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Thoracic Outlet Syndrome

 Dr. Robert Thompson treats patients at

Center for Advanced Medicine
Heart and Vascular Center
4921 Parkview Place, 8th Floor, Suite A
St. Louis, MO 63110

Phone:  314-747-8272     1-877-799-0909
Fax: 314-747-3548
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Question:  I’m a 25 year-old violinist with pain in my neck and shoulder and increasing numbness and tingling in my fingers. My doctor says it may be thoracic outlet syndrome (TOS). What is it and how is it treated? 

Answer:  Thoracic outlet syndrome (TOS) arises from compression of the blood vessels or brachial plexus nerves in the base of the neck, where they pass over the first rib and underneath the collarbone. Neurogenic TOS is characterized by pain and fatigue in the neck, shoulder, arm and/or hand, along with numbness and tingling extending to the hand and fingers.
 
Symptoms are typically aggravated by use of the arm, particularly in elevated positions, but may also interfere with sleep. In some, neurogenic TOS may interrupt normal daily activities or become disabling.

TOS often results from a neck or arm injury, or repetitive strain activities ranging from extensive keyboard use to heavy lifting. Abnormal postures and muscle imbalances play a role, and in some people an extra (cervical) rib may contribute to neurovascular compression.

Athletes playing overhead sports or musicians who play certain instruments can be prone to TOS.

Diagnosis of neurogenic TOS is challenging, with variable symptoms that overlap with shoulder, cervical spine, or peripheral nerve compression disorders. In most patients there is localized tenderness just above or below the collarbone and reproduction of symptoms by positional arm maneuvers.

Imaging studies and nerve conduction tests are usually negative, but help exclude other conditions. In our multidisciplinary center (www.tos.wustl.edu), we frequently use local anesthetic scalene muscle blocks to help confirm the clinical diagnosis and predict responsiveness to treatment.

Conservative treatment of neurogenic TOS helps to reduce pressure on the affected nerves, through specific exercise programs, manual therapy, and alterations in work habits. Surgical treatment is considered for those who have not improved with physical therapy and are unable to live and work comfortably.

This usually involves a lower neck incision with removal of the first rib and attached scalene muscles, as well as scar tissue surrounding the brachial plexus nerves.

Thoracic outlet decompression surgery is relatively uncommon and potentially demanding, but with appropriate patient selection and surgical experience an excellent outcome can be achieved in 85-90% of patients. For optimal diagnosis and treatment, you should seek evaluation by a specialist with dedicated expertise in the comprehensive management of TOS.
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Copyright 2014 Washington University School of Medicine
Copyright 2014 Washington University School of Medicine