Thoracic Outlet Syndrome
Basics
Description
Description
- The symptoms of thoracic outlet syndrome (TOS) are produced by compression of the brachial plexus, subclavian vein, or subclavian artery during their passage from the cervical area toward the axilla and proximal arm
- Subdivided into 3 categories depending on the predominant symptoms:
- Neurogenic thoracic outlet syndrome (NTOS):
- Comprises 90–98% of adult patients
- Female > male
- True (1–3%): Those with objective findings
- Disputed (90%): Those with no or limited objective findings
- Venous thoracic outlet syndrome (VTOS):
- 2–4% of patients
- Arterial thoracic outlet syndrome (ATOS):
- Least common, <1%
- Male = female
- Neurogenic thoracic outlet syndrome (NTOS):
- Vascular manifestations are more common in adolescents, seen in >50% of teens with TOS
- Right extremity is more commonly affected
Etiology
Etiology
- Anatomic anomalies:
- Bony anomalies include cervical rib, first thoracic rib, or clavicular abnormalities:
- Cervical ribs occur in <1% of the population, ∼70% in women, and most are asymptomatic
- Less commonly, fracture of the clavicle and trauma to the sternoclavicular and costoclavicular joints
- Congenital bands or anomalous muscles
- May play a role in neurologic and venous types but is almost always implicated in arterial type
- Bony anomalies include cervical rib, first thoracic rib, or clavicular abnormalities:
- Neurogenic:
- Often have a history of neck trauma, such as whiplash (hyperextension injuries) or with repetitive motion patterns
- Venous:
- May be preceded by excessive activity, especially in adolescent athletes
- Caused by acute thrombosis of the subclavian vein (also called Paget–Schrötter disease) or by venous impingement
- Arterial:
- Often develop spontaneously
- Unrelated to trauma or work
- May experience true claudication with overhead exercises
- Almost always have a complete cervical rib or an anomalous first rib
- Caused by subclavian artery aneurysm or subclavian/axillary artery impingement:
- Arterial emboli that arise from either mural thrombus in the subclavian artery aneurysm or from thrombus forming distal to subclavian artery stenosis
- Descent of the shoulder girdle and sagging musculature can also predispose to TOS:
- Aging
- Obesity
- Heavy breasts
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Citation
Schaider, Jeffrey J., et al., editors. "Thoracic Outlet Syndrome." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307338/all/Thoracic_Outlet_Syndrome.
Thoracic Outlet Syndrome. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307338/all/Thoracic_Outlet_Syndrome. Accessed February 1, 2025.
Thoracic Outlet Syndrome. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307338/all/Thoracic_Outlet_Syndrome
Thoracic Outlet Syndrome [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2025 February 01]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307338/all/Thoracic_Outlet_Syndrome.
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