- Neurogenic thoracic outlet syndrome (NTOS)
- 353.0 Brachial plexus lesions
- G54.0 Brachial plexus disorders
- Entrapment of the neurovascular bundle comprising the
brachial plexus, subclavian artery and/or subclavian vein,
neurogenic or vascular types (venous and arterial)
- Symptomatology and management is different depending on the
primary structure compressed
- Compression on the brachial plexus
- Direct compression can occur at:
- Scalene triangle
- Cervical rib/first rib
- Pectoralis minor
- Costoclavicular space
- Unstable humeral head in an anterior/inferior position2
- Diagnosis is made by clinical examination and thorough
diagnosis of exclusion
- Most common to least common incidence is brachial plexus,
subclavian artery, and subclavian vein compression, respectively3
- Thoracic outlet syndrome involving the subclavian vein and
artery requires immediate medical attention and is often the result
of trauma or clot.4
- Worse with repetitive postural habits, pain at rest, night
- No gold standard of diagnostic imaging exists for certain
- Neurological examination and diagnostic imaging is required
to rule out the most common differential diagnoses.
- Double crush syndrome is a possibility.6
- Young and middle-aged adults most commonly affected7
- Females to males 3:17
- Can develop spontaneously, gradual onset due to poor posture
- Teenagers with a cervical rib
- There is increased incidence with participation in sports
- Correlated with a high incidence of forward head carriage
and rounded shoulders8
- Intermittent numbness and tingling in the forearm, wrist
- Most often in the medial forearm and hand
in the distribution of C8/T1 nerve roots but can be whole
- Feeling of weakness and fatigue in the upper extremity (UE)
especially with arm overhead
- Pain in the arm, neck, shoulders, and upper back
- Aggravated by overhead activities, repetitive activities,
and activities that depress the shoulder girdle5
- Pain is worse at night.5,9
- Pain can be better with rest.
- Postural examination may reveal low lying shoulder girdle
on affected side, forward head carriage, and anteriorly rounded
- Isolated venous type of thoracic outlet syndrome presents
with unilateral upper extremity edema, pain, cyanosis, paresthesia,
fatigue, and heaviness of the UE5
- Isolated arterial type of thoracic outlet syndrome presents
with cool extremities, absent arterial pulse, possible distal gangrene,
muscle cramps in the hand, paresthesia, swelling/heaviness
of the UE5
- Difficulty with overhead activities
- Pain with repetitive occupational fine motor tasks such as
- Pain/difficulty with prolonged seated postures
- Difficulty carrying a bag on the ipsilateral side
- Inability to sleep on the affected side
- Poor posture: forward rounded posture, military/retracted
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