Speaker: Address underlying pathology to treat thoracic outlet syndrome
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WAIKOLOA, Hawaii — Treatment of neurogenic, venous or arterial thoracic outlet syndrome should be addressed at the underlying pathology to avoid consequences and frustration for patients and physicians, according to a presenter.
“The thing about thoracic outlet syndrome – it’s tricky. It’s a challenging diagnosis. It’s not a specific test. It’s a clinical diagnosis,” Christopher S. Ahmad, MD, said in his presentation at Orthopedics Today Hawaii. “It’s frustrating to the patient, and it’s frustrating to the doctor,” he added.
The first step in diagnosing thoracic outlet syndrome is to rule out other pathologies, according to Ahmad. Humeral stress reaction, biceps tendinitis, cervical radiculopathy and nerve compression should all be ruled out, he said.
Similar to carpal tunnel syndrome, thoracic outlet syndrome is a compression problem, which can lead to vague symptoms depending on whether the pathology is neurogenic, vascular or arterial, Ahmad said.
Neurogenic thoracic outlet symptoms, such as numbness and paresthesia, are usually caused by compression of the brachial plexus by the cervical ribs, ligamentous bands or scalene muscles, Ahmad added. Failure of nonoperative treatment, such as rest, stretching, muscle relaxants and NSAIDs, should lead to referral to a vascular surgeon, he said.
Venous thoracic outlet syndrome is “not a hard diagnosis,” but it requires immediate attention, according to Ahmad. It is often caused by repetitive motion which leads to subclavian vein compression and the formation of a thrombus. These symptoms include swelling, cyanotic discoloration, heaviness and fatigue, he said. Nonsurgical treatment options are anticoagulants, thrombolysis and balloon angioplasty, while surgical options include axillary-subclavian vein decompression, rib resection and muscle removal.
Ahmad also outlined arterial thoracic outlet syndrome, in which symptoms include finger ischemia, numbness, tingling or discoloration. Treatment for this diagnosis can include anticoagulation, decompression or interposition bypass graft reconstruction, he said.
“You have to be ready to diagnose [thoracic outlet syndrome]. There is [a] consequence if you miss it, and the treatment is really at the underlying pathology,” Ahmad concluded.
Perspective
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As Ahmad states, the diagnosis of thoracic outlet is challenging and is based on the patient’s history and physical examination. Because the clinical presentation is variable and the diagnosis is challenging to make, thoracic outlet syndrome is often missed or not considered.
Physical therapy is the mainstay of nonoperative treatment and is successful in about half of the patients who present with this disorder. A variety of surgical approaches exist for patients who fail nonoperative treatment and include transaxillary, supraclavicular or posterior approaches to decompress the thoracic outlet. The decision on the approach is directed by the constellation of symptoms and the surgeon’s preference.
The literature reports generally good outcomes after surgery but there is variability, which is likely due to the challenges with diagnosis. Anterior Scalene blocks are used by some surgeons to predict the likelihood of success with surgery. This is a disorder that should always be considered in patients with pain and symptoms that do not appear straightforward.
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Ahmad CS. What is thoracic outlet syndrome? Presented at: Orthopedics Today Hawaii 2022. Jan. 9-13, 2022; Waikoloa, Hawaii.
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