Thoracic outlet syndrome in a Maryland Worker’s Compensation case.

What is Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a condition caused by compression of nerves or blood vessels in the thoracic outlet, the area between the base of the neck and the armpit, including the front of the shoulders and chest.

There are three types of TOS:

  1. Neurogenic (neurological) thoracic outlet syndrome. Characterized by compression of the brachial plexus. The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensation in your shoulder, arm and hand. The nerves become compromised from an extra cervical rib, present at birth.
  2. Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome occurs when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) under the collarbone (clavicle) are compressed.
  3. Nonspecific-type thoracic outlet syndrome. This type is also called disputed thoracic outlet syndrome. Some doctors don’t believe it exists, while others say it’s a common disorder. Symptoms are chronic pain in the area of the thoracic outlet that worsens with activity, but a specific cause of the pain can’t be determined. There is no neurological deficit but patients experience neurological symptoms and pain. Typically, these patients’ electrodiagnostic studies (ENG / NCV) are normal.

Thoracic outlet syndrome

Causes of Thoracic Outlet Syndrome

Thoracic outlet syndrome is caused by an enlargement or change of the tissues in or near the thoracic outlet. Causes of enlargement of the tissues may include:

  • Trauma or injury- The most frequent cause is trauma, either sudden (as in a clavicle fracture caused by a car accident or those suffering from neck injuries), or repetitive occupations involving lots of lifting of the arms and repetitive use of the wrists and arms or repetitive stress injury (RSI) caused by certain types of work environments.
  • Weight lifting
  • Cervical rib (an extra rib extending from the neck present at birth)
  • Weight gain
  • Growth of a tumor

Symptoms of Thoracic Outlet Syndrome

Thoracic outlet syndrome may include the following symptoms:

  • Neck, shoulder, and arm pain
  • Numbness in the arm, hand or fingers
  • Impaired circulation to the extremities (causing discoloration)
  • Weakness in the shoulders, arm and hands

Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed. When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome include:

  • Muscle wasting in the fleshy base of your thumb
  • Numbness or tingling in your arm or fingers
  • Pain or aches in your neck, shoulder or hand
  • Weakening grip

Signs and symptoms of vascular thoracic outlet syndrome can include:

  • Discoloration of your hand (bluish color)
  • Arm pain and swelling, possibly due to blood clots
  • Blood clot in veins or arteries in the upper area of your body
  • Lack of color (pallor) in one or more of your fingers or your entire hand
  • Weak or no pulse in the affected arm
  • Cold fingers, hands or arms
  • Arm fatigue with activity
  • Numbness or tingling in your fingers
  • Weakness of arm or neck
  • Throbbing lump near your collarbone

How do you test for Thoracic Outlet Syndrome?

Several tests are used to detect thoracic outlet syndrome and determine how to treat it:

  • Computed tomography (CT) scan
  • Magnetic resonance imagining (MRI)
  • arteriography or venogram
  • Stress maneuver testing—placing the arm or head in certain positions—may be done with any of the above tests.
  • An anesthetic block injection can temporarily improve symptoms and aid diagnosis.

Thoracic outlet syndrome

Treatments for Thoracic Outlet Syndrome

Ice can be used to decrease inflammation. Heat can also relieve sore muscles by improving blood circulation to them.

Physical therapy, stretching, acupuncture, and chiropractic adjustment, are common non-invasive approaches used in the treatment of Thoracic Outlet Syndrome. The goal of stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, or tendons that are causing the problem.

Medication-Botox was compared to a placebo injected into the scalene muscles. No effect in terms of pain relief or improved movement was noted. However, in a six-months follow-up, paresthesia (abnormal sensations such as in pins and needles) was seen to be significantly improved.

Injections with nerve blocking agents to suppress pain and reduce swelling and compression.

Surgery when the other treatment does not provide relief..- Surgical approaches have also been used successfully in TOS.

Microsurgery can be used approaching the area from above the collar bone (supraclavicular) followed by neurolysis of the brachial plexus, removal of the scalene muscle (scalenectomy), and the release of the underlying (subclavicular) blood vessels.

In cases where the first rib (or a fibrous band extending from the first rib) is compressing a vein, artery, or the nerve bundle, part of the first rib and any compressive fibrous tissue, can be removed in a first rib resection surgical procedure; scalene muscles may also need to be removed (scalenectomy). This allows increased blood flow and the reduction of nerve compression. In some cases, there may be a rudimentary rib or a cervical rib that can be causing the compression, which can be removed using the same technique.

Best results come from a combination of medical treatment and physical therapy. Specifics will vary depending on the source of the condition.

Nerve Related

  • Specialized physical therapy and injections to relieve muscle spasm may resolve your symptoms.
  • If symptoms are severe and persist and you are a good candidate for surgery, a procedure called thoracic outlet decompression is the next step.
  • If surgery is not suitable for you or does not relieve your symptoms, you will want to consider ongoing medication to manage pain.

Artery related

  • If arterial compression is diagnosed, a surgery called thoracic outlet decompression is the next step. Depending on the damage to the artery, an arterial bypass may be part of this surgery.

Vein Related

  • If arm swelling or a blood clot in the vein is due to thoracic outlet compression, thoracic outlet decompression is the next step.
  • If there is a clot in the vein, you may be directed to have thrombolytic therapy.
  • You may also benefit from some type of vein reconstruction: angioplasty, patch angioplasty, or venous bypass

Issues peculiar to Maryland Workers Compensation cases.

  1. Back in the 1980’s and 1990s Thoracic Outlet Syndrome became a disfavored diagnosis and the surgery was often not authorized. Back then multiple surgeries were usually done to treat each symptom. After five or six surgeries the clients were often worse off and likely permanently and totally disabled and this diagnosis lost favor at the commission. More recently, the treatments have been more conservative and usually involve one surgery and the clients seem to be improving and the workers compensation commission has been more open to this diagnosis and the treatment
  2. If the electrodiagnostic studies (ENG / NCV) are normal, insurance company doctors will opine that the client does not have Thoracic Outlet Syndrome however this does not exclude the diagnosis. Vascular studies seem to be the accepted diagnostic test at this time
  3. Symptoms can be similar to symptoms of shoulder, hand or neck injuries so agreeing to this surgery without exhausting these other possibilities could result in having an unnecessary surgery.
  4. Thoracic Outlet Syndrome can be caused by other means other than trauma. In occupational disease claims there may be a defense that the Thoracic Outlet Syndrome is an aggravation of an underlying condition and under the Blake case would not be a compensable occupational disease.

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