furthermore, the typical general measures such as rest and monitoring of the surgical wound apply. If inflammation, bleeding or pain is noticed, the physician must be consulted. Lastly, the elimination of possible reinforcers applies to thoracic outlet syndrome. Malpositions often develop, which can lead to joint wear and other complications in the long term. These physical problems must be corrected during physical therapy. In turn, the patient can support the physical therapy by targeted training of the affected regions at home.
