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SYMPTOMS OF TOS

What are the symptoms of the thoracic outlet syndrome?

Symptoms of thoracic outlet syndrome depend on the type of TOS, yet most of them overlap in various forms of disease.

Neurogenic TOS – nTOS

Neurogenic TOS is caused by compression of the brachial plexus. Five cervical roots branching from the spinal cord – C5, C6, C7, C8 & T1 form a complex network of nerves in the shoulder area, which is called the brachial plexus. The brachial plexus is by far the most frequently compromised structure in thoracic outlet syndrome, and this type is called neurogenic or n-TOS. There are three cardinal symptoms of n-TOS – pain, sensory and motor disturbances. Pain is by far the most frequent and consistent symptom. It is caused by brachial plexus mechanical compression/irritation. The pain is usually located in the shoulder and may radiate to the head, neck, back, armpit, chest, arm, hand, and fingers and may be constant or intermittent. Headache starting at the base of the neck, propagating to the back of the head and further to the top of the head, and sometimes all the way to the forehead and temples is quite typical for TOS patients. Sometimes, pain is located on one side of the neck and head base behind the ear or in the lower jaw.

Arm pain and chest pain are very typical for n-TOS. Sometimes, chest pain may mimic a heart attack, and patients might have a diagnostic workup for heart disease. Pain gets worse by physical activity, carrying groceries, and raising the affected arm. The costoclavicular space in between the collar bone and the first rib is the area where the nerves and vessels travel on their route to the arm. This space is narrowed by raising the arm. Thus, overhead activities such as talking on the phone usually trigger the pain. The patients, therefore, usually avoid the phone holding on the affected side or frequently pass the phone from one hand to another during long phone calls. In most cases, pain radiates from the shoulder all the way to the fingers. Since the lower part of the brachial plexus is mostly affected by the ring and pinky fingers (innervated by C8 and T1 nerve roots), involvement is very typical. However, it may cause diagnostic challenges because this area corresponds to the ulnar nerve (which is formed from C8 and T1 nerves), and physicians may wrongly diagnose ulnar nerve entrapment instead of TOS.

In addition to pain, patients frequently develop arm and hand numbness and tingling. Numbness is seldom constant and almost always in advanced cases. Intermittent numbness is typically provoked by physical activity such as grocery bag carrying is quite typical. Some patients experience morning numbness upon waking up, which may require several minutes in bed to vanish. Also, numbness is usually accompanied by the sensation of pins and needles or tingling in the arm(s) and finger(s). In some cases, patients might be unaware of numbness or its magnitude due to severe pain and might be surprised during neurological examination that pain and numbness actually coexist in the same limb.

Motor deficits or muscle weakness are initially present as early fatigue but later progress to significant weakness and wasting (atrophy), especially in the hand (Gilliatt-Sumner hand).

Venous TOS – vTOS

Venous TOS – vTOS is much more rare than n-TOS. This form of disease is caused by compression of the subclavian vein, which is the main draining vessel carrying venous blood from the upper limb back to the heart. As a result, the arm becomes congested with venous (low in oxygen) blood. Cyanosis (bluish discoloration) of the arms and fingers, limb swelling due to enlarged veins, tissue edema (fluid accumulation), and pain are the main presenting symptoms. Symptoms may diminish when the arm is raised up so blood easily flows back. However, in some cases, the vein is being compressed in between the clavicle bone and the first rib, especially when the arm is raised. In these cases, arm elevation doesn't relieve the symptoms and can even aggravate them. The Subclavius muscle running between the clavicle (collar bone) and the first rib may become hypertrophic (enlarged) and cause compression. This condition is especially common in athletes and heavy lifters. In some cases, the subclavian vein is so severely compressed that it becomes thrombosed, i.e., a blood clot develops inside it, resulting in a blood flow block. This form of v-TOS is called Paget-Schroetter disease. The clinical course may get further complicated if the clot (or part of it) dislodges from a subclavian vein and is taken up by blood flow, causing pulmonary thromboembolism. This condition is life-threatening and requires immediate intervention. Chronic subclavian vein thrombosis leads to a gradual flow decrease. Thus, compensatory collateral veins enlarge to bypass the obstructed segment. Usually, some of these collateral veins are visible in the shoulder and upper chest area.

Pain is a frequent sign in v-TOS. It might be due to venous congestion of the affected arm or concomitant neurogenic TOS. It is usually proportional to the degree of congestion, though. The pain is usually accompanied by a tingling sensation in the hands and fingers and is induced by exercise and physical activity. Muscle weakness may be also present.

Arterial TOS – aTOS

Arterial TOS – aTOS is the rarest form of TOS and is caused by compression of the subclavian artery. This artery is the main vessel supplying the arm, and blood flow decrease leads to limb ischemia (lack of oxygen). Ischemia may not be evident during resting when oxygen demand is low. However, exercise, physical activity, and working increase oxygen consumption by arm muscles, and ischemia emerges. Such inability to maintain even light physical load is called intermittent vascular claudication. In the vast majority of cases, n–TOS is also present with neurogenic claudication, further worsening the patient's condition.

Pain, tingling, paleness, early fatigue, and coldness are presenting symptoms. In some cases, a subclavian artery may get thrombosed and result in a sudden loss of blood flow to the arm. Such acute cases require immediate intervention to avoid arm gangrene. Chronic thrombosis may further narrow the artery (in addition to external compression) and facilitate ischemia. Thrombi may dislodge and travel along the blood flow toward the limb and cause arm and hand ischemia. In rare cases, thrombi may travel retrogradely into brain vessels and cause thromboembolism of brain vessels with stroke. Chronic cases may mimic and thus get misdiagnosed as Raynaud syndrome.

There is growing evidence that thoracic outlet syndrome may impede the brain's blood supply. It is believed to develop due to insufficient blood flow in the vertebral artery. Two vertebral arteries are among four vessels providing blood supply for the brain (the other two are carotid arteries). It is a branch of the subclavian artery, and any impairment of flow in the parent (subclavian) vessel may cause disturbance in the daughter (vertebral), resulting in insufficient blood supply to the brain. Although the mechanism of vertebral (or vertebrobasilar) insufficiency is poorly understood, the permanent or temporary impairment of brain blood flow in TOS is well documented. In extreme cases, the patient may present with stroke due to significant brain blood flow impairment thromboembolism. However, in the vast majority of cases, symptoms are not so severe and tend to be temporary. Exercise-induced symptoms are quite typical. Since vertebral arteries supply the brainstem, cerebellum, and back part of the brain, insufficient blood supply may result in disturbance of these brain regions. Symptoms may include dizziness, tinnitus, visual disturbances, and gait problems.

Also, cerebral hypoperfusion has been documented in TOS. Recently, it became evident that cerebral hyperperfusion might be much more common. The vertebral arteries are branching off from subclavian arteries proximal (prior to) obstruction. Once obstructions develop, the blood is diverted to vertebral arteries, causing cerebral hyperperfusion syndrome. Clinical presentation might include a sense of fullness in the head and pulsations. Headache, tinnitus, balance, and visual disturbances.

Combined symptoms

Vascular symptoms may be combined with neurogenic. In these cases, a combination of the above-mentioned symptoms may be present.

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Thoracic outlet syndrome is a condition where the space between the collarbone and the first rib narrows, compressing the nerves or blood vessels. This can lead to pain in the neck and shoulder and numbness in the fingers. Learn more about TOS in our Thoracic Outlet Syndrome section.

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Risk factors for thoracic outlet syndrome include poor posture, obesity, repetitive arm or shoulder movements, and anatomical abnormalities such as an abnormal rib or a narrow space between the shoulder and rib. Learn more in our Thoracic Outlet Syndrome section.

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The diagnosis of TOS is made in conjunction with the patient's history, symptoms, physical examination, imaging tests, and neurophysiological tests. Treatment can include physical therapy, pain management, and surgery in severe cases. Learn more about treatment options in our Thoracic Outlet Syndrome Treatment section.

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