University of Maryland Rounds features clinical and research updates from the University of Maryland School of Medicine and the University of Maryland Medical Center. 

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A rare and often puzzling condition known as thoracic outlet syndrome meets its match when patients come to University of Maryland Medical Center (UMMC). Patients with thoracic outlet syndrome (TOS) can develop pain, numbness, disability or blood clots in their arms. The correct diagnosis and treatment is essential to continuing the function or athletic activities. 

Thoracic outlet syndrome encompasses a group of disorders occurring with compression of the nerves, arteries or veins in the lower neck and upper chest area. The name thoracic outlet syndrome is for the space — the thoracic outlet — between the clavicle and the first rib in the upper chest region.  

About 200,000 cases of thoracic outlet syndrome, or TOS, are diagnosed nationally each year, while up to three new patients show up each week at UMMC at to be evaluated for the condition. TOS mimics numerous other disorders, including those affecting the shoulders and cervical spine, says Rajabrata Sarkar, M.D., Ph.D., chief of the Division of Vascular Surgery.

Dr. Sarkar, also the Barbara Baur Dunlap Professor of Surgery and Physiology at University of Maryland School of Medicine, hopes UMMC will continue to increase the volume of these patients when they learn of its multidisciplinary expertise in TOS, including a team of experienced thoracic and vascular surgeons and orthopedic rehabilitation experts.

“It’s a relatively uncommon disorder, but it’s important because it tends to affect younger people in a working-age population and disable their upper extremity so their arms don’t work properly,” he says. “It can be very disabling and often threaten the function of the limb.”

Who’s at Risk for TOS

While TOS isn’t completely understood, those who develop it often were born with a narrow thoracic outlet or an extra first rib, says Dr. Sarkar, a nationally known researcher in blood vessel growth and development who came to UMMC in 2009. Additional risk factors include trauma to the neck, repetitive arm use at work which can compress nerves, or other bony or soft tissue abnormalities.

“In general, it’s an interaction between the way we’re put together and what happens later in life” he explains. “Many patients only develop symptoms after trauma like a motor vehicle accident, or from the repetitive stretching of nerves, like electricians who work with their arms over their head.”

The type of TOS a patient suffers from influences not only its symptoms, but its treatment. The three types include:

  • Neurogenic TOS: Affecting the vast majority of total TOS patients, neurogenic TOS symptoms include hand weakness or numbness; diminished hand muscles; and/or pain, tingling, numbness and weakness of the neck, chest and arms. “This generally causes dysfunction of the arm and can cause trouble with activities of daily living,” Dr. Sarkar says.
  • Venous TOS: Developing suddenly, venous TOS triggers symptoms such as hand swelling; heaviness and weakness in the hand and arms; and swollen veins in the chest wall. “You can have long-term heaviness or dysfunction of the arm, and if it’s not treated, creates an ongoing risk of clotting again,” he says.
  • Arterial TOS: The least common but most serious type, arterial TOS can cause poor circulation and/or cold sensitivity in the arms, hands and fingers. “Patients can lose parts of fingers,” Dr. Sarkar says.

Treatment Depends on Type of TOS

For the 90% of TOS patients with milder cases of the neurogenic type, physical therapy often offers long-lasting relief, Dr. Sarkar says. Many patients with neurogenic TOS also adjust their lifestyle or change professions to avoid having to raise their arms over their heads on a regular basis, which can be problematic.

Most of those with arterial or venous TOS, however, require surgery to fix the problem so potentially permanent damage isn’t done to their arms, hands or fingers. The surgery typically involves removing an extra rib or compressive tissue and sometimes repairing or replacing the involved artery or vein.

Since UMMC’s multidisciplinary team also includes spine surgeons and others who deal with neurologic problems of the shoulders and arms, this helps provide a timely diagnosis when TOS symptoms overlap with other, more common conditions, Dr. Sarkar says. When patients go to a single physician, they can often wait months to years before receiving the correct diagnosis, he notes.

“When you’re familiar with TOS, however, like we are, you tend to see more patients with it and be more precise in its diagnosis,” he adds. “The whole point is to provide better care and avoid patients sitting around for a long time with an increased risk of blood clots, permanent damage to the artery or muscle wasting. Our multidisciplinary approach will hopefully lead patients and referring physicians to recognize us as a potential referral center for thoracic outlet syndrome.” 

Contact the team in Vascular Surgery at 410-328-6840.