Thoracic Outlet Syndrome

THE CLINICAL SYNDROME

Thoracic outlet syndrome is the name given to a constellation of signs and symptoms including paresthesias and aching pain of the neck, shoulder, and arm that are thought to be due to compression of the brachial plexus and subclavian artery and vein as they exit the space between the shoulder girdle and the first rib or congenitally abnormal structures such as cervical ribs. Either one or all of the structures may be compressed, giving the syndrome a varied clinical expression. Thoracic outlet syndrome is seen most commonly in women between 25 and 50 years of age. The subject of significant debate, the diagnosis and treatment of thoracic outlet syndrome remain controversial.

Compression of the brachial plexus results in pain and weakness of the affected upper extremity.

SIGNS AND SYMPTOMS

Although the symptoms of thoracic outlet syndrome vary, compression of neural structures accounts for most clinical symptomatology. Paresthesias of the upper extremity radiating into the distribution of the ulnar nerve may be misdiagnosed as tardy ulnar palsy. Aching and in coordination of the affected extremity are also common findings. If vascular compression exists, edema or discoloration of the arm may be noted, and in rare instances, venous or arterial thrombosis may occur.Rarely, the symptoms of thoracic outlet syndrome can be caused by arterial aneurysm, and auscultation of the supraclavicular region will reveal a bruit.

Provocation of the symptoms of thoracic outlet syndrome may be elicited by a variety of maneuvers, including the Adson test and the elevated arm stress test. The Adson test is carried out by palpating the radial pulse on the affected side with the patient’s neck extended and the head turned toward the affected side. A diminished pulse is suggestive of thoracic outlet syndrome. The elevated arm stress test is performed by having the patient hold his or her arms over the head and open and close the hands. A patient without thoracic outlet syndrome can perfume this maneuver for approximately 3 minutes, whereas patients suffering from thoracic outlet syndrome will experience the onset of symptoms within 30 seconds.

TREATMENT

Physical Therapy

The primary treatment for patients suffering from thoracic outlet syndrome is the rational use of physical therapy to maintain function and to help palliate pain. Shoulder abnormalities, including subluxation and adhesive capsulitis, must be aggressively searched for and treated. Occupation therapy to assist in activities of daily living is also important to avoid further deterioration of function.

Drug Therapy

Gabapentin

Gabapentin is the first-line pharmacologic treatment for the neuritic pain of thoracic outlet syndrome. Start with a 300-mg dose of gabapentin at bedtime for 2 nights and caution the patient about potential side effects, including dizziness, sedation, confusion, and rash. The drug is then increased in 300-mg increments, given in equally divided doses over 2 days, as side effects allow until pain relief is obtained or a total dosage of 2400 mg/ day is reached. At this point, if the patient has experienced partial relief of pain, blood values are measured and the drug is carefully titrated upward using 100-mg tablets. Rarely will more than 3600 mg/ day be required.

Invasive Therapy

Branchial Plexus Block

The use of brachial plexus block with local anesthetic and steroid serves as an excellent adjunct to drug treatment of thoracic outlet syndrome. This technique rapidly relieves pain while medications are being titrated to effective levels. The initial block is carried out with preservative-free bupivacaine combined with methylprednisolone. Subsequent daily nerve blocks are carried out in a similar manner, substituting a lower dose of methylprednisolone. This approach may also be used to obtain control of breakthrough pain.

Surgical Treatment

In the absence of demonstrable pathology (e.g., a cervical rib), the outcome of surgical treatment for thoracic outlet syndrome is dismal regardless of the surgical technique chosen. In patients with a clear etiology for their symptoms for whom all attempts at conservative therapy have failed, the judicious use of surgical treatment may be a reasonable last step.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age –related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.