Thoracic Outlet Syndrome

What is thoracic outlet syndrome?

Thoracic outlet syndrome occurs when the nerves or vessels (veins and arteries) to the arm are compressed as they come out of the chest, in the space between your collarbone and your first rib ( the thoracic outlet). Dr Freeman is experienced in the management of thoracic outlet syndrome and in performing surgery in appropriately selected patients.

What is neurogenic thoracic outlet compression syndrome?

The nerves to the arm may be compressed between the first rib and the clavicle because of a loss of muscle tone, bands crossing the thoracic outlet, abnormalities of the muscles in this area, extra (cervical) ribs, and fracture of the first rib or clavicle. There are particular people who are at risk including for example typists and swimmers. Most patients are in the 25- to 45-year age group and the problem is more common among women than men. The symptoms are pain, pins and needles and weakness in the arm.

Therapy for neurogenic thoracic outlet compression syndrome should always begin with non-operative treatment. This includes exercises and physiotherapy. Patients should avoid heavy lifting and working with the arm above shoulder level. Non-operative treatment should be continued for several months. Many patients will improve significantly and will not require surgery. Indications for surgery include failure of non-operative treatment after several months and persisting disabling symptoms that interfere with work and activities of daily living. The goal of surgery is to create more room for the nerves including possibly removal of any extra (cervical) rib.

What is venous thoracic outlet compression syndrome?

The vein taking blood from the arm back to the chest (subclavian vein) can become compressed and develop a blood clot (deep vein thrombosis). This can occur in young patients and is more common in men. Often it occurs during exercise, especially when the arms are above the head. Patients experience pain and swelling in the arm and the arm may turn a bluish colour due to the compression. The main concern here  is that there is a risk that a blood clot could travel to the lungs (pulmonary embolus).

Ultrasound will identify most cases of subclavian vein deep vein thrombosis. All patients will need blood thinning treatment. Some patients are suitable for insertion of a tube directly into the vein to deliver medication that will directly dissolve the blood clot. In order to improve blood flow and to create more room for the vein, once the blood clot has been dissolved the first rib may need to be removed. In some cases, the vein may also need to be repaired to prevent further blood clots in the future.

Patients who require a tube (catheter) in the chest veins for medical treatment, for example to administer chemotherapy to treat cancer or for dialysis to treat renal failure, may also develop blood clots in these veins. This is more common with larger catheters like those used for dialysis. Patients may develop swollen arms and the clots can spread to the lungs (pulmonary embolism). Treatment is with blood thinning medication and the catheter may need to be removed.

What is arterial thoracic outlet compression syndrome?

Arterial complications are often associated with bony abnormalities including an extra (cervical) rib or fracture of the first rib or clavicle. Compromised circulation to the hand can cause pain, colour changes and pins and needles. In extreme cases, if no treatment is initiated, patients are at risk of gangrene. For this reason patients with arterial thoracic outlet compression syndrome usually requires surgery to create more space for the artery and to repair the artery in order to restore blood flow to the hand.

Sydney Vascular Ultrasound provides specialised vascular and venous diagnostic imaging in Burwood, Bankstown and Liverpool.