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Thoracic outlet syndrome

Thoracic outlet syndrome is a rare condition that involves pain in the neck and shoulder, numbness and tingling of the fingers, and a weak grip. The thoracic outlet is the area between the rib cage and collar bone.

Causes, incidence, and risk factors

Blood vessels and nerves coming from the spine or major blood vessels of the body pass through a narrow space near your shoulder and collarbone on the way to the arms. Sometimes, there is not enough space for the nerves to pass by or through the collarbone (clavicle) and upper ribs.

Pressure (compression) on these blood vessels or nerves can cause symptoms in the arms or hands. Problems with the nerves cause almost all cases of thoracic outlet syndrome.

Pressure may happen if you have:

  • An extra rib, above the first one
  • An abnormal tight band connecting the spine to the ribs.

People with this syndrome often have injured the area in the past or overused the shoulder.

People with long necks and droopy shoulders may be more likely to develop this condition because of extra pressure on the nerves and blood vessels.

Symptoms

Symptoms of thoracic outlet syndrome may include:

  • Pain, numbness, and tingling in the pinky and ring fingers, and the inner forearm
  • Pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse)
  • Signs of poor circulation in the hand or forearm (a bluish color, cold hands, or a swollen arm)
  • Weakness of the muscles in the hand

Signs and tests

Your doctor or nurse will examine you and ask questions about your medical history and symptoms. When you lift something, your arm make turn pale.  Sometimes the following tests are done to confirm the diagnosis:

Tests are also done to rule out other problems, such as carpal tunnel syndrome or a damaged nerve due to problems in the cervical (neck) spine.

Treatment

Physical therapy is often used to treat thoracic outlet syndrome. It helps:

  • Make your shoulder muscles stronger
  • Improve your range of motion in the shoulder
  • Promote better posture

Your doctor may prescribe pain medicine.

If there is nerve pressure on a vein, your doctor may give you a blood thinner to dissolve a blood clot. This will help reduce swelling in your arm.

You may need surgery if physical therapy and changes in activity do not improve your symptoms. The surgeon may make a cut either under your armpit or just above your collarbone.

During surgery, the following may be done:

  • An extra rib is removed and certain muscles are cut.
  • A section of the first rib is removed to release pressure in the area.
  • Bypass surgery is 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.

Expectations (prognosis)

Surgery to remove the extra rib and break up tight fiber bands may ease symptoms in some patients. Surgery can be successful in more than half of patients. A few patients have symptoms that return after surgery.

Complications

Complications can occur with any surgery and depend on the type of procedure and anesthesia.

Risks related to this surgery include:

  • Damage to nerves or blood vessels, causing muscle weakness
  • Lung collapse

References

Putnam JB. Lung, Chest Wall, Pleura, and Mediastinum. In: Townsend CM, ed. Sabiston Textbook of Surgery. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 58.

Updated: 12/10/2012

Robert A. Cowles, MD, Associate Professor of Surgery, Yale University School of Medicine, New Haven, CT. Review provided by VeriMed Healthcare Network. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, and Stephanie Slon.


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