Thoracic Outlet Syndrome Treatment in Delhi, India

There are three types of thoracic outlet syndrome:

1. Neurogenic Thoracic Outlet Syndrome

   This, the most common kind of thoracic outlet syndrome, is marked by the compression of the brachial plexus. These are a group of nerves that sends signals from the spinal cord and control the movements of various muscles and sensations in the shoulder, arm, and hand area.

2. Venous Thoracic Outlet Syndrome

   This occurs when one or more of the veins get compressed by the clavicle leading to blood clots.

3. Arterial Thoracic Outlet Syndrome

   This is the least common type. It occurs when one of the arteries gets compressed under the clavicle resulting in bulging of the artery, also known as an aneurysm.

Thoracic outlet syndrome symptoms can differ depending on its type.

Symptoms of Neurogenic Thoracic Outlet Syndrome

1. Pain or weakness in the area of the shoulder and arm
2. Tingling sensation in the fingers
3. Weakness in the arm
4. Atrophy of the thumb

Symptoms may persist or ease down, but they are often triggered when arms are held up for a more extended period, causing discomfort.

Symptoms of Venous Thoracic Outlet Syndrome

1. Oedema of the arm, hand, or fingers
2. Cyanosis of the hand and arm
3. Numbness and paresthesia in the hand and arm
4. Very prominent and visible veins on the shoulder, neck, and hand area.

These symptoms occur because compression of the vein may result in blood clots, termed Effort thrombosis or Paget-Schroetter syndrome. Effort thrombosis is a sort of deep vein thrombosis. This is more commonly seen in the legs. 

Symptoms of Arterial Thoracic Outlet Syndrome

1. Decreased sensation in hands
2. Pain in the hand and arm area, especially during overhead movements of the arm
3. Embolism of an artery in the hand or arm
4. Aneurysm of the subclavian artery

Thoracic outlet syndrome usually occurs by compression of the nerves or blood vessels in the thoracic outlet region, just under the clavicle. The various cause of the compression varies and can include:

1. Anatomical Defects

   Inherited defects present at the time of birth may include the Cervical rib, which is an extra rib situated above the first rib.

2. Poor Posture

   Drooping of shoulders or holding head forward results in compression in the thoracic outlet area.

3. Trauma

   Any trauma, most commonly a road traffic accident, can cause internal damage and compression of the nerves in the thoracic outlet.

4. Body Building

   Over-built-up muscles in the neck may grow too large and end up compressing nerves or the subclavian nerves.

5. Repeated Overhead Motions

   People involved in various activities or other jobs requiring overhead arm actions may develop thoracic outlet syndrome.

6. Weight Gain

   Along with extra muscle mass, sometimes excess fat in the neck region may press on nerves or subclavian vessels.

7. Tumour in the Neck

   Although rare, a neck tumour may cause compression.

Diagnosing thoracic outlet syndrome can be challenging at times because the symptoms and severity can vary significantly among people with the disorder. The doctor conducts a thorough physical examination and other imaging tests to diagnose thoracic outlet syndrome.

1. Physical Examination

   The doctor examines external signs of thoracic outlet syndrome, such as a depression in the shoulder, a bony abnormality above the clavicle, swelling, or pale discolouration in the arm. The doctor may try various ranges of motion of the shoulder and try to reproduce the symptoms. This will help specify which position and movements trigger the symptoms, thereby identifying thoracic outlet syndrome.

2. Medical History

   The doctor will likely ask about the past medical history and occupation, and physical activities involved in the day-to-day life.

3. Imaging and Nerve Study Tests

   To confirm the diagnosis of TOS, the doctor may suggest the following tests:

   
   

   1. Ultrasound

      It's often the first imaging test to detect thoracic outlet syndrome diagnosis. Doctors may use this test to determine if there is vascular, thoracic outlet syndrome, or other associated vascular issues.

   2. X-ray

      It helps to reveal an extra rib or cervical rib. Further, they can also rule out several other conditions responsible for causing the symptoms.

   3. Computerized Tomography (CT) Scan

      This uses X-rays to obtain cross-sectional images of the body. A dye is injected into a vein to analyze the blood vessels via CT angiography.

   4. Magnetic Resonance Imaging (MRI)

      This is done to determine the location and cause of blood vessel (vascular) compression

   5. Arteriography and Venography

      In these tests, the doctor inserts a thin, flexible tube called a catheter through a small incision, usually in the groin area. The catheter is moved through major arteries in arteriography or the veins in venography to the involved blood vessels.
      Then the doctor injects a dye through the catheter to show X-ray images of the involved arteries or veins. Doctors can check for a compressed vein or artery.

   6. Electromyography (EMG)

      During an EMG, the doctor inserts a needle electrode through the skin into various muscle groups. The test is used to evaluate the muscles' electrical activity while they contract and relax. This test can determine nerve damage as well.

Treatment depends on whether TOS is either neurogenic or vascular. Accordingly, the treatment approach varies.

Treatment for Neurogenic TOS includes

1. Physical therapy is ideally the first line of treatment.
2. Botulinum toxin injections are productive when physical therapy doesn't entirely help to relieve the symptoms.
3. If symptoms keep on persisting even after physical therapy sessions and injections, then finally, surgery can be recommended. Surgery involves cutting small neck muscles (anterior and middle scalene) and removing the cervical or first rib.

Treatment for Venous Thoracic Outlet Syndrome

Surgery is usually recommended for venous TOS. This may involve separating the scalene and subclavius muscles and the first rib. The vein itself needs to be treated as well. Blood clots often form around the site of the compressed vein. Treatments comprise:

1. Medication

   Blood thinners for treatment of clots formed

2. Thrombolysis

   A procedure to remove a clot and usually performed before surgery for TOS.

3. Post-rib Resection Venogram

   A post-surgical procedure done after two or three weeks of surgery to treat any unresolved damage to the vein. It can be treated with balloon angioplasty, in which a balloon is used to expand the narrowed vein.

Treatment for Arterial Thoracic Outlet Syndrome

Surgery is usually the preferred choice for arterial Thoracic Outlet Syndrome. This involves removing both the scalene muscles in the neck, the cervical rib if present, and the first rib. Other treatments are:

1. Medication: Blood thinners to dissolve clots present
2. Reconstruction or Replacement of the artery, if there is an aneurysm or contains a clot

Several factors appear to escalate the risk of TOS. These are as follows:

1. Sex: Females are more prone to be diagnosed with thoracic outlet syndrome than males.
2. Age: Thoracic outlet syndrome may occur at any age but is most commonly diagnosed in adults between the ages of 20 and 50.

Thoracic outlet syndrome should be treated immediately. Otherwise, it can cause grave issues like:

1. Pain and swelling in the arm that worsens with time
2. Neural damage
3. Blood flow issues, like gangrene or ischemic ulcers
4. Blood clots cause a severe condition called pulmonary embolism

The outlook for people with thoracic outlet syndrome is generally very good, especially when the treatment begins promptly. Typically, the symptoms will resolve with medication and physical therapy sessions. Surgery also tends to be effective in managing the condition.

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