Diagnosis of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a nonspecific label. When employing it, one should define the type of TOS as arterial TOS, venous TOS, or neurogenic TOS. Each type has different symptoms and physical findings by which the three types can easily be identified. Neurogenic TOS (NTOS) is by far the most common, comprising well over 90% of all TOS patients. Arterial TOS is the least common accounting for no more than 1%. Many patients are erroneously diagnosed as "vascular" TOS, a nonspecific misnomer, whereas they really have NTOS. The Adson Test of noting a radial pulse deficit in provocative positions has been shown to be of no clinical value and should not be relied upon to make the diagnosis of any of the three types. The test is normal in most patients with NTOS and at the same time can be positive in many control volunteers. Arterial TOS is caused by emboli arising from subclavian artery stenosis or aneurysms. Symptoms are those of arterial ischemia and x-rays almost always disclose a cervical rib or anomalous first rib. Venous TOS presents with arm swelling, cyanosis, and pain due to subclavian vein obstruction, with or without thrombosis. Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesia, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds.