P. David Adelson, MD
Director, Barrow Neurological Institute at Phoenix Children's Hospital
Chief, Pediatric Neurosurgery at Barrow at Phoenix Children's
Director, Brachial Plexus and Peripheral Nerve Clinic at Barrow at Phoenix Children's
Thoracic Outlet Syndrome is a disorder in which the nerves of the brachial plexus and/or blood vessels in the neck are compressed as they pass from the neck to the arm. It can affect children and adults of all ages and genders.
Those who have it will typically have pain that extends down the arm, usually in the hand of the fourth and fifth fingers only, but can also involve pain in the forearm and upper arm. At Barrow Neurological Institute at Phoenix Children's Hospital, we treat children with Thoracic Outlet Syndrome with physical and pain medicine, as well as surgical treatments.
A teenage swimmer, who was having difficulties with pool workouts, came to see me.
When the teenager raised her arms above her head, they would begin to get feel numb. Exams, x-rays and tests performed by other physicians were normal.
Then she came to Barrow Neurological Institute at Phoenix Children’s Hospital.
I asked her to recreate the motions that made her symptoms occur. When she lifted her arms for a minute or two, she began to complain of a pins-and-needles feeling in her fingers and a change of temperature in her arms. When she lowered her arms, the sensations disappeared. We suspected she had Thoracic Outlet Syndrome. Imaging tests of her neck and shoulders confirmed the diagnosis of the syndrome.
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome is a relatively rare disorder in which the nerves of the brachial plexus and/or subclavian blood vessels are compressed as they pass from the neck down to the arm. This syndrome usually results from excess pressure placed on them by either muscles in the neck, called the anterior scalene muscles, or bony structures of the thoracic outlet. Patients with Thoracic Outlet Syndrome will most often complain of pain that extends down the arm usually in the hand of the fourth and fifth fingers only but can also involve the forearm and upper arm. Most times this pain may be sharp burning or aching, and cause numbness or tingling.
Thoracic outlet syndrome can affect adults and children of all ages and gender though it tends to not become prevalent until the teenage years and into adulthood. It can also develop spontaneously in middle age when it is seen more commonly in women than men because of poor muscular development and posture. It can be common amongst those who are tall and thin, as with those who have Ehlers-Danlos Syndrome. It may also affect those who participate in sports that require repetitive motions of the arms and shoulders. This includes swimmers, volleyball players and other athletes competing in baseball and weight lifting. Sports are not the only activity that may result in this syndrome. The repetitive motions required to play stringed instruments and to work in carpentry and construction can also cause Thoracic Outlet Syndrome.
Thoracic Outlet Syndrome is often diagnosed with a neurological exam in which the arm is placed in different positions so symptoms can be reproduced. This helps us determine whether the syndrome is caused by compression of the nerves of the brachial plexus (neurogenic) or by the compression of the subclavian artery or vein, which are located in the neck.
In this kind of exam, changes in sensation, motor function and adequate blood flow can sometimes be seen.
As in the case of the teenage swimmer, a neurological exam alone is not always enough to diagnose thoracic outlet syndrome. Imaging and other studies may also be necessary. X-rays and computerized tomography (CT) scans can be used to evaluate for congenital issues like the presence of cervical ribs (pictured in figures 1 and 2). Magnetic resonance imaging (MRI) can also be useful because it can show variation in the blood vessels or nerves, which is evidence of compression (pictured in figure 3).
Treatment of the syndrome most often involves physical therapy and medicines for symptomatic pain relief. However, in the 10 to 20 percent of cases that do not improve with those treatments, surgery can be used to increase the space by which the blood vessels and nerves passed through the thoracic outlet.
The outcomes of surgical treatment for Thoracic Outlet Syndrome are good, with up to 80 percent of patients experiencing improvement in symptoms.
The risks of surgery are like those of any type of intervention including lack of improvement, actual injury to the nerves being treated, bleeding, lymphatic fluid leakage, infection and anesthetic reactions. These are all uncommon, but need to be taken into consideration when deciding to move forward with surgery.
In the case of the teenage swimmer, medical and physical therapy was used, but the pain continued to worsen. She and her family decided to undergo surgery as treatment. I performed decompression with a release of the muscle in her neck that was constricting the blood vessels and nerves at her thoracic outlet. She went home the same day as surgery and immediately noticed that she no longer had significant pain, numbness and tingling that she used to get at night. Just six weeks after surgery, she returned to her activities and competitive swimming and has remained pain-free.
For children or adults with symptoms or signs that may or may not be Thoracic Outlet Syndrome, please feel free to contact Dr. Adelson at (602) 933-0975.
More about the photos:
Figure 1: Anteroposterior (AP) x-ray, which provides a picture from front to back, showing a cervical rib on the right (yellow arrow).
Figure 2: A computerized tomography (CT) scan with 3D reconstruction showing the congenital anomaly, a cervical rib with bony attachment to the first thoracic rib.
Figure 3: Magnetic resonance angiography (MRA) image showing the swimmer's arm down at the side and the arm up above the head with an arrow pointing to the compression of the subclavian artery.