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Thoracic Outlet Syndrome (Dr. Clair 5/5/10)

Wednesday, May 5, 2010 – Noon


Thoracic outlet syndrome (TOS) is a term used to describe a group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels in the lower neck and upper chest area. Making a proper diagnosis is the most important step in TOS. Although many cases of TOS can’t be prevented, the condition is treatable. Dr. Daniel Clair, Chairman of the Department of Vascular Surgery at Cleveland Clinic answers questions about the diagnosis and treatment of TOS.

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Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Daniel Clair. We are thrilled to have him here today for this chat. Thank you for joining us Dr. Clair. Let’s begin with the questions.

Speaker_-_Dr__Daniel_Clair: thank you for having me today.

Thoracic Outlet Syndrome (TOS) Symptoms

Donna: My main question is what are symptoms of TOS and what can cause it? I was in a moderate auto accident several years ago and had several diagnoses, one of which was TOS when my left arm had numbness coming and going. (I used my left arm to brace myself during the accident and doctors stated I probably injured my neck by doing this). The accident was a rear end crash with me in the front passenger location and hit from behind. The only treatment suggested was some pretty radical surgery and I opted not to do it. I don’t have severe symptoms but what should a PCP know about this and what should be watched as progressive deterioration, if in fact, that occurs?

Speaker_-_Dr__Daniel_Clair: The main symptoms involve compression of the vein or artery or irritation of the nerves that supply the arm. These are usually related to nerve and bony structures in the thoracic outlet. It is not unusual for these symptoms to begin to manifest after a traumatic injury.

It is often not easy to diagnose as there is no TOS test. Many PCPs will not know about it or understand it. You should have a formal evaluation by some one experienced in dealing with this problem to determine if this is the source of your discomfort. There are exercises that can be done which can help with symptoms in as many of 70% of people.

stimpysan: I had a spinal fusion C6-C7 in 2006 with complications since. Was diagnosed with TOS in 2008 in my left arm which was the same arm that went numb with the disc herniation. Last month I was rediagnosed with TOS by a cardiologist and thoracic surgeon after having atrial fibrillation problem. All testing said my heart is O.K. My question is can TOS cause major pain starting in your left tricep, going up over your shoulder, across your chest to your sternum while your sleeping only. If I get up and move around it usually goes away in a few minutes. It will be sore then for hours.

Speaker_-_Dr__Daniel_Clair: The answer to your question is Yes - it can cause these symptoms - and you may have this condition - however I would recommend an evaluation by a physician who specifically treats TOS.

stimpysan: could you explain to my wife some of the symptoms of TOS and how badly it can affect your way of life. I look OK to her but she can't understand how overwhelming the pain can be. I think that is the worst thing about having this , is that most doctors don't understand it or believe in it.

Speaker_-_Dr__Daniel_Clair: Anyone who deals with patients with this problem can tell you that in certain situations the disability can be dramatic and affect almost every aspect of a patient’s life. You are correct - while on the inside the patient may look fine, they can suffer tremendously from this problem.

sam_w: I have TOS and pain in my right shoulder and numbness in my right arm – but I also get numbness and pain sometimes in my leg too – is this from the same thing?

Speaker_-_Dr__Daniel_Clair: It is unlikely that your leg discomfort is related to TOS.

Exercises, Physical Therapy and TOS

JimHatesTingling: Are there specific exercises a person can do at home to help alleviate the numbness in arms at night?

Speaker_-_Dr__Daniel_Clair: We have exercises that we provide our patients instruction on how to perform. If you are seeing a physical therapist, you should talk to them about instruction on how to perform these exercises. They are helpful in a majority of patients

JimHatesTingling: Will I ever be able to do the exercises I enjoy (i.e pushups, chinups, pullups) again?

Speaker_-_Dr__Daniel_Clair: It is possible. It depends on how severe your condition is and if the exercise or more aggressive therapy provides relief of symptoms and the ability to do the exercises you would like to do.

JimHatesTingling: My insurance only provides 30 therapy visits per year, should I try to spread them out over the year or should I try to "cure" the syndrome in one continuous program?

Speaker_-_Dr__Daniel_Clair: Initially, I would recommend several visits with a physical therapist to make sure you are doing the exercises correctly and see if you are obtaining benefit from the exercises. This could easily be achieved by 3 - 4 visits. Then perhaps further visits down the road to insure you are headed in the right direction.

If 3 - 6 months of therapy do not at least begin to resolve some of your symptoms, you should be re-evaluated by a physician who treats this disease to make sure the diagnosis is correct and also discuss more aggressive therapies than physical therapy alone.

stimpysan: are there any exercises that actually work

Speaker_-_Dr__Daniel_Clair: Yes - and in fact more than 2/3 of patients will get relief with exercise alone for neurogenic TOS.

JimHatesTingling: I've had to stop jogging because the movement in my arms and shoulders seems to aggravate the condition. Do you know of any specific exercises or equipment a person with TOS can use to maintain their cardiovascular health?

Speaker_-_Dr__Daniel_Clair: This is where physical therapy to help with the relief of symptoms may be beneficial. the reason is that the therapy is specifically aimed at increasing the space in the thoracic outlet by posture assisting exercises. Other options available for cardiovascular fitness that do not affect the shoulder as much include cycle training or spinning classes and potentially even elliptical training.

tuyrl: I have TOS with arm, shoulder back pain. Can you talk about any options for relief without surgery. What do you recommend to your patients?

Speaker_-_Dr__Daniel_Clair: Normally with neurogenic TOS my initial recommendation is for a physical therapy program which is monitored and reassessment after 3 to 6 months to determine how the symptoms are progressing.

jasont: I was diagnosed with thoracic outlet syndrome and going through PT – does this really work? I also am very tired all of the sudden and sometimes have extreme cold and sweating – is that related?

Speaker_-_Dr__Daniel_Clair: Physical therapy does work in up to 2/3 of patients in alleviating neurogenic symptoms - the other symptoms you are complaining of sound more like an infections process than symptoms of TOS. In order to fully determine whether they are related you should be evaluated by a physician.

Progress of TOS

stimpysan: Using the Ross test I have severe nerve pain in both shoulders, biceps and triceps. I loose blood flow in the left arm. I can't hold a jug of milk for more than a minute without intense pain. I have no ins. Is this only going to get worse and can it cause permanent damage?

Speaker_-_Dr__Daniel_Clair: It is possible that this may progress if this truly is TOS. The longer an individual has this problem without resolution, it does appear the more difficult complete resolution of the problem is to achieve.

There are some available online resources that offer some simple things that can be done to alleviate symptoms - these are best initiated with the assistance of a physical therapist to make sure you are doing them correctly and often can provide significant relief to individuals. At Cleveland Clinic we have financial counseling to assist those without insurance.

JimHatesTingling: Is TOS something that is chronic, am I in most likelihood going to have to deal with this the rest of my life? I'm 45)

Speaker_-_Dr__Daniel_Clair: It is somewhat of a chronic condition as the physical therapy exercises will need to be performed regularly. If symptoms persist or worsen with physical therapy then surgery may be indicated and while the success rate of surgery for neurogenic TOS is on the order of 60 - 70% for those who obtain relief from surgery, it is usually lifelong and sustained.

Diagnostic Testing of TOS

gina: Is there any diagnostic testing recommended to rule in or out TOS? CT scan or MRI?

Speaker_-_Dr__Daniel_Clair: Yes. We usually will want to confirm the absence of potential alternative diagnoses such as cervical spine spondylosis or cervical radiculopathy as potential causes of the discomfort. We normally will utilize duplex ultrasound to assess the artery or vein in both symptomatic and asymptomatic positions.

Finally, there are some evaluations which can be done during a physical exam to help assess where the problem is and how it may be dealt with.

rudygalindo: I have been told that the Neo Vista MRI is the best to look at the anatomy and diagnose TOS. I am looking for a center that has this. Do you have this at Cleveland Clinic and what do you think about this type of diagnostic test?

Speaker_-_Dr__Daniel_Clair: Unfortunately, there is no single diagnostic test that can determine if you have TOS or not. The assessment still involves an experienced clinician to fully make the determination.

Medications and TOS

stimpysan: what would you recommend for OTC pain relievers for TOS

Speaker_-_Dr__Daniel_Clair: Not knowing your medical doctor, I would recommend you discuss this with your doctor what options are available to you without drug interactions. Obviously Tylenol and drugs like Motrin or Aleve can be utilized to provide some relief.

sereneblue: Can you talk about the role of Botox injections in TOS. I have read they are helpful but also dangerous.

Speaker_-_Dr__Daniel_Clair: These injections are early in the evaluation process and the results at least from my understanding have been mixed.

Arterial Thoracic Outlet Syndrome

carolee: Does arterial TOS always require surgery?

Speaker_-_Dr__Daniel_Clair: Arterial TOS is the least common type and nearly always requires surgical intervention to treat the problem.

I would like to expand on this however as although arterial TOS does involve compression of the artery - simply having compression of the artery in your arm in an over-extended position does not necessarily mean you have arterial TOS. Most often arterial TOS involves anatomic or structural defects of the artery related to this compression. In this situation, surgery is most often required.

Thoracic Outlet Syndrome Surgery

mike: Can they do minimally invasive or robotically assisted surgery for TOS?

Speaker_-_Dr__Daniel_Clair: Robotic surgery has been utilized to treat TOS. In the initial experience with this approach - it involves an intra-thoracic approach to the first rib. There appears to be an increased length of stay and increased post operative pain. For this reason , we have continued to use standard approaches to rib resection. We are exploring alternatively minimally invasive approaches to traditional surgery.

jj143: What does surgery for arterial TOS involve? Is there a big incision? What is the recovery like?

Speaker_-_Dr__Daniel_Clair: That really depends on what the extent of your arterial damage is. the less significant the injury to your artery - the less aggressive surgical treatment is and visa versa.

786retwu: I am having surgery for TOS in a few weeks and wonder if there are any helpful tips you can provide to help me through this surgery. Even though I have had symptoms for over two years and the thought of feeling better is very appealing, I am nervous about the surgery itself and recovery.

Speaker_-_Dr__Daniel_Clair: It sounds like you’re having surgery for neurogenic TOS. It is important to remember that the surgery is not always successful in alleviating pain completely. It is also important to remember that immediate and complete relief of pain may not be achieved although the surgery was successful. In other words it may take some time for you to achieve the significant relief of symptoms.

The recovery should be associated with continual physical therapy to assist with gradual increase in arm activity and strengthening to assure that you have slow and progressive recovery following this. We generally start people in physical therapy early in the recovery.

smiath4: I am confused as to when you need a thoracic surgeon vs. a vascular surgeon for TOS? Who do you go to for treatment of neurogenic thoracic outlet syndrome?

Speaker_-_Dr__Daniel_Clair: What you really need is to assure you are dealing with a surgeon that has significant experience in dealing with this problem - that is the most important qualification when choosing a surgeon.

123y765: Can you talk about the success of surgery for TOS, specifically decompression surgery?

Speaker_-_Dr__Daniel_Clair: The success rates vary tremendously depending on the underlying type of TOS. The patient enjoys a greater than 90% success rate for venous TOS. While, the results for neurogenic TOS are not as optimistic with success rates of about 60 - 70% even in experienced hands.

pamela: When do they decide to remove a rib or not – is it based on surgeon preference?

Speaker_-_Dr__Daniel_Clair: There are surgeons who advocate scalene muscle removal without first rib removal as an adequate surgical decompressive therapy. In most series evaluating this, recurrence rates are higher when the rib is not removed. The majority of surgeons who treat patients for this problem extensively combine removal of the scalene muscle, first rib resection and freeing up of scar tissue in the region in order to deal with this problem. Removal of the rib results in no cosmetic or functional disability compared with muscle removal alone and for that reason, the surgery often involves rib removal.

Sleep and Thoracic Outlet Syndrome

JimHatesTingling: Can the firmness of a sleeping mattress have impact on symptom severity?

Speaker_-_Dr__Daniel_Clair: There are a number of things about how one sleeps that can affect symptom severity - mattress, pillow, sleeping position have all been associated in some way with symptoms severity by different patients. What works for you may not work for someone else.

JimHatesTingling: The biggest aggravation to me is the interruption of sleep. I can live with pain and even the tingling, but to be constantly woke at night is not ignorable.

Speaker_-_Dr__Daniel_Clair: I agree. In some instances the physical therapy can help not only while you are awake but also help alleviate some symptoms at night.

JimHatesTingling: So is my problem atypical? I rarely have issues during the day, but the more active I am in the day, the more severe my symptoms are at night...

Speaker_-_Dr__Daniel_Clair: That is actually fairly typical of people with any neurogenic problem.

Thoracic Outlet Syndrome and Other Conditions

Maggie02: Does TOS have anything to do with herniated thoracic discs and the pain generated from that?

Speaker_-_Dr__Daniel_Clair: Sometimes TOS is misdiagnosed as a herniated disc usually in the cervical region but the presence of a disc rupture does not cause TOS.

stimpysan: when I take my blood pressure in my left arm it fells like the muscle collapses and the readings sometimes are much higher than the right. Can TOS cause this?

Speaker_-_Dr__Daniel_Clair: What you have sounds extremely unusual - it is not clear to me that your left arm is elevated in pressure as much as it sounds like your right arm may have decreased blood pressure. I would suggest an evaluation by a physician to address this issue.

beauty34: Is arterial TOS a risk factor for stroke?

Speaker_-_Dr__Daniel_Clair: Not that I am aware of.

karenrathr: I have migraines and thoracic outlet syndrome. Would surgery stop this?

Speaker_-_Dr__Daniel_Clair: It is possible that headaches may be related to TOS. It would be impossible to guarantee - in particular migraines - would be relieved with TOS surgery.

JimHatesTingling: My doctor did not originally diagnose my TOS, as someone previously stated, I too have a herniated disk in my neck. It was my PT that diagnosed it from a suggestion by my chiropractor. How would one diagnose between the two types?

Speaker_-_Dr__Daniel_Clair: There are tests which can specifically assess for cervical disc disease or cervical myelopathy or radiculopathy vs. TOS.

Other Questions about Thoracic Outlet Syndrome

sarahc: I have been thinking about massage to help with pain relief but wonder if it will cause harm if I have thoracic outlet syndrome.

Speaker_-_Dr__Daniel_Clair: There is no evidence that massage therapy will cause damage as long as it is performed carefully.

Maggie02: where exactly is the thoracic outlet?

Speaker_-_Dr__Daniel_Clair: Behind the clavicle and over the top of the first rib that sits behind the clavicle. There is an image on our website -

JimHatesTingling: Do you know of any support groups for TOS?

Speaker_-_Dr__Daniel_Clair: the American TOS Association - * has forums, communities and support groups

Other Questions

witter123: I am 74 yr old with a 4.5 cm mid-ascending aorta dilation. Had this artery replaced with a homograft in 2001. I have CHF stage C, NYHA III, clear lungs, BNP less than 300, no swelling legs/feet, no CAD, major organs ok. Will I still be a candidate for open chest surgery to fix this if the dilation continues to grow? Prior surgery was done at CCF.

Speaker_-_Dr__Daniel_Clair: Although this is not a TOS question - the answer is YES - you would be a candidate for surgery and you should be carefully followed by a cardiologist or surgeon who can deal with this problem. If you are interested - please call our Resource Line and we can help you find a physician - 866-289-6911.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Clair is now over. Thank you again Dr. Clair for taking the time to answer our questions about TOS.

JimHatesTingling: Thank you Dr. Clair!

Speaker_-_Dr__Daniel_Clair: Thank you for having me today.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 05/10

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