Thanks for joining us May 18 for a live chat on thoracic outlet syndrome with Dr. Paul Christo of Johns Hopkins. The condition, which affects approximately 8 percent of the population, involves compression of nerves between the base of the neck and armpit, causing neck pain, headache, numbness and weakness down the arm.
Christo is director of the Multidisciplinary Pain Fellowship Training Program at Johns Hopkins University School of Medicine. He also has a radio talk show Saturday nights on WBAL.
Read the transcript below.
Note: Comments made here are for informational purposes only and do not represent or substitute as medical advice. Patients are advised to consult their own physician or pharmacist for advice, diagnosis and treatment.
Hi, Dr. Christo will be joining us at noon but feel free to add your questions to the queue now and we'll get to them when the chat starts.
Wednesday May 18, 2011 11:34 Baltimore Sun Health
Baltimore Sun Health:
Welcome to our live chat on thoracic outlet syndrome. Dr. Paul Christo from Johns Hopkins is here to take your questions. We have a few that were submitted in advance and we'll get to as many as possible within the hour, so please be patient.
Wednesday May 18, 2011 12:01 Baltimore Sun Health
Hello, I look forward to your questions.
Wednesday May 18, 2011 12:02 drchristo
Baltimore Sun Health:
So let's get started.
Wednesday May 18, 2011 12:02 Baltimore Sun Health
[Comment From RoseRose: ]
I’ve been treated in the past for TOS with physical therapy exercises. It doesn¿t seem to help. They taped my shoulder blade so that it was pulled back and down which helped a lot. But the tape caused my skin to get irritated. I still get numbness and tingling every time I raise my arms above my head. Are there specific exercises I can do? The electrical stimulation seems to help more than the exercises. Are there surgical options? I don¿t have an extra rib.
Wednesday May 18, 2011 12:02 Rose
RoseMarie, I¿m assuming that we are talking about neurogenic TOS and not TOS caused by problems with the artery or the vein (vascular). Physical therapy can be fairly helpful. There is some data that heat packs, an exercise program, and cervical traction are beneficial. Patients have also reported that postural correction and shoulder girdle strengthening exercises have produced relief. A helpful diagnostic test is called an anterior scalene block performed under CT guidance. If patients report good relief, a botox injection into that muscle has demonstrated good results, though this form of minimally-invasive treatment is rather new. Surgery can also help and there are different approaches.
Wednesday May 18, 2011 12:08 drchristo
[Comment From DesireeDesiree: ]
I¿m hoping you can help me. A little over a year ago I “pulled” some muscles in my upper back/shoulder which started muscle spasms, headaches, tingling in my hand (usually when it is held up in the air), tenderness and pain in my shoulder and a weakness in my thumb. I was told by my doctor today that there is no medical reason for my hand going numb. Carpal tunnel and a pinched nerve in the neck have been ruled out after nerve testing and an MRI of my neck have been done. If I do have this syndrome would anything have shown up on the MRI of my neck and what area of the body do you need to test on in order to check for this problem? I¿m not sure I can handle the constant headaches anymore. Some days it hurts just to have my head upright.
Desiree, most often MRI and nerve testing isn¿t very helpful in making the diagnosis of neurogenic TOS (NTOS). A physical exam and then a relatively new block called an anterior scalene block can help confirm the diagnosis. People with NTOS can have headaches, neck pain, and pain in the arm. Most patients report pain or worsening of their pain when they lift their arms up or type, for example. I would consider seeing a specialist in this condition ( a surgeon or pain specialist). If you¿re in the Baltimore area, Dr. Julie Freischlag (surgeon) and I (nerve block, botox injection) work together in treating this condition.
Wednesday May 18, 2011 12:15 drchristo
[Comment From MiramMiram: ]
I have had the diagnosis of TOS for approximately 20 years. Approximately 17 years ago, I had a partial right first rib resection. I am in my 50 now and after a head trauma/facial fractures; I have become symptomatic again. My symptoms are swelling and stiffness in hands and forearms upon awakening, weakness in both hands, no over head reaching without causing dizziness, pain at base of neck with headaches that run up the back of my neck into my scalp and forward to my temples and above my eyes. It has taken away my ability to do any kind of upper body exercise or carrying any sort of weight/ a few lbs or greater without pain. What are the recommendations when you have a major accident, like I had to move on with a quality of life. I have tried four separate physical therapist, two surgeons have recommended surgery, I have a neuologist that I have worked for and I have also had the brachial plexus study by Dr. Collins at UCLA and have been told my venous blood return is impinged.
Wednesday May 18, 2011 12:17 Miram
Miram, if you have vascular TOS (venous blood flow impaired) then many patients will have a chest xray, duplex ultrasound, and even venography to further document and confirm the problem. A lot of patients will have arm pain with activity, arm and hand swelling, blue discoloration of the arm or hand, and dilated veins in the shoulder or chest area. You may be a candidate for repeat first rib resection and anterior scalenectomy. If you have a clot in the vein, then surgeons use blood thinners before and after surgery as part of treatment. I think surgery depends on how significant the bood flow reduction is, so have a frank discussion with one of the surgeons to determine likelihood of success and any problems you may encounter if you don¿t have another surgery.
Wednesday May 18, 2011 12:26 drchristo
[Comment From JayJay: ]
TOS is a very confusing condition with many doctors not believing in it. If you get 1st, 2nd and 3rd opinions that are all different, how does one determine the real issues associated with shoulder/arm pain? Why do so many differ on the conditions existence?
Wednesday May 18, 2011 12:27 Jay
Neurogenic TOS (NTOS) is a complex disorder and the diagnosis and treatment continue to provoke controversy. The way the symptoms present can overlap with other conditions from the spine, shoulder, or wrist. Yet, evidence suggests that people with untreated NTOS have a quality of life that can be as impaired as those suffering from chronic heart failure. A careful history and physical examination are critical. Electrodiagnostic studies (EMG/NCT), x rays, MRI help exclude other causes. The anterior scalene block may be an effective confirmatory test for NTOS and it¿s one that I perform to try to determine whether patients are good candidates for surgery or for botox injection into the muscle.
Wednesday May 18, 2011 12:35 drchristo
[Comment From CandiceCandice: ]
My name is Candice Gray and I live in Roanoke, VA. I have suffered from Thoracic Outlet Syndrome for almost four years. I was in my second year of nursing school when I delivered my fourth child. About a week after her birth I had pain in my neck and shoulders so bad I took a 7 day old baby, a 2 year old , and a 5 year old to the ER. Since that day I have not had one day w/o pain or been symptom free. I graduated school, got my license , and went to work at a local hospital. I went to the Dr. all the time with c/o pain. I think they got to the point they thought I was a drug seeker or just plain crazy. About 6 weeks after I started my job my L arm turned blue and ice cold. It was then I was diagnosed with TOS. I had a L first rib resect. and went back to work 3 weeks later. After being back my R arm did the same thing. I had a R first rib resection and have not been able to work since TOS has completely devastated my life. It took me a few months to realize I had the same symptoms. I consulted with the vascular surg who did my first surgeries and he said there was no way I could still have symptoms, I needed to loose a few pounds and go back to work. I hit the internet and found UVA. Where I had a partial scalenectomy. It has helped the headaches some but I still can not perform simple daily activities much less ever effectively care for a patient. I have been through a roller coaster of emotional and physical changes in my life.
Wednesday May 18, 2011 12:37 Candice
[Comment From CandiceCandice: ]
I have been told If I run two miles a day my shoulders and neck won't hurt, as well as a host of other diagnosis ranging from scoliosis, possibly MS, Reynaud's phenomenon and just yesterday a Neurologist at UVA said he was thinking Autonomic Dysreflexia. I know my pain is REAL and I KNOW that it is not normal that when I do not slouch my shoulders forward that I loose feeling in my hands and they turn purple. I have slouched forward for almost four years. I am so tired of going to doctors and them telling me it's out of their scope of practice. I worked so hard to become a nurse. I only finished the eighth grade and went on to get my RN license I am not afraid of hard work but I can not work I am physically unable, It is causing financial difficulties and strain in my marriage, my whole family is suffering. If you have any suggestions I would so greatly appreciate it.
Wednesday May 18, 2011 12:37 Candice
Candice, you could consider trying medications such as neurontin, lyrica, nortripytline, for instance that are used for chronic pain conditions. I have performed CT guided anterior scalene blocks and botox injections for patients who have already had surgery, but we don¿t have much data on the usefulness of botox for patients once they¿ve had surgery. I typically perform botox injections on patients before they have surgery or instead of surgery. That being said, you may be a candidate for a diagnostic anterior scalene muscle block on the left side followed by botox potentially. I¿m assuming that you do not have a vascular cause of TOS in saying all of this. Botox to the side with partial scalenectomy is possible, but it¿s technically difficult and may not be helpful.
Wednesday May 18, 2011 12:46 drchristo
[Comment From BeckyBecky: ]
I have exhausted all forms of physical therapy and surgery; first rib recsection and scalenectomy is being recommended. A local surgeon does this procedure arthroscopically, any thoughts?
Wednesday May 18, 2011 12:47 Becky
Becky, the surgeon that I work with performs this surgery using a transaxillary approach (under the arm) for the rib resection and the scalenectomy. Three main approaches are described: first rib resection, scalenectomy, and rib resection with scalenectomy. These are done open, or by making an incision into the skin and targeting the nerves and muscles with dissection. Data on comparing these approaches are lacking. I'm not aware of using an arthroscopic approach, but I don't perform this surgery either. I would make sure that you understand the risks and complications of this approach compared to the more standard approaches that I've described. Also, ask about the chances of success using arthroscopy compared to more conventional techniques.
Wednesday May 18, 2011 12:54 drchristo
[Comment From PaulPaul: ]
I have TOS. At my last dental visit 2 weeks ago, my dentist said she could tell that I clench my teeth at night and that it was probably a cause for a lot of the muscle tension around my neck and jaw which may be causing my TOS. Is my dentist correct? I'm a little skeptical hearing this information from a dentist.
Wednesday May 18, 2011 12:55 Paul
Paul, TOS is often caused from whiplash injuries, exercise induced enlargement of the scalene muscle, an extra rib in the chest, repetitive work-related injury, abnormalities in the first rib, fibrous bands, and narrowing of the area surrounding the anterior scalene muscle and nerves in the area. It's unlikely that jaw tension is causing TOS.
Wednesday May 18, 2011 12:59 drchristo
Baltimore Sun Health:
That's all the time we have for today. Thanks for your questions.
Wednesday May 18, 2011 1:01 Baltimore Sun Health
Thank you for your questions today. I hope it was helpful.