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Condition/Disorder Syndrome

  • Neurogenic thoracic outlet syndrome (NTOS)

ICD-9-CM Code

  • 353.0 Brachial plexus lesions

ICD-10-CM Code

  • G54.0 Brachial plexus disorders

Preferred Practice Pattern1

Key Features

Description

  • 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

Essentials of Diagnosis

  • 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 pain5

General Considerations

  • No gold standard of diagnostic imaging exists for certain diagnosis.

  • Neurological examination and diagnostic imaging is required to rule out the most common differential diagnoses.

  • Double crush syndrome is a possibility.6

Demographics

  • Young and middle-aged adults most commonly affected7

  • Females to males 3:17

  • Can develop spontaneously, gradual onset due to poor posture or post-trauma

  • 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

Clinical Findings

Signs and Symptoms

  • Intermittent numbness and tingling in the forearm, wrist and hand.

    • Most often in the medial forearm and hand in the distribution of C8/T1 nerve roots but can be whole hand

  • 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 shoulders7

  • 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

Functional Implications

  • Difficulty with overhead activities

  • Pain with repetitive occupational fine motor tasks such as ...

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