Scott Webb: Most of us have never heard of thoracic outlet syndrome. It's not terribly common. Elliot Vascular Surgery is now capable of treating all types of this unique syndrome. And joining me today to tell us about thoracic outlet syndrome is Dr. Elena Rinehardt. She's a board-certified vascular surgeon.

This is your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Doctor, thanks so much for your time today. We were sort of joking a little bit that this is a topic that I have never done. I have done maybe a thousand of these, but I do not know what thoracic outlet syndrome is, but I'm pretty sure you do. So, let's start there. What is that and what are the different types?

Dr. Elena Rinehardt: So, I think that's a great comment because not only is this condition somewhat mysterious to those in the general public, but I think it's also a hard topic for medical professionals who don't specialize in it. But it's a condition that I see and treat frequently, so I think it's important to get the information out. So, when we talk about the thoracic outlet, what we're talking about is the space in the neck between the first rib, which is the rib closest to the head, and the collarbone. There are nerves, muscles, and blood vessels that travel through this very narrow space.

And thoracic outlet syndrome is a term that's used to describe any problem related to this general space. So, the structures that are at risk for compression are the nerves, the veins, and the arteries. There's also a space just below the clavicle that's related to the pectoralis minor muscle, and it's called the pectoralis minor space. The nerves from the thoracic outlet continue to travel through the space. So, nerves and blood vessels can get compressed and also cause symptoms in the arm.

Scott Webb: All right. So yeah, it's not something that most of us would be familiar with, and you did a great job explaining it. So that gives us a place, a good jumping-off point there. So, then what happens with each type of thoracic outlet syndrome? What do people experience?

Dr. Elena Rinehardt: So, the most common problem I see is called neurogenic thoracic outlet syndrome. That affects the majority of the patients, and it involves compression of a bundle of nerves called the brachial plexus. All of these nerves travel from the neck to supply the arm. So, if there's compression, patients can have arm pain, skin hypersensitivity, weakness, numbness, or even loss of muscle mass in the hand if it's been going on for a long time.

The second most common problem I see is venous thoracic outlet syndrome, and this is diagnosed when a patient has an unexplained blood clot in the arm, veins, or a discoloration of their hand, like a blue discoloration, swelling, or tingling in the hand.

And the least common type that we see is called arterial thoracic outlet syndrome, which is when there is wear and tear that happens on the artery, and it can disrupt the blood flow to the hand, so the hand will be pale, numb, painful, and likely cold to touch.

Scott Webb: It Hmm. makes me wonder, doctor, is this something that we do to ourselves? Is it the result of an injury? Is it just sort of wear and tear and being a human? You know, how does this happen exactly? And who's at the highest risk?

Dr. Elena Rinehardt: So, for neurogenic thoracic outlet and pectoralis minor compression, typically, the history involves people who've experienced injuries, or they're involved in physical activities that predispose them to compression. There are some people that are just born with an additional rib in the neck called a cervical rib or an extra muscle, or a variation in muscle attachments that contribute to this problem, but that's obviously not their fault. When we see cervical ribs, they're most commonly seen in women, and they can also predispose patients to get symptoms after an injury.

And when we're talking about injuries, it's typically a repetitive injury. So, for example, patients that come in are athletes like swimmers or baseball or softball players. Patients who enjoy weightlifting and those who do repetitive motions at work, like stacking boxes or typing or mechanical work. So, for example, car mechanics or people who do a lot of work on the computer and keyboard. When people get neck trauma, it can also cause inflammation in the neck, and it can exacerbate the problem. So, with neck trauma, the most common type of injury is a motor vehicle crash. A broken rib or a broken collarbone or, in the winter, falls from standing, like falling on ice.

Scott Webb: Yeah, it's such a wide range of folks that you see, and we were sort of joking before we got rolling that hopefully I would be able to follow you, and I am, and that this would be really education for me and the listeners. And it is. I never knew that some folks have an extra rib. So good stuff today, doctor. I was wondering, do you treat all types of thoracic outlet syndrome at Elliot?

Dr. Elena Rinehardt: So, we are now able to treat all of these different types of thoracic outlet syndrome and pectoralis minor syndrome. And the good news for patients is that not all will require surgery. So, a lot of patients that I see get a lot of benefits from posture training or reassessing the ergonomics of their workspace and having some sessions with an occupational therapist or a physical therapist. There's also a simple test that we can do to identify patients with nerve compression who would benefit from surgical treatment.

It's a little bit more straightforward for patients who have a blood clot in their veins or arteries because, for those patients, the time to treatment is pretty quick. And we now have new technology that allows us to remove blood clots from arteries and veins in one session. So, we just do this by placing a small tube inside the blood vessel with a patient very lightly sedated. And we get the clot out as quickly as possible. The reason it helps to do this is because we can decrease the amount of inflammation around the blood vessels, and it can decrease debilitating symptoms for patients long-term.

Previously, the treatments we had available involved people staying in the intensive care unit for multiple days just to receive medications and then undergoing surgery. So, I think in terms of the ease of treatment, it's been reduced to a couple of treatment sessions rather than having to stay in the hospital for prolonged periods.

Scott Webb: Yeah. And I'm sure that's music to the ears of all listeners who might be suffering from this, and you kind of described a little bit earlier the different ways this may sort of present, but for all of us lay people, we're experiencing things or seeing our hand change colors, let's go through again just the symptoms that should really prompt us to see a doctor.

Dr. Elena Rinehardt: Yeah, and as I mentioned earlier, this condition will affect patients who are younger and older. So, depending on the age, it's kind of a slightly different trigger. But for younger patients, anyone who's experiencing unexplained arm swelling or blood clots should really have an evaluation with an ultrasound. If a blood clot is found, typically, the treating physician will prescribe blood thinners and refer the patient to a vascular surgeon. At that point, we may schedule a minimally invasive procedure for clot removal or a subsequent operation to remove the rib.

But essentially the goal of treatment is to free up the area for the blood vessels and nerves and allow for a faster recovery. And this is relevant in particular when we're talking about a dominant arm that's affected. For middle-aged or older patients, if they experience a sudden loss of a pulse or reduced blood flow in the arteries, in the hand, or arm. They should be evaluated in the emergency room because time is really of the essence to prevent damage to the hand and help preserve function.

For patients with nerve compression, they've typically seen multiple specialists such as a neurologist, a spine surgeon, an orthopedic surgeon, perhaps a physical therapist, and they're referred to us having undergone extensive testing, conservative treatments and have really not found an answer to their problem. So, typically, for patients with nerve compression, they're coming with a full workup that's already been completed, and we're kind of the last stop in that evaluation.

Scott Webb: It's really interesting. I have little sayings, little buzz sayings, doctor, when we think about heart attacks, so time is hard or strokes, time is brain. I'm gonna add to that list from you today. Time is hand, right? It's really important. Time is of the essence. So, all good stuff today, doctor, and I think as we wrap up, we want to know if there is anything that we can do to reduce our risk? It sounds like some folks it might be their work, or sports, or repetitive motions. Others may have the extra rib and so on, but is there anything that we can do specifically to avoid getting thoracic outlet syndrome?

Dr. Elena Rinehardt: Yeah, I think that's a really important question because, as we mentioned, for people who just have variations in their anatomy, that's nothing they're doing wrong. And I think it would be pretty hard to discourage somebody from participating in a favorite sport, or perhaps that sport is how they make a living. Obviously, avoiding accidents in general is a good recommendation, but there's only so much you can do. I think the main takeaway is when a hand is affected, especially if it's a dominant hand or dominant arm, it's important to get evaluated quickly, and meet with a vascular surgeon to discuss treatment options early on.

Because honestly, when we see patients here, we're able to get them better symptoms and arm function improvement from our treatments. Patients with nerve compression typically they've had symptoms for multiple years. So again, speaking with a vascular surgeon can lead to a more complete evaluation and referrals for the appropriate type of therapy or a minimally invasive procedure or surgery with a focus on improving or restoring arm functions.

Scott Webb: Yeah, that's perfect and good to know that at Elliot Vascular Surgery, you guys can handle all the variations, the types of thoracic outlet syndrome. Doctor, this has been so educational today. Before we got started, I told you that I really love learning from these things. It's my favorite part about this, and I hope that listeners learned, they heed your advice, and if they have any of these signs and symptoms that they reach out to their provider. So, thanks so much. You stay well.

Dr. Elena Rinehardt: Thank you.

Scott Webb: And for more information on thoracic outlet syndrome, go to elliothospital.org/website/vein-and-vascular-care-center.php.

And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.