Which clinical history findings are characteristic of thoracic outlet syndrome?

Updated: Jan 10, 2019
  • Author: Daryl A Rosenbaum, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Answer

The initial presentation of thoracic outlet syndrome is dependent on whether the compression is primarily vascular, neurogenic, or a combination of both. It is also dependent on the underlying continuum of histopathologic changes noted with chronic nerve compression, ranging from intermittent to constant debilitating symptoms. [16] Three symptomatic patterns emerge; these are vascular, true neurogenic, and disputed or nonspecific-type thoracic outlet syndrome.

Vascular thoracic outlet syndrome is rare and can involve the subclavian artery or vein. Both forms of vascular thoracic outlet syndrome tend to occur in young patients who perform vigorous overhead arm activity such as throwing. With venous obstruction (if secondary to thrombosis, Paget-von Schrötter syndrome), patients may present with upper extremity swelling, venous distention, or diffuse arm or hand pain (including the forearm). [16, 17]

With arterial obstruction, patients may report color changes of their affected upper extremity, claudication, or diffuse arm or hand pain (including the forearm). Because of arterial collateral blood flow, the initial symptoms tend to be mild, with arm ache and fatigue, particularly after overhead activity. Patients typically seek medical evaluation after ischemic events (eg, ulceration, gangrene, absent pulses) occur. [16]

Neurogenic thoracic outlet syndrome involves compression of the brachial plexus. Similar to vascular thoracic outlet syndrome, a pure neurogenic presentation is also rare. Patients present with painless atrophy of the intrinsic muscles of the hand, and athletes may report difficulty grasping a racket or ball as a result of intrinsic muscle weakness. They may also report sensory loss or paresthesias. Pain is often reported but is not as dramatic as in the nonspecific-type thoracic outlet syndrome. [11] Again, neurogenic thoracic outlet syndrome tends to affect individuals who perform overhead arm activities.

The disputed or nonspecific-type thoracic outlet syndrome refers to a large group of patients with unexplained pain in the arm, scapular region, and cervical region. Typically, their symptoms begin after a traumatic event (eg, motor vehicle accident). Much debate surrounds this diagnosis, with certain providers believing the disorder is underdiagnosed. [8] and others believing it is overdiagnosed. [9]


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