Thoracic outlet syndrome

Case history #1

A 36-year-old right-handed woman presents complaining of pain in the right side of her neck, shoulder, anterior chest, upper back, arm, and hand. The pain is described as dull and aching, but occasionally burning, with frequent radiation from the anterolateral neck to the hand. Along with the pain, she has developed severe numbness in the right arm and hand, involving all fingers, which frequently awakens her at night. She works as a computer operator and first noticed symptoms about 2 years ago, with gradual progression to dropping things and marked difficulty working with the arm overhead, as well as difficulty with common daily tasks (e.g., vacuuming, sweeping, mopping, driving an automobile, typing). Cold exacerbates her symptoms with occasional pale or red discoloration in the fingers. She has previously had two 12-week courses of physical therapy without improvement of her symptoms. Physical exam reveals 3+/3 supraclavicular tenderness and 1+/3 subcoracoid tenderness on the right, with reproduction of her typical arm and hand symptoms upon palpation at each location. The upper limb tension test is positive on the right and she had to discontinue the Elevated Arm Stress Test after 30 seconds due to severe pain, paresthesia, and heaviness. The right radial pulse is normal with the arm at rest but abolished during overhead arm positioning. There is no muscle atrophy in the right hand and the grip strength is within normal limits, but slightly diminished compared to the left side. Cervical spine imaging and upper extremity electrodiagnostic testing are both normal and the QuickDASH score is 60. Surgical treatment is considered for right neurogenic thoracic outlet syndrome (TOS).

Case history #2

An otherwise healthy 25-year-old man presents with the spontaneous onset of left arm swelling, cyanotic discoloration, heaviness, and aching pain. These symptoms began 3 days ago in the absence of a specific injury, incident, or event and with no history of a central venous catheter, pacemaker, or deep vein thrombosis. He is a former baseball pitcher and continues regular physical training but works in an office setting. There is marked swelling and cyanosis in the entire left arm and prominent subcutaneous collateral veins around the shoulder and anterior chest, but no distinct supraclavicular, subcoracoid, or axillary tenderness. He has no chest pain or shortness of breath. A Duplex ultrasound of the left upper extremity demonstrates a clot in his left axillary-subclavian vein and a chest CT shows no pulmonary embolism. He is started on intravenous heparin and the diagnosis of venous TOS (Paget-Schroetter syndrome) is confirmed by catheter-based venography and successful suction thrombectomy, with a moderate residual subclavian vein stenosis at the level of the first rib after balloon angioplasty. Further management with long-term anticoagulation or definitive surgical treatment is discussed.

Other presentations

Arterial thoracic outlet syndrome (TOS) can present acutely with symptoms of upper extremity ischemia, including sudden onset of arm pain, numbness, weakness, and pale discoloration of the hand. These symptoms may occur without any preceding injury. Clinical exam often reveals poor capillary refill, decreased sensation in the fingers, diminished grip strength, and an absence of detectable pulses at the wrist by Doppler ultrasound. Blood pressure measurements may show significant discrepancies between the affected and unaffected arms.

Palpation may reveal a firm, nontender mass in the supraclavicular space and a prominent pulsatile mass above the mid-clavicle. Imaging, such as a chest x-ray, may identify anatomic anomalies like a cervical rib. In cases of acute ischemia, surgical intervention, such as brachial artery embolectomy, can retrieve thrombi and restore blood flow. Intraoperative arteriograms often demonstrate a subclavian artery aneurysm with mural thrombus, which are characteristic findings of arterial TOS. These cases may require further surgical options to address the underlying vascular and anatomic issues.