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Guide to Thoracic Spine

What is Thoracic outlet syndrome (TOS)?

Thoracic outlet syndrome known as TOS in short is used to describe a group of conditions that result in compression of the neurovascular structures (arteries, veins and nerves) that exit the lower neck and upper chest area. The name given to thoracic outlet syndrome is named after the space between your lower neck and upper chest (Thoracic outlet) where a bunch of nerves and blood vessels exit the neck to go into the arms.

What are the symptoms of Thoracic outlet TOS?

There are different versions of TOS and the symptoms can vary from patient to patient depending on what type of TOS is occurring. The different types of TOS are:

Vascular TOS – This TOS occurs as a result of one or more veins or arteries being compressed under the collar bone. The symptoms experienced from this TOS can be numbness or tingling, weakness of the arm and neck, discolouration of your hand and arm fatigue with activity.

Neurogenic TOS – This is the most common type of TOS and can be characterised by compression of the brachial plexus which is a network of nerves and blood vessels that come from your spinal cord. The symptoms experienced from this TOS are usually one-sided numbness, tingling or paraesthesia of the arm and shoulder, constant ache with paraesthesia and pain down the inside of the arm.

What causes Thoracic outlet syndrome (TOS)?

Some of the common causes that can cause TOS include but are not limited to:

  • Physical trauma either from sports injury to motor vehicle accident
  • Repetitive injuries from work or sports-related
  • Prior neck or shoulder trauma
  • Tight chest muscles
  • Presence of an extra rib (cervical rib on C7 vertebra)

There are also risk factors that may increase the likelihood of TOS such as:

  • Poor posture that results in rounded shoulders
  • Bodybuilding that leads to increased muscle mass and reduced space in the thoracic outlet
  • Excess callus formation after a fracture of the collar bone

How is TOS diagnosed?

The diagnosis of TOS can be complicated due to the symptoms and their severity being different in individuals. The diagnosis will be based on the presenting symptoms and the completion of a complete physical examination which will include, orthopaedic, neurological and provocative tests that are designed to reproduce your symptoms which will help your practitioner determine the cause of your condition. Your practitioner may request additional imaging if needed to confirm the diagnosis of TOS.

How is TOS treated?

In the absence of acute and threatening neurovascular problems, conservative care is an effective treatment choice for TOS. The treatment for TOS varies depending on what is found during the examination but majority of the treatments will involve lifestyle modification, myofascial release on tight muscles, spinal manipulation to address areas of dysfunction in the spine and stretching advice.

The prognosis of TOS with conservative treatment is excellent with 85% of patients improving with appropriate multidisciplinary management.

References

Sharp WJ, Nowak LR, Zamani T, Kresowik TF, Hoballah JJ, Ballinger BA, Corson JD. Long-term follow-up and patient satisfaction after surgery for thoracic outlet syndrome. Annals of vascular surgery. 2001 Jan 1;15(1):32-6.

Vizniak, N., Carnes, M. and Vizniak, N., 2007. Quick Reference Conservative Care Conditions Manual. Vancouver: Professional Health Systems.

 Fugate, Mark W.; Rotellini-Coltvet, Lisa; Freischlag, Julie A. (2009). “Current management of thoracic outlet syndrome”. Current Treatment Options in Cardiovascular Medicine 11 (2): 176–83.

Sucher, BM, Physical Medicine and Rehabilitation for Thoracic Outlet Syndrome. 2013.

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