Thoracic Outlet Syndrome Compensation Claims

If you’re suffering from neck, arm, and shoulder pain or numbness, it may have been suggested to you that you could be suffering from thoracic outlet syndrome (TOS). 

 

First, let’s discuss the thoracic outlet. The thoracic outlet is the ring-shaped space formed by your top ribs, below the collarbone, between the lower neck and upper chest. It’s located next to the large muscle running vertically in the neck, and in front of the muscle that extends across the back of the neck, and the bottom of the thoracic outlet extends behind the clavicle, underneath the pectoralis muscles and in front of the shoulder. This area contains a significant grouping of nerves, arteries, and veins.

When there is compression, irritation, or injury of these nerves and blood vessels, the condition is known as thoracic outlet syndrome. This is not one condition, but a group of disorders that fall under the umbrella term ‘thoracic outlet syndrome” (TOS). TOS can affect anyone, regardless of age or gender, and in fact is common among athletes whose sports require repetitive arm and shoulder movement. However, the most common form of the disorder is neurogenic TOS, and it typically affects mature women. According to recent research, TOS tends to affect women disproportionately.

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To arrive at a diagnosis of TOS, a doctor must perform a complete physical exam, along with diagnostic testing. Some cases require an evaluation by a skilled neurologist to rule out neurological conditions. Some of the diagnostic tests used to identify thoracic outlet syndrome include nerve conduction studies, vascular studies, x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and blood tests.

Symptoms of thoracic outlet syndrome include pain, numbness, tingling, and weakness in the arm, but they can vary, based on the type of TOS the patient is experiencing. There are three different types of thoracic outlet syndrome, and each has its own set of symptoms:

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Neurogenic Thoracic Outlet Syndrome

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Neurogenic thoracic outlet syndrome involves lower neck and cervical rib abnormalities that compress and irritate the nerves supplying movement and feeling to the arm and hand. Neurogenic TOS is the most common type of TOS, affecting about 95 percent of all people with thoracic outlet syndrome. The symptoms include pain, weakness, or numbness in the shoulder, arm, or hand, an arm that tires quickly, tingling in the fingers, neck pain, and pain in the back of the head. It can also cause prickling, numbness, and weakness of the neck and chest. The symptoms of neurogenic TOS are made worse when the arms are elevated. The longer the arms are held up, the worse the symptoms become.​

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Venous Thoracic Outlet Syndrome

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Venous thoracic outlet syndrome is the result of damage to the major veins in the upper chest and lower neck. Venous TOS comes on suddenly, typically after tiring and unusual arm exercise. Symptoms of venous TOS include oedema (swelling) of the fingers, hand, or arm, discolouration  of the hand or arm that causes them to become blue or dark, and a feeling of tingling, aching, or fullness in the arm. A patient with venous TOS may have noticeably prominent veins in the shoulder, neck, or hand. Venous thoracic outlet syndrome affects four percent of people with TOS, and it can result in deep vein thrombosis, as the compression of the vein can cause blood clots.​

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Arterial Thoracic Outlet Syndrome

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Arterial thoracic outlet syndrome is rare, affecting only one percent of patients with TOS. It’s the most serious type of thoracic outlet syndrome and involves compression of the main artery, caused by congenital bony abnormalities in the upper chest and lower neck. Symptoms of arterial TOS include numbness, tingling, pain, cold sensitivity, coldness, and white discolouration  in the fingers or hand. The forearm and hand may cramp with activity, and the fingers may develop pain or sores. Arterial TOS also presents with poor blood circulation to the arms, hands, and fingers, but the symptoms of this type of TOS do not extend to the neck or shoulder. It can result in an embolism of an artery in the arm or hand or an aneurysm of the subclavian artery.

Sometimes, TOS pain is confused with angina, the chest pain that occurs because of an inadequate supply of oxygen to the heart. However, the pain of angina typically increases when the patient is walking, while TOS pain does not occur or increase. Further, while TOS pain usually gets worse when the arm is raised, this is not true of angina pain.

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Thoracic outlet syndrome is caused by abnormal compression of the blood vessels and nerves in the thoracic outlet. But how does this compression occur? Sometimes it’s the result of a congenital abnormality. Some people are born with an extra cervical rib, and this increases the chance that a nerve or blood vessel will be compressed between the ribs and muscles. In other instances, an abnormal muscle in the neck, or an abnormal first rib or collarbone (clavicle) compresses the blood vessels or nerves.

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More commonly, though, TOS is caused by trauma to the neck or strenuous use of the neck or arm. Whiplash that results in persistent arm and hand symptoms could be an indication of thoracic outlet syndrome. TOS can also be caused by bodybuilding, if the muscles in the neck become too large and compress the nerves and blood vessels, repeated overhead motions, weight gain, or a tumour in the neck. Arterial TOS, however, is caused by blood clot formation due to changes in the artery, often because of an abnormality like an extra rib.

Thoracic outlet syndrome treatment is generally most effective when TOS is identified in the early thoracic outlet syndrome stages. If left untreated, it can result in serious complications, including permanent arm pain and swelling, open sores on the finger known as ischemic ulcers, gangrene, blood clots, pulmonary embolism, or permanent nerve damage.

 

In some cases, people with TOS can develop coexisting complex regional pain syndrome (CRPS), which is characterised by skin hypersensitivity, vasoconstriction in the hands and fingers, and nerve pain, or allodynia. Sometimes, CRPS can be triggered by surgery, so doctors treating patients with TOS must make careful decisions regarding surgical procedures.

 

Diagnosis of TOS needs careful consideration from a medico-legal point of view, to rule out congenital causes that do not relate to an accident. Also, your lawyer needs to understand any alternative diagnosis or at least ensure you are seen by an appropriate expert.

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Treatment of TOS differs depending on the type. Treatment can be either conservative (non-surgical) or surgical.

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• Neurogenic TOS is always treated first with physical therapy and over-the-counter pain relievers. If these measures are not completely effective at alleviating symptoms, a nerve block using injections of botulinum toxins may help. If conservative therapies fail, surgery may be recommended. Surgical treatment for neurogenic TOS involves removing pressure on the nerves of the arm/decompression by cutting muscles in the neck or removing the cervical or first rib. There is a possibility that neurogenic TOS will recur months or years after treatment particularly if there is scar tissue from the surgical site.

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• To treat venous thoracic outlet syndrome, medications are given to treat and reduce the risk of blood clots and pulmonary embolism. Anticoagulant medications reduce the risk of clot formation. Thrombolytic medications are given in the hospital, where they’re administered by injection or catheter. These drugs work to dissolve clots, and they work anywhere from hours to days after administration. After a clot has been treated, surgery is often recommended. This surgery addresses the cause of the problem by correcting the narrowing that’s affecting the vein.

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• Arterial thoracic outlet syndrome typically requires surgery. Thrombolytic medications are given before the surgery, which can involve the muscles in the neck, the cervical rib, and the first rib, or reconstruction or replacement of the artery commonly referred to as a bypass.

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Most patients with venous or arterial thoracic outlet syndrome require surgical intervention. However, these surgeries are only necessary for 10 to 20 per cent of all thoracic outlet syndrome patients. Surgery can correct the symptoms in up to 95 per cent of venous or arterial TOS cases. Decompression surgery, used for cases of neurogenic TOS, has a 50 to 70 per cent success rate. In some cases, the condition fails to respond to surgery. This is why doctors try to exhaust every other treatment measure before resorting to invasive surgical techniques for their patients with neurogenic thoracic outlet syndrome.

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