Francis Caputo, MD
Francis Caputo, MD

Tuesday, March 13, 2018 | 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 (arteries and veins) in the lower neck and upper chest area. Thoracic outlet syndrome is named for the space (the thoracic outlet) between your lower neck and upper chest where this grouping of nerves and blood vessels is found. Francis Caputo, MD answers your questions on thoracic outlet syndrome.

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Types of Thoracic Outlet Syndrome (TOS)

walterk: What is the difference between neurogenic thoracic outlet syndrome and vascular thoracic outlet syndrome? Isn’t the treatment the same?

Francis Caputo, MD: Neurogenic TOS is defined as symptoms primarily of pain numbness and potential cool hand. Vascular TOS can be broken down into venous or arterial. In venous presentation is usually with a DVT. In arterial, presentation includes blue fingers or ischemic finger with possible splinter hemorrhages or other clot preventing blood flow into the hand. Treatment for all includes decompression however vascular TOS would also treat the underlying problem in the vein or artery.

penny2795: I have been reading online about TOS and it seems there is a difference between venous and arterial TOS. I have pain and numbness in my arm/fingers. My doctor said it was TOS but did not say it was anything more than that - how is it diagnosed and is it treated differently?

Francis Caputo, MD: Pain and numbness may be indicative of neurogenic TOS. See above answer.

Causes of TOS

marghiap: I had a difficult pregnancy and delivery. My son who is now 27 was diagnosed with thoracic outlet syndrome and is requiring surgery - could that be related to difficulty giving birth at that time?

Francis Caputo, MD: Likely not unless there was some difficulties with shoulder dystocia (where the baby's shoulder gets stuck in the birth canal). More common is a mechanical obstruction from muscle development or abnormal bony arrangements.

bobbyt42: Is thoracic outlet syndrome rare?

Francis Caputo, MD:

sheila: Have you ever dealt with thoracic outlet syndrome which involves the opening to the arms being too small.

Francis Caputo, MD: In general TOS is related to the opening of the arm being too small or the bone and muscle arrangement developed in a manner that makes the space of the artery, vein or nerve too tight.

andyfromdallas: I have weakness and numbness in my right arm - my doctor states he believes it is TOS. I played a lot of tennis through high school and college - could this be related. He stated it is not a rotator cuff issue but TOS with vascular issues that will require treatment. How do I know if he is right or not?

Francis Caputo, MD: TOS is more common in people who have performed upper arms sports with repetitive movement especially with overhead movement such as tennis, volleyball, and baseball. An evaluation by a TOS specialist can identify if your diagnosis is correct.

Diagnosis of Thoracic Outlet Syndrome (TOS)

kmc67: I had 2 car accidents years ago within 6 months of each other. My lower neck, shoulder and chest bother me a lot, pain and burning. Sleeping, then waking up in morning is the worst. I have seen orthopedic doctors, sports medicine doctor recently and have had physical therapy no one has ever mentioned this syndrome to me. How do I best take care of this and get out of pain without pain pills? I do wear a neck collar sometimes because it make me feel better. Should I wear it more? What are my alternatives? Thank you.

Francis Caputo, MD: Diagnosing TOS is not easy. There is no specific testing that is useful only in thoracic outlet. Clinical findings include pain in the shoulder or arm with numbness in the fingers sometimes especially with using your arms above the shoulders. It is important to differentiate this from neck pain as treatment is different.

kmc67: I have pain lower left side of neck, sometimes burning pain and just pain that last for hours. Have resorted to a neck brace and after sleeping it is generally worse. Pain in upper chest, sometimes thought I was going to have a heart attack. No one has ever diagnosed this syndrome but physical therapy hasn't helped and don't want a lot of pain meds. I had injury in my 20's due to someone hitting my car. Lately it has been terrible. I have been told it's not arthritic, had an MRI of my shoulder area. What are my next steps and how and who gives you this diagnosis? Obviously no one I have gone to has ever mentioned it. Can it bring pain and weakness into the hand area? Thanks.

Francis Caputo, MD: See prior response. Several physicians are familiar with the diagnosis of TOS including neurologists, vascular specialists, orthopedics, and sports medicine.

sunny22: How is thoracic outlet syndrome diagnosed? How do you know it is actually TOS and not another condition?

Francis Caputo, MD: Diagnosis is based upon a careful description of the symptoms, a physical exam, and supportive testing. Experience in diagnosing thoracic outlet is helpful. It is important that all other shoulder or cervical spine diagnoses be ruled out.


klt89: I have had DVT in the past and have recently been diagnosed with thoracic outlet syndrome. I have been told to see a surgeon? Would that be a vascular surgeon? Is the DVT related?

Francis Caputo, MD: DVT in the arm is either caused by TOS or a catheter or IV line inside the vein. The management is usually under guidance of a vascular or thoracic surgeon. In the Cleveland area, it is with a vascular surgeon.

Surgery for TOS

autumn1732: When do you know that surgery is actually needed for TOS?

Francis Caputo, MD: If the TOS is vascular in nature, surgery is needed to prevent further blood vessel complications. For neurogenic TOS, surgery is usually reserved for failure of PT, other conservative measures and a patient's functional impairment. This is more likely with the presence of a cervical rib. The majority of neurogenic TOS is managed conservatively not needing surgery.

lucinda88: If you need to have surgery for TOS, what is the length of recovery? Do you expect to have full return of motion and no pain after recovery from surgery - is that an expectation?

Francis Caputo, MD: The length of recovery is variable. With return to full shoulder motion at about 1 month. I recommend most patients tell work they will be out 4-6 weeks however with flexibility at work or part time options, return may be sooner. The hope is to decrease pain and numbness especially with arm use. The results of surgery are best seen in improvement of "classic TOS symptoms”. Non classic symptoms may not always disappear or may just be less. Some patients continue to have mild symptoms however improved function.

brandon82: What are the surgical treatments of TOS? When is cervical rib removal included in the surgery?

Francis Caputo, MD: Surgical treatment involves removal of first rib as well as scalene muscles. This will not affect a patient's long term function. In my practice cervical rib is removed in all patients with TOS and presence of a cervical rib upon x-ray.

barbaraS: Ultrasound done and showed that I have Thoracic Outlet syndrome. I tried PT was unable to continue. I am scheduled for decompression surgery. Can you describe what that involves?

Francis Caputo, MD: Decompression surgery involves removing the first rib and scalene muscles from the bottom of the thoracic triangle. This is done from either an incision above your arm pit or collar bone. If there is scar tissue present around the nerves, we also remove that at the time of surgery.

Botox Treatment for TOS

charlesPK: Have you heard of Botox injections instead of surgery for TOS? Would that affect surgery if we tried that first prior to having surgery? Have already tried PT - unsuccessful. Looking for next options.

Francis Caputo, MD: Yes - Botox has been described for TOS. It is usually reserved for patients who are unable to undergo surgery. Repeat injection can lead to some scar tissue making surgery more difficult. In addition, patients are not a candidate for Botox unless they have success with temporary blocks with local anesthetic (such as lidocaine at the dentist office).

Reviewed: 08/18

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