New Perspectives On Neurogenic Thoracic Outlet Syndrome

New Perspectives on Neurogenic Thoracic Outlet Syndrome
Published on Practical Pain Management (http://www.practicalpainmanagement.com)
New Perspectives on Neurogenic Thoracic Outlet

Syndrome
The quality of life for patients with neurogenic thoracic outlet syndrome is profoundly diminished.
Emerging evidence supports minimally invasive chemodenervation of the cervicothoracic musculature
with onobotulinum toxin as a treatment option.
By Paul J Christo, MD, MBA [1]
Volume 14, Issue #8
[2]The definition,
incidence, diagnosis, and treatment of thoracic outlet syndrome (TOS) are somewhat controversial.
Originally coined in 1956, the term TOS indicated a compression of the neurovascular structures in the
interscalene triangle corresponding to the possible etiology of the symptoms.1 The controversy is
centered on the fact that TOS refers to the anatomy or location of the problem without identifying the
causeeither vascular or neurogenic.
Therefore, TOS generally is defined as a group of disorders caused by compression of the brachial
plexus, subclavian artery, or subclavian vein in the thoracic outlet, the area between the clavicle
(collarbone) at the base of the neck and the first rib, including the front of the shoulders and chest. TOS
is a progressive condition marked by the impingement of the nerves and blood vessels that feed the
thoracic outlet.
Neurogenic TOS (NTOS), the most common form of TOC, can result from inadequate space caused by
scalene hypertrophy, fibrosis, or congenital abnormalities, such as the occurrence of a cervical rib.
Other causes include repetitive motions that can enlarge or change the tissue in or near the thoracic
outlet (similar to carpel tunnel syndrome). These repetitive activities include assembly line work, typing,
and other movements; hyperextension-flexion injuries; neck injuries from motor vehicle accidents
(whiplash); and sports-related injuries, particularly from swimming, baseball (pitching), weightlifting,
and volleyball.
Frequent symptoms of NTOS include numbness; tingling in the fingers; pain in the neck, shoulder or
arm; muscle spasms around the scapula; headaches; and weakness in the upper extremities (Table 1).2
Page 1 of 10

[3]
Pathophysiology
In many patients, the etiology of NTOS involves a combination of a double hit of a congenital
predisposition and an injury to the area that compromises the outlet. The narrowed space affects the
scalene muscles, the brachial plexus, the long thoracic and suprascapular nerves, and the stellate
ganglion (Figure 1).
Page 2 of 10

[4]
Although the notion of NTOS as a complex spectrum disorder provokes some controversy in the field, its
impact on patients is beyond dispute. Data indicate that the quality of life for a patient with untreated
TOS is as impaired as that of someone with chronic heart failure.3
TOS has been divided into 3 forms:
Neurogenic TOS (brachial plexus compression)

1. True neurogenic TOS
2. Common neurogenic TOS
Arterial (subclavian artery compression)
Venous (subclavian vein compression)
As noted, nearly all cases of TOS (95%) are neurogenic in origin. NTOS is an underappreciated and often
overlooked cause of shoulder and neck pain and numbness. Like patients with other chronic pain
conditions, patients with untreated neurogenic TOS experience a diminished quality of life, reduced
financial well-being, functional limitations, and an increased risk for depression and anxiety.4-6
True NTOS, which is confirmed with objective findings, accounts for only 1% of cases, whereas common
NTOS, which has symptoms suggestive of brachial plexus compromise but no objective findings, makes
up 99% of neurogenic cases of TOS.7,8 The remaining cases of TOS are arterial (1%) and venous
(3%-5%).1
Neurogenic TOS occurs in an estimated 3 to 80 per 1,000 individuals, the wide range reflecting the lack
of confirmation in many patients with signs and symptoms indicative of the condition. Women with
NTOS outnumber men by 3 to 4:1. The syndrome is particularly common in people who perform
Page 3 of 10

repetitive tasks with their upper extremities, such as violinists, data entry personnel, and workers on
assembly lines. Athletes with repetitive overhead arm motion, including volleyball players, swimmers,
baseball pitchers, and weightlifters, also are at increased risk, as are people who have experienced neck
trauma.9
Histologic studies suggest that injury to either the anterior scalene muscle (ASM) or the middle scalene
muscle are the main causative factors of NTOS. Muscle fibrosis is a prime finding on examination of
excised scalene muscles, with NTOS patients having 3 times as much scar tissue as unaffected
subjects.8-10
The ASM derives from the transverse processes of the C3-C6 vertebrae. The muscle, which attaches to
the first rib, serves as an accessory muscle of respiration, and also rotates the neck slightly. Spasm of
the ASM puts traction on the brachial plexus and causes edema of the muscle and nerves, which, in
turn, limits the space of the outlet. Development of scar tissue and fibrosis of the ASM further worsen
neural compromise and perpetuate pain.8,11
Targeting treatment to relieve tension and spasm of the ASM can interrupt the chain of events that
leads to NTOS.
Diagnosis
There is no one standard for the diagnosis of TOS. The diagnosis of NTOS can be difficult because it
often has a nonspecific clinical presentation. In a classic case, the patient will complain of pain
originating in the area of the shoulder and radiating along the inner aspect of the arm. Other common
symptoms involve pain in the neck; the trapezius, mastoid, and anterior chest wall musclesall from
upper plexus compression (C5-C7). Physical examination will reveal tenderness in the scalene muscles,
trapezius, and chest wall. Patients may have a positive Tinel sign over the brachial plexus in the neck,
reduced sensation in the fingers to light touch, and positive provocative maneuvers.9
Complicating the differential diagnosis, however, is that the entire arm often is involved without
dermatomal preference. The clinician must distinguish cervical radiculopathy from disk herniation or
stenosis and rule out carpal tunnel syndrome.
A thorough history and physical examination are key to accurate diagnosis of NTOS. Testing for NTOS is
unreliable. Ancillary testing lacks sensitivity and specificity. Similarly, provocative testing, including the
Adson maneuver,12 has unknown reliability and specificity. The Adson maneuver, in particular, produces
many false positive results and no longer is considered useful for identifying patients with NTOS.13
Provocative maneuvers, nerve tension tests, and thumb pressure over the brachial plexus can assist in
the determination of NTOS, but the elevated arm stress test, or Roos stress test, is perhaps the most
reliable indicator.13 Another potentially useful diagnostic test includes the Spurling test to identify
cervical disk disease.8,14,15
Imaging Studies
Patients with NTOS often have normal results on electromyelography (EMG) and nerve conduction tests.
However, these studies can be used to exclude other causes of neuropathic symptoms, such as
radiculopathy, carpal tunnel syndrome, cubital tunnel syndrome, and polyneuropathy.
A chest x-ray may be warranted to identify cases of cervical rib. Magnetic resonance imaging and
computed tomography (CT) also can help to rule out conditions that mimic NTOS.
Some evidence suggests that a medial antebrachial cutaneous nerve conduction study can detect
milder cases of NTOS. This test measures sensory function of the lower trunk of the brachial plexus and
Page 4 of 10

often yields positive results in patients with negative findings on an EMG or nerve conduction tests.
However, additional studies are required to validate the utility of the test.9,16
Anterior Scalene Block
First described in 1939, the anterior scalene block (ASB) is an intramuscular confirmatory test for NTOS.
The block paralyzes the muscle in spasm, allowing the first rib to descend and decompresses the
thoracic outlet.17 A positive response to an ASB test correlates well with good surgical outcomes,
whereas temporary muscle relaxation helps predict benefit from decompression. In one study, EMGguided block provided relief in 94% of patients who underwent surgery.18
A variety of imaging techniques can improve the success of ASB. CT guidance for scalene injections, in
particular, has been shown to minimize Horners sign, dysphonia, brachial plexus block, and
dysphagia.17
Treatment
Conservative
Conservative treatment for NTOS involves steps to minimize pressure on the brachial plexus, restoring
muscle balance in the neck, and improving neural mobility. Correcting ergonomic issues and poor
posture can help, as can nerve glides, stretching exercises, and biofeedback. A 14-month course of
postural correction and strengthening of the shoulder girdle led to significant reductions in pain and
high patient satisfaction in one study.19
Physical Therapy
Some data support the use of heat packs, exercise programs, and cervical traction for the treatment of
NTOS.20,21 A course of inpatient rehabilitation, followed by a home exercise program, appears to have a
high rate of satisfaction among patients who have undergone this regimen. However, data suggest that,
in general, no single approach to physical therapy is sufficient on its own. Indeed, without other
interventions, physical therapy may lead to worse outcomes for some patients. In one study, 42 patients
(37 women, 5 men) diagnosed with NTOS who had participated in physical therapy at least 6 months
prior to the study were selected.22 At the end of the follow-up period, 25 patients reported symptomatic
improvement, 10 reported that they were the same, and 7 patients had worse symptoms. Poor overall
outcome was related to obesity (P<0.04), workers compensation claims (P<0.04), and associated
carpal or cubital tunnel syndrome (P<0.04). Neck and shoulder symptoms were improved in 38 patients.
Improvement in hand and arm pain was significantly better in those without concomitant distal nerve
compression (P<0.06).22
Cognitive behavioral therapy is an important adjunct to treatment, helping patients modify their
perception of pain, reframe their experience in positive terms, and minimize catastrophizing about their
condition.
Pharmacologic Approaches
A variety of pharmacologic agents can provide relief of symptoms, if not improvement in the physiologic
underpinnings of NTOS. These include non-steroidal anti-inflammatory drugs (eg, ibuprofen [Advil,
Motrin, others]), muscle relaxants (eg, tizanidine [Zanaflex, others]), tricyclic antidepressants (eg,
nortriptyline [Pamelor, others]), serotonin-norepinephrine reuptake inhibitors (eg, duloxetine [Cymbalta,
others]), and membrane stablizers (eg, gabapentin [Neurontin, Horizant, others]). If the patients quality
of life deteriorates during pharmacologic treatment and other therapies fail, sustained-release opioids
are an option.9
Page 5 of 10

Chemodenervation
Injection of onobotulinum toxin Type A (Botox) is a relatively new and promising approach to the
treatment of NTOS.23 Studies indicate that onobotulinum toxin is safe and effective for an increasing
number of neuromuscular ailments. Approved indications for onobotulinum toxin injections include
hemifacial spasm, blepharospasm, strabismus, and chronic migraine, among others. Successful off-label
use also has been described for lumbosacral myofascial pain, piriformis syndrome, and lateral
epicondylitis.
Administration of onobotulinum toxin for NTOS involves a single, low-dose injection (20 units) into the
ASM under CT-guidance. In one study, 27 patients with NTOS experienced substantial pain relief for up
to 3 months following low-dose injections of onobotulinum toxin under CT guidance.23 The primary
outcome was pain and sensation on a visual analog scale (VAS) at 1, 2, and 3 months after therapy.
Short Form McGill Pain Questionnaire scores were evaluated before treatment and at 1, 2, and 3 months
after therapy. Patients reported substantial relief from treatment at both 1 and 2 months, and
statistically and clinically significant relief in both sensory and VAS scores at the 3-month point (29%
and 15%, respectively).23
Onobotulinum toxin reduces muscle overactivity in the area of the injection by blocking the release of
acetylcholine, weakening the muscle for as long as 3 to 4 months. The toxin also may reduce pain and
inflammation in some patients, perhaps by inhibiting the release of neuropeptidesparticularly
substance P and glutamatethat are implicated in nociceptive transmission and central
sensitization.24,25 Some evidence suggests that onobotulinum toxin can improve wound healing and
reduce scarring in injured muscles.5,26
Injections of onobotulinum toxin represent a minimally invasive approach for patients hoping to avoid
surgery, or a bridge to surgery for those seeking to delay the procedure. Successful injections may
obviate the need for surgeryand the potential complications from surgeryand limit the time patients
must take off from work, home duties, and other activities of daily living. This benefit can be substantial
because the common course for surgical patients involves 8 weeks of physical therapy starting 2 weeks
after the procedure, necessitating 2 to 3 months leave from work, as well as no heavy lifting (>10
pounds) for 6 months.5
Although chemodenervation can be performed using multiple imaging modalities, the evidence for CT
guidance is strong (Table 2). CT allows clinicians to visualize nearby anatomy (in real-time in the case of
CT fluoroscopy), and, unlike ultrasound, it is not vulnerable to obscuring by adiposity or osseous
structures. CT imaging is fast, accurate, reliable, and safe, leading to a higher percentage of successful
anesthetic blocks compared to other modalities: 82% versus 38% for ultrasound, 18% for EMG +
fluoroscopy, and 72% for EMG alone.17,27,28 This advantage is borne out by the high rate of improvement
after surgery associated with CT-guided blocks (70%) to confirm true cases of neurogenic TOS.5,23
Page 6 of 10

[5]
Keeping exposure time to 60 seconds or less limits the amount of ionizing radiation patients receive.
Surgical Decompression
Multiple approaches to surgical decompression for NTOS are available, although comparative efficacy
data for the techniques do not exist. Studies suggest that initial rates of success are high, approaching
90%; however, complications occur in more than 30% of patients and longitudinal data show a 60%
recurrence of symptoms within the first year after surgery and 80% within the second year. In addition,
60% of patients report persistent disability within the first year after surgery.29
Conclusion
Neurologic TOS is the most common type of TOS, as well as the most often overlooked and
misdiagnosed form of the condition. It causes persistent pain, impaired function, and emotional distress.
If untreated, the quality of life for patients with NTOS is profoundly diminished. Emerging evidence
supports minimally invasive chemodenervation of the cervicothoracic musculature with onobotulinum
toxin. Clinicians and patients should consider this approach before attempting surgical decompression.
References:
References
1. Hooper TL, Denton J, McGalliard MK, Brisme JM, Sizer PS Jr. Thoracic outlet syndrome: a
controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip
Ther. 2010;18(2):74-83.
2. Christo PJ, McGreevy K. Updated perspectives on neurogenic thoracic outlet syndrome. Curr Pain
Headache Rep. 2011;15 (1):14-21.
3. Chang, DC, Rotellina-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for
thoracic outlet syndrome improves patients quality of life. J Vasc Surg. 2009;49(3):630-635.
4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education.
Relieving pain in America: a blueprint for transforming prevention, care, education and research.
Washington, DC: National Academies Press (US); 2011.
5. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to
common pain conditions in the US workforce. JAMA. 2003;290(18):2443-2454.
6. Leong IY, Farrell MJ, Helme RD, Gibson SJ. The relationship between medical comorbidity and selfrated pain, mood disturbance, and function in older people with chronic pain. J Gerontol A Biol
Sci Med Sci. 2007;62(5):550-555.
7. Atasoy, E. Thoracic outlet compression
syndrome. Orthop Clin North Am. 1996;27(2):265-303.
8. Brantigan CO, Roos DB. Etiology of
neurogenic thoracic outlet syndrome. Hand Clin. 2004;20(1);17-22.
9. Sanders RJ, Hammond SL, Rao NM.
Thoracic outlet syndrome: a review. Neurologist. 2008;14(6):365-373.
10. Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression
syndrome. Histochemical and morphometric studies. Arch Surg. 1986;121(10):1141-1144.
11. Atasoy E. Thoracic outlet syndrome: anatomy. Hand Clin. 2004;20(1);7-14.
12. Demirbag D, Unlu E, Ozdemir F, et al. The relationship between magnetic resonance imaging
findings and postural maneuver and physical examination tests in patients with thoracic outlet
syndrome: results of a double-blind, controlled study. Arch Phys Med Rehabil. 2007;88(7):
844-851.
13. Physiopedia. Roos stress test. http://www.physio-pedia.com/Roos_Stress_Test. Accessed August
17, 2014.
14. Roos, DB. New concepts of TOS that explain etiology, symptoms, diagnosis and treatment. Vasc
Page 7 of 10

Surg. 1979;13:313-21
15. Rayan GM, Jensen C. Thoracic outlet syndrome: provocative examination maneuvers in a typical
population. J Shoulder Elbow Surg. 1995;4(2):113-117.
16. Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of
botulinum toxin in the treatment of this syndrome. Toxins. 2012;4(11):1223-1235.
17. Mashayekh A, Christo PJ, Yousem DM, Pillai JJ. CT guided injection of the anterior and middle
scalene muscles: technique and complications. Am J Neuroradiol. 2011;32(3):495-500.
18. Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using electrophysiologically
guided anterior scalene blocks. Ann Vasc Surg. 1998:12(3):260-264.
19. Crosby CA, Wehbe MA. Conservative treatment for thoracic outlet syndrome. Hand Clin.
2004;20(1): 43-49.
20. Taskaynatan MA, Balaban B, Yasar E, et al. Cerivcal traction in conservative management of
thoracic outlet syndrome. J Musculoskeletal Pain. 2007;15 (1): 89-94.
21. Gulbahar S, Akalin E, Baydar M, et al. Regular exercise improves outcome in droopy shoulder
syndrome: a subgroup of thoracic outlet
syndrome. J Musculoskeletal Pain. 2005;13(4):21-26.
22. Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic
outlet syndrome. J Hand Surg Am. 1995;20(4): 542-548.
23. Christo PJ, Christo DK, Carinici AJ, Freischlag FA. Single CT-guided chemodenervation of the
anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med.
2010;11(4): 504-511.
24. Aoki K. Review of proposed mechanism for the antinociceptive action of botulinum toxin type A.
Neurotoxicology. 2005;26(5):785-793.
25. Sheean G. Botulinum toxin for the treatment of musculoskeletal pain and spasm. Curr Pain
Headache Rep. 2002;6(6):460-469.
26. Childers MK, Wilson DJ, et al. Treatment of painful muscle syndromes with botulinum toxin: A
review. J Musculoskel Rehab. 1998;10:89-96.
27. Torriani M, Gupta R, Donahue DM. Botulinum toxin injection in neurogenic thoracic outlet
syndrome: results and experience using an ultrasound-guided approach. Skeletal Radiol.
2010;39(10):973-980.
28. Jordan SE, Ahn SS, Gelabert HA. Combining ultrasonography and electromyography for
botulinum chemodenervation treatment of thoracic outlet syndrome: comparison with
fluoroscopy and electromyography guidance. Pain Physician. 2007;10(4):541-546.
29. Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet
syndrome in Washington state workers compensation. Neurology. 2000;54(6):1252-1257.
View Sources [6]

References
1. Hooper TL, Denton J, McGalliard MK, Brisme JM, Sizer PS Jr. Thoracic outlet syndrome: a
controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip
Ther. 2010;18(2):74-83.
2. Christo PJ, McGreevy K. Updated perspectives on neurogenic thoracic outlet syndrome. Curr Pain
Headache Rep. 2011;15 (1):14-21.
3. Chang, DC, Rotellina-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for
thoracic outlet syndrome improves patients quality of life. J Vasc Surg. 2009;49(3):630-635.
4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education.
Relieving pain in America: a blueprint for transforming prevention, care, education and research.
Washington, DC: National Academies Press (US); 2011.
5. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to
common pain conditions in the US workforce. JAMA. 2003;290(18):2443-2454.
6. Leong IY, Farrell MJ, Helme RD, Gibson SJ. The relationship between medical comorbidity and selfrated pain, mood disturbance, and function in older people with chronic pain. J Gerontol A Biol
Page 8 of 10

Sci Med Sci. 2007;62(5):550-555.
7. Atasoy, E. Thoracic outlet compression
syndrome. Orthop Clin North Am. 1996;27(2):265-303.
8. Brantigan CO, Roos DB. Etiology of
neurogenic thoracic outlet syndrome. Hand Clin. 2004;20(1);17-22.
9. Sanders RJ, Hammond SL, Rao NM.
Thoracic outlet syndrome: a review. Neurologist. 2008;14(6):365-373.
10. Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression
syndrome. Histochemical and morphometric studies. Arch Surg. 1986;121(10):1141-1144.
11. Atasoy E. Thoracic outlet syndrome: anatomy. Hand Clin. 2004;20(1);7-14.
12. Demirbag D, Unlu E, Ozdemir F, et al. The relationship between magnetic resonance imaging
findings and postural maneuver and physical examination tests in patients with thoracic outlet
syndrome: results of a double-blind, controlled study. Arch Phys Med Rehabil. 2007;88(7):
844-851.
13. Physiopedia. Roos stress test. http://www.physio-pedia.com/Roos_Stress_Test. Accessed August
17, 2014.
14. Roos, DB. New concepts of TOS that explain etiology, symptoms, diagnosis and treatment. Vasc
Surg. 1979;13:313-21
15. Rayan GM, Jensen C. Thoracic outlet syndrome: provocative examination maneuvers in a typical
population. J Shoulder Elbow Surg. 1995;4(2):113-117.
16. Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of
botulinum toxin in the treatment of this syndrome. Toxins. 2012;4(11):1223-1235.
17. Mashayekh A, Christo PJ, Yousem DM, Pillai JJ. CT guided injection of the anterior and middle
scalene muscles: technique and complications. Am J Neuroradiol. 2011;32(3):495-500.
18. Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using electrophysiologically
guided anterior scalene blocks. Ann Vasc Surg. 1998:12(3):260-264.
19. Crosby CA, Wehbe MA. Conservative treatment for thoracic outlet syndrome. Hand Clin.
2004;20(1): 43-49.
20. Taskaynatan MA, Balaban B, Yasar E, et al. Cerivcal traction in conservative management of
thoracic outlet syndrome. J Musculoskeletal Pain. 2007;15 (1): 89-94.
21. Gulbahar S, Akalin E, Baydar M, et al. Regular exercise improves outcome in droopy shoulder
syndrome: a subgroup of thoracic outlet
syndrome. J Musculoskeletal Pain. 2005;13(4):21-26.
22. Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic
outlet syndrome. J Hand Surg Am. 1995;20(4): 542-548.
23. Christo PJ, Christo DK, Carinici AJ, Freischlag FA. Single CT-guided chemodenervation of the
anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med.
2010;11(4): 504-511.
24. Aoki K. Review of proposed mechanism for the antinociceptive action of botulinum toxin type A.
Neurotoxicology. 2005;26(5):785-793.
25. Sheean G. Botulinum toxin for the treatment of musculoskeletal pain and spasm. Curr Pain
Headache Rep. 2002;6(6):460-469.
26. Childers MK, Wilson DJ, et al. Treatment of painful muscle syndromes with botulinum toxin: A
review. J Musculoskel Rehab. 1998;10:89-96.
27. Torriani M, Gupta R, Donahue DM. Botulinum toxin injection in neurogenic thoracic outlet
syndrome: results and experience using an ultrasound-guided approach. Skeletal Radiol.
2010;39(10):973-980.
28. Jordan SE, Ahn SS, Gelabert HA. Combining ultrasonography and electromyography for
botulinum chemodenervation treatment of thoracic outlet syndrome: comparison with
fluoroscopy and electromyography guidance. Pain Physician. 2007;10(4):541-546.
29. Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet
syndrome in Washington state workers compensation. Neurology. 2000;54(6):1252-1257.
First published on: September 1, 2014
Page 9 of 10

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