Why is diagnosing Thoracic Outlet Syndrome so difficult?

Join Arthur Jenkins, MD for a free, online education event that answers the question, "Why is diagnosing Thoracic Outlet Syndrome a challenging and difficult task for many clinicians?" A noted and compassionate TOS surgeon Dr. Jenkins covers a broad range of topics with an emphasis on the multiple challenges that physicians face when attempting to diagnose Thoracic Outlet Syndrome. Participant Q + A at the end of event. Join us.

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What are the symptoms of thoracic outlet syndrome?
Symptoms of thoracic outlet syndrome differ for each type of TOS
Doctors classify TOS into one of three types. Compression of different vital structures determines the type of TOS. Symptoms of thoracic outlet syndrome differ for each type of thoracic outlet syndrome.

To clarify, three vital structures pass through the thoracic outlet on each side:

Brachial plexus
Subclavian artery
Subclavian vein
Symptoms of thoracic outlet syndrome result from compression of the brachial plexus, subclavian artery, and subclavian vein
Anatomy of the thoracic outlet

In each thoracic outlet, compression or injury of each of these vital structures may occur. Therefore, different signs and symptoms of thoracic outlet syndrome result from compression of these different vital structures. Thus, patients can suffer one or more of the three types of TOS.

What are the symptoms of thoracic outlet syndrome for each type of TOS?

Five nerve roots arise from the spinal cord on each side of the neck. Then, these nerve roots travel out of the spine to the thoracic outlet. In each thoracic outlet, the roots form a complex branching network, called the brachial plexus. Compression of the brachial plexus or tension on the brachial plexus results in neurogenic TOS. Given the complexity of the structure of the brachial plexus, patients can suffer a broad range of symptoms.

Since compression or tension affects different parts of the brachial plexus in each patient, doctors typically see a complex clinical picture.

Patients may report the following symptoms of neurogenic TOS:

Pain in the neck, shoulder, chest, back (between the shoulder blades, shoulder, arm or hand, on one or both sides
Numbness, tingling, or coldness in the arms, hands, or fingers
Weakness of grip, or of the arms
Muscle wasting in the hands
Symptoms of neurogenic TOS depend on:

Which part of the brachial plexus is involved
What structures compress the plexus (bony vs. soft tissue)
How long compression or tension persists
Whether compression or tension is persistent or intermittent
The degree of compression or tension.
As a result, doctors often find the diagnosis of thoracic outlet syndrome quite challenging.

A single, large subclavian vein drains almost all of the blood from each arm. Compression of this vein can cause impaired venous drainage of the arm. When compression is severe or prolonged, it can cause damage to the inner vein wall. As a result, blood clot can form within the vein.

Patients may note the following symptoms of venous TOS:

Swelling and heaviness of one arm
Cyanosis (abnormal blue color) of the affected arm
Easy fatigue of the affected arm
New, shallow veins of the shoulder and chest
Shortness of breath, if blood clots travel to the lungs
Weakness, difficulty speaking, or other signs of stroke, in the rare event of blood clot traveling to the brain
SYMPTOMS OF VENOUS TOS
Back to Symptoms

A single, large subclavian artery provides most of the blood flow to each arm. Compression of this artery causes damage to the arterial wall. Damage to the inner wall can cause scar tissue and stenosis (narrowing of the artery). In contrast, damage to the full thickness of the wall can result in an aneurysm (focal ballooning of the artery). As a result of this aneurysm, a doctor may feel a pulsatile mass in the thoracic outlet. When arterial damage occurs, blood clots may form. These clots can break off and travel to distal arteries. As a result, blood flow stops, and gangrene of the affected area may develop.

Patients may experience:

Coldness of the arm
Loss of pulse in the affected arm
Profound weakness
Pale color of the arm
Numbness or tingling
A throbbing mass between the collar bone and the neck
Blockage of arterial blood flow is a surgical emergency. The patient should be diagnosed and treated urgently to prevent loss of function or loss of limb.