Thoracic outlet syndrome ( TOS ) is a condition in which there is compression of nerves, arteries, or veins in the passage from the neck down to the armpit. There are three main types: neurogenic, venous, and arterial. The neurogenic type is the most common and comes with pain, weakness, and sometimes muscle loss at the base of the thumb. This type of vein causes swelling, pain, and perhaps a bluish tint on the arm. The type of artery causes pain, coldness, and pallor of the arm.
TOS may occur due to trauma, repetitive arm movement, tumor, pregnancy, or anatomical variations such as cervical ribs. Diagnosis may be supported by studies of neural conduction and medical imaging. Other conditions that can produce similar symptoms include rotator cuff tears, cervical disk disorders, fibromyalgia, multiple sclerosis, and complex regional pain syndromes.
The initial treatment for the neurogenic type is by exercising to strengthen the chest muscles and improve posture. NSAIDs such as naproxen can be used for pain. Surgery is usually performed for arterial and venous types and for neurogenic types if they do not improve with other treatments. Blood thinners can be used to treat or prevent blood clots. This condition affects about 1% of the population. This is more common in women than men and it most often occurs between 20 and 50 years. This condition was first described in 1818 and the term "thoracic outlet syndrome" was first used in 1956.
Video Thoracic outlet syndrome
Signs and symptoms
TOS mainly concerns the upper limbs, with signs and symptoms manifesting on the shoulders, neck, arms and hands. Pain may be present intermittently or permanently. Can be sharp/piercing, burning, or ill. TOS can only involve the hands (as in the little finger and the adjacent half), all the hands, or the inner aspect of the forearm and upper arm. Pain may also be on the side of the neck, pectoral area below the clavicle, armpit/axilla area, and upper back (ie, trapezius and rhomboid areas). Changes in the color of the hand, one hand is colder than the other, muscle weakness of hands and arms, and tingling is usually present.
TOS is often the main cause of upper refractory limb conditions such as frozen shoulder syndrome and carpal tunnel that often oppose standard treatment protocols. KL can be associated with a Forward head posture.
The painful, swollen and blue arms, especially when they occur after severe physical activity, may be the first sign of subclavian venous compression associated with unknown and complicated TOS by thrombosis, Paget-Schroetter syndrome or so-called -induced thrombosis.
TOS may be associated with cerebrovascular artery insufficiency when it affects the subclavian artery. It may also affect the vertebral artery, in which case it may produce visual impairment, including temporary blindness, and cerebral embolism.
TOS may also cause eye problems and vision loss as a state of vertebral artery compression. Although very rare, if brainstem compression is also involved in individual KL presentation, temporary blindness can occur when the head is held in a certain position. If left untreated, TOS may cause neurologic deficits as a result of hypoperfusion and hypometabolism of certain areas of the brain and cerebellum.
Maps Thoracic outlet syndrome
Cause
TOS can be attributed to one or more of the following factors:
- Congenital abnormalities are often found in people with TOS. These include cervical rib, prolonged transverse process, and muscle abnormalities (eg, in the anterior scalenus muscle, scalenus-shaped scalenus medius) or fibrous connective tissue anomalies.
- Trauma (eg, whiplash injury) or repetitive stretching is often implied.
- Less common causes include tumors, hyperostosis, and osteomyelitis
Diagnosis
Adson's sign and costoclavicular maneuvers lack specificity and sensitivity and should consist only of a fraction of the mandatory comprehensive history and physical examination performed with patients suspected to have TOS. There are currently no single clinical signs that make the diagnosis of TLC with any degree of certainty.
Additional maneuvers that may be abnormal to the TOS include Wright's Test, which involves hyperabducting the upper arm with multiple extensions and evaluating the loss of radial pulsation or signs of skin blanching in the hand indicating decreased blood flow by maneuver. "Compression test" is also used, using pressure between the clavicle and the medial humerus head causing pain and/or numb radiation to the affected arm.
Doppler arteriography, with probes at the fingertips and arms, tests the strength and "smoothness" of blood flow through the radial artery, with and without the patient performing various arm maneuvers (which causes compression of the subclavian artery at the thoracic outlet). The movements can cause symptoms of pain and numbness and produce graphs with reduced arterial blood flow to the fingertips, providing strong evidence of impingement of the subclavian artery in the thoracic canal. Doppler arteriography does not use a probe at the fingertips and arms, and in this case it is likely to be confused with plethysmography, which is a different method of using ultrasound without direct visualization of the affected vessels. It should also be noted that Doppler ultrasound (not really 'arteriography') will not be used in the radial artery to make a diagnosis of TOS. Finally, even if the Doppler study of the appropriate artery should be positive, it will not diagnose neurogenic TOS, by far the most common TOS subtype. There is considerable evidence in the medical literature to show that arterial compression is not the same as compression of the brachial plexus, although they can occur simultaneously, in varying degrees. In addition, arterial compression by itself does not make the diagnosis of arterial TOS (the rarest form of TOS). Lower arterial compression rates have been shown in normal individuals in various arm positions and are considered not as important without the other criteria for arterial TOS.
Classification
Based on affected structure and symptomatology
There are three main types of TOS, named after the cause of symptoms; however, these three classifications become disliked because TOS can involve all three types of compression to varying degrees. Compression can occur in three anatomical structures (arteries, veins and nerves), can be isolated, or, more commonly, two or three structures compressed to a greater or lesser degree. In addition, the compression force may vary in magnitude in each affected structure. Therefore, the symptoms may vary.
- Neurogenic TOS includes interference produced by compression of brachial plexus nerve components. The neurogenic form of TOS accounts for 95% of all KL cases.
- TOS artery is caused by compression of the subclavian artery. This is less than one percent of cases.
- Venous TOS is due to subclavian venous compression. This means about 4% of cases.
Based on the event
There are many causes of TOS. The most common cause is trauma, either suddenly (as in clavicle fractures caused by car accidents), or recurrent (as in the legal secretary who works with his hands, wrists and arms at a fast-paced table station with ergonomic posture for many years -year). KL is also found in certain occupations involving multiple arms removal and repeated use of the wrist and arm.
One cause of arterial compression is trauma, and recent cases involving clavicle fractures have been reported.
The two groups of people most likely to develop TOS are those who suffer neck injuries due to traffic accidents and those who use computers in non-ergonomic posture for long periods of time. KL is often a recurring stress injury (RSI) caused by a particular type of work environment. Other groups that may develop TOS are athletes who often lift their arms overhead (like swimmers, volleyball players, dancers, badminton players, baseball pitchers, and weightlifters), rock climbers, electricians who work long hours with their hands on over their heads, and some musicians.
With the structure that causes the narrowing
It is also possible to classify TOS based on the location of the obstruction:
- Anterior scalena syndrome (compression of the brachial plexus and/or the subclavian artery caused by muscle growth).
- Cervix rib syndrome (compression of the brachial plexus and/or subclavian artery caused by bone growth).
- Costoclavicular syndrome (narrowing between the clavicle and the first rib) - is diagnosed by costoclavicular maneuvering.
Some people are born with incomplete and very small extra ribs above their first rib, which extends out into the superior thoracic outlet chamber. These raw ribs cause fibrous changes around the brachial plexus nerve, induce compression and cause symptoms and signs of TOS. This is called the "cervical rib" because of its attachment to C-7 (the 7th cervical vertebra), and surgical removal is almost always recommended. The symptoms of TOS may appear first in early adolescence when a child becomes more athletic.
Treatment
The evidence for treatment of chest outlet syndrome in 2014 is poor.
Physical measurements
Stretching, occupational and physical therapy is a common non-invasive approach used in KL treatment. The purpose of stretching is to reduce compression in the thoracic cavity, reduce blood vessels and nerve impregnation, and realign bones, muscles, ligaments, or tendons that cause problems.
- One commonly-stretched stretch includes moving the shoulders anteriorly (forward - called "bending"), then returning to neutral position, then returning it backwards (called "curved"), then returning to neutral , followed by shrugging as high as possible, and then returning to neutral, repeated in a cycle as tolerated.
- Another set of stretches involves tilting and lengthening the neck opposite the injured side while keeping the arm wounded down or wrapped around the back.
- Occupational or Physical Therapy may include passive or active range of motion exercises, work up to a weighted or limited set (as tolerated).
- Physical therapy usually consists of the mobilization of all or all of the articulation of the shoulder belt, including the first rib, additional miofascial release (MFR) or Active Release Technique (ART) to the connected muscles, and passive or active use. range of motion exercises.
- The nerve launch can be done by extending the injured arm with the fingers straight sideways to the side and tilting the head to both sides. A tender, tender feeling is commonly felt on all sides of the wounded. Initially, just do this and repeat. After this exercise is mastered and no tremendous pain is felt, start stretching your fingers back. Repeat with a variety of variations, tilting the hand up, back, or down.
TOS is quickly exacerbated by bad posture. Active breathing exercises and ergonomic desk settings and movement practices can help maintain active posture. Often the muscles in the back become weak because of prolonged (year) "bending" and other bad posture.
Ice can be used to reduce muscle inflammation that is sick or injured. Heat can also help relieve muscle pain by improving blood circulation to them. While the entire arm is generally painful in the TOS, some help can be seen when ice or heat is intermittently applied to the thoracic area (the neck, armpit, or shoulder blades).
Drugs
In the review, botox was compared with placebo injected into the scalena muscles. No effect in case of pain reliever or increased movement recorded. But within six months of follow-up, paresthesia (abnormal sensations such as on pins and needles) was seen to increase significantly.
Surgery
Surgical approach has also been successfully used in TOS. Microsurgery can be used near the area from above the collarbone (supraclavicular) followed by brachial plexus neurolysis, scalena muscle lift (skrupenectomy), and subclavicular release of blood vessels. This approach avoids the use of resection, and has been found to be an effective treatment. In cases where the first rib (or a fibrous rib extends from the first rib) compresses the vein, artery, or nerve file, part of the first rib and any fibrous tissue, may be removed in the first rib resection surgical procedure; the scalena muscles may also need to be removed (scalenectomy). This allows increased blood flow and reduced nerve compression. In some cases there may be an imperfect rib or cervical rib that can cause compression, which can be removed using the same technique.
Physical therapy is often used before and after surgery to improve recovery times and results. Potential complications include pneumothorax, infection, loss of sensation, motor problems, subclavian vessel damage, and, as in all operations, very little risk of serious permanent injury or death.
Famous cases
Several Major League Baseball players, notably pitchers, have been diagnosed with thoracic outlet syndrome, including San Diego Padres who started pitcher Tyson Ross, San Diego Padres started Richard Clayton pitcher, Cincinnati Reds started throwing Matt Harvey, Kansas City Royals pitcher Luke Hochevar, San Diego Reverend Padres Shepherd Phil Hughes, Atlanta Braves started throwing Mike Foltynewicz, St. Louis Cardinals started throwing Chris Carpenter and Jaime Garcia, formerly three-time SP star Josh Beckett, former SP Shaun Marcum, Philadelphia Phillies SP Matt Harrison, MLB pitcher Clayton Richard, and former SP Noah Lowry Giants. Started pitcher Chris Young, who previously struggled with a shoulder problem, underwent surgery for TOS in 2013 and felt "completely different" after the recovery. Young exceeded expectations while returning to the premier league at the age of 35, becoming a valuable member of the Seattle Mariners 2014 preliminary rotation. New York Mets began pitcher Matt Harvey announced on 7/8/2016 that he chose to have a season-ending operation for KL after saying "his shoulder is dead, his arm is dead, that there is no energy there and that he can not feel the ball "after his last start.
Musician Isaac Hanson has pulmonary embolism as a consequence of chest outlet syndrome.
UFC fighters Matt Serra has ribs taken to reduce TOS, as well as singer Tamar Braxton.
Boston Bruins defenseman Adam McQuaid was diagnosed with KL in September 2012, and as a result was nominated for the Bill Masterton Memorial Trophy.
In early 2016, New York Island defector Adam Pelech left the warm-up before the game with a seemingly minor injury, and was later diagnosed with "an undisclosed injury." Pelech was held for more than two months before returning to the Islanders minor league affiliate, and upon returning, a previously publicized TOS diagnosis. Treatments include surgery removing the first ribs and muscle and tissue sections.
The Japanese band Maria broke up in 2010 due to Tattoo drummer TOS which made it impossible for her to continue playing.
See also
- May-Thurner syndrome - a similar compressive pathology involving the left communicular iliac vein
- Backpacks palsy - a compressive pathology similar to those involving long chest nerves, or adjacent brachial plexis nerves
References
External links
- thorax in NINDS
- Physical Therapy Angle - Outlet Torax Syndrome
Source of the article : Wikipedia
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