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Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a rare condition that involves a combination of 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 collarbone.

So what are the causes of TOS?

Blood vessels and nerves coming from the spine or major blood vessels of the body pass through a narrow space near the shoulder and armpit on their way to the arms. As they pass by or through the collarbone and upper ribs, they may not have enough space. Pressure or compression on these blood vessels or nerves can cause symptoms in the arms or hands. Problems with the nerves account for almost all cases of thoracic outlet syndrome.

Compression can be caused by a number of things including an extra cervical rib (above the first rib) or an abnormal tight fibrous band connecting the spinal vertebra to the rib. Patients often have a history of injury to the area or overuse of the shoulder.

Symptoms of TOS may include pain, numbness, and tingling in the last three fingers and 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, weakness of the muscles in the hand.

The diagnosis of TOS is typically made after the doctor takes a careful history and performs a physical examination. Sometimes tests are done to confirm the diagnosis including: electromyography (EMG), MRI, Nerve conduction velocity study, and an x-ray. Tests may also be performed to make sure there are no other problems, such as carpal tunnel syndrome or a damaged nerve due to problems in the cervical (neck) spine.

There are several options when treating TOS. Physical therapy may help strengthen the shoulder muscles, improve the range of motion, and promote better posture. Treatment may also include pain medication. Conservative approaches using physical therapy are helpful for many patients.

In severe cases surgery may be recommended if physical therapy and changes in activity do not improve your symptoms. The types of surgical procedures that may be performed may include; 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 re-route blood around the compression or remove the area that is causing the symptoms. It is estimated that surgery can be successful in 50-80% of patients.