Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and today we're highlighting thoracic outlet syndrome with my guest, Dr. Jarrad Rowse. He's a Vascular Surgeon with UAB Medicine. Dr. Rowse, thank you so much for being with us today. As we set the table here, why don't you let other providers, kind of give us a working definition, what is thoracic outlet syndrome?

Jarrad Rowse, M.D.: Yeah, thanks for having me, Melanie. So, thoracic outlet syndrome is really a constellation of symptoms that come in really three different types. So, when we describe thoracic outlet syndrome, the most common type is neurogenic thoracic outlet syndrome, and that is a constellation of pain, numbness, tingling that affects not only the neck, shoulder, and entire upper extremity, but originates typically from the thoracic outlet, which is right at the junction with the neck and the chest.

So, what we see with that most commonly is what I said before, the numbness, tingling, pain in young, active, healthy people otherwise typically. The other two types of thoracic outlet syndrome are arterial and venous; venous being the next most common. Venous thoracic outlet often presents as an upper extremity DVT in an otherwise young and healthy person. They can have arm swelling, pain and often fatigue in their arm due to the swelling.

These are often these come about fairly quickly and can be quite problematic for folks who have new onset DVT. And least infrequently is arterial thoracic outlet. And this is where we have arterial damage due to compression of the thoracic outlet space.

And this leads to lack of blood flow to the arm, including thromboembolism, as well as it can develop subclavian or axillary aneurysms due to the arterial abnormality. And these are a little more urgent and in need of urgent attention in that regard.

Host: Dr. Rouse, how does it happen as you're talking and it's young, otherwise healthy people? What's the most common reason this happens?

Jarrad Rowse, M.D.: Well, one of the most common anatomic reasons that we know is the cervical rib. So this is an extra enumerated rib that comes off the cervical spine. This can lead to compression of any structure in the artery, vein or the nerves. Most commonly, it impacts the artery or the nerves.

The other most common things that we see that can lead to these are just sort of developmental in the sense that there's some anatomic predisposition to thoracic outlet. We don't have clear definitions or defined guidelines for that, but what we do know is patients often have elongated upper torsos and necks. 

They often are participatory in activities such as repetitive overhead activities. We often see this in athletic individuals who grew up doing sports or actively doing sports such as swimming, tennis, volleyball, basketball, pitchers will see this, baseball players, softball players. So, a lot of it may actually have to do with the activities that they're doing as well as we can see this just in folks who've had trauma. So, motor vehicle collisions or other reasons that may lead to sudden abrupt trauma to the upper extremities or neck can lead to these diagnoses. Most commonly in that setting for trauma is often neurogenic, but I've seen patients with clavicular fractures or other orthopedic injuries that can lead to damage to the artery or the veins. So those are really the most common reasons why people may have this.

Host: How is it diagnosed? What role does imaging play, modalities such as MRI, CT angiography? Just really tell us about how you accurately diagnose thoracic outlet syndrome.

Jarrad Rowse, M.D.: So, the easiest ways to diagnose and the easiest diagnoses within thoracic outlet are the arterial and the venous. So, for arterial thoracic outlet, we can often start with an ultrasound of the upper extremity, particularly focusing on the subclavian artery. We can, in the vascular lab with this ultrasound, we can often do maneuvers to assess with the arm in overhead positions, whether or not we do we see arterial compression or do we see an aneurysm or arterial abnormality within the artery itself?

If there's concern for venous thoracic outlet in a patient, you know, you're concerned for DVT with upper extremity swelling, a venous duplex is the most common and very reliable at finding an associated axillary subclavian DVT, which is pretty much pathognomonic for venous thoracic outlet syndrome.

From there if there is a diagnosed DVT, typically as a vascular surgeon we'll proceed with either a CT scan of the chest and upper extremity or proceed directly to venogram to assess for clot burden and intervention on the clot, particularly in the acute phase of the clot.

Neurogenic thoracic outlet is really the most complex and sort of most difficult to diagnose within the, within thoracic outlet syndrome. It's often a diagnosis of exclusion for most patients because most often it's more, it's much more likely to have cervical disc disease or shoulder pathology that causes these abnormalities.

And there can be overlap between these as well, particularly, in patients who've had injuries or either had trauma. So often most of the patients I see that are being assessed for neurogenic thoracic outlet, are referred from either an orthopedic physician, a sports medicine physician, a spine physician who has ordered MRIs of the cervical spine, evaluated the shoulder, often have EMGs which can be non contributory in this diagnosis because they're often normal in patients who have neurogenic thoracic outlet. What makes it even more complicated is neurogenic thoracic outlet by definition isn't always a nerve problem. 

The nerves themselves aren't damaged. The nerves are just compressed and therefore lead to the symptoms. Hence why we may not see that on MRIs or static imaging, other static imaging like a CT scan and EMGs because there's no underlying true nerve damage or other problems with the nerve, we don't see positive EMGs.

So, really it's a clinical diagnosis at first, before we really move forward with any other further advanced treatment, invasive testing or surgery.

Host: Well, then let's talk about some of the treatment modalities, Dr. Rowse. Why don't you start with the conservative measures, the role of physical therapy in managing thoracic outlet syndrome, how that integrates with the other treatments and when does this then become surgical?

Jarrad Rowse, M.D.: Yeah, so, physical therapy is really our first line treatment for again, neurogenic thoracic outlet. An arterial and venous thoracic outlet doesn't really have much of a role. Most of those will be recommended to be treated surgically for which will be to prevent either blood clots in venous thoracic outlet or in arterial, it's the un thoracic outlet we need to treat the underlying arterial pathology, repairing the aneurysm and restoring flow to the arm if needed. Physical therapy for neurogenic thoracic outlet syndrome is a mainstay because the underlying pathology here really is a musculoskeletal problem for the large majority of patients.

So it's because the scalene muscles, which are the middle, anterior and middle, which anterior and posterior to the brachial plexus, as well as often the pec minor muscle can cause brachial plexus compression as well. So the goal with physical therapy is to provide the muscles to relax to help with posture so that we can open up the thoracic outlet and the pec minor space in order to relieve that compression. And the hopes with continued physical therapy is that we can get sustained relief from the symptoms. Doesn't mean it can always, can't come back, but integrating these things into people's lives with the stretching and the other types of exercises we do, can often provide lifelong relief from thoracic, neurogenic thoracic outlet syndrome.

After two or three months of physical therapy, we really had no substantial relief and really no improvement in the symptoms, often the next step would be to consider surgery. Now, before I consider surgery for neurogenic thoracic outlet, the next step would be a series of ultrasound guided blocks to help really define the diagnosis and help manage expectations if we're going to think about surgery.

The first area we target is the anterior and middle scalene muscles. So, often working with our pain management colleagues, we will have them under ultrasound, inject into these areas to temporarily paralyze using lidocaine or sometimes lidocaine or bupivacaine combination with a corticosteroid in order to provide relaxation of the scalene muscles and then decompress medically the thoracic outlet. Now, these don't provide long term relief for most people, but it does provide a diagnostic test because if the patient improves substantially after this block, then thinking about surgical intervention for long term relief is highly correlated with long term results with good outcomes with surgery. The same can be held true for Pec Minor Syndrome, which for me sort of is in the same arena as Thoracic Outlet Syndrome, and I treat it very similarly. And so, the Pec Minor block can also really can be helpful in defining whether or not and what symptoms it's contributing to in that room. So once we have those blocks, if we have substantial relief with either or both, then the next step would be discussion of surgery for the patient. There's multiple ways to approach the surgery for thoracic outlet syndrome.

Specifically focusing on neurogenic, the approach that I take is a superclavicular approach. Other approaches are done through a transaxillary approach and there's some evolving, literature supporting doing this robotically through the chest. I still feel that the supraclavicular approach allows me to fully visualize the nerves, decompress the space and open up all the scar tissue around the brachial plexus and allow for full thoracic outlet decompression.

The surgery is more than just removing the first rib, which is kind of what we think about as being a bony structure underlying the thoracic outlet, and that can lead to to this really being a problem space, but we also have focus on the scalene muscles, resecting them to prevent recurrence, as well as freeing up any fibrocartilaginous bands that may develop in this ongoing process around the brachial plexus.

So for that diagnosis, that's how I approach that. Venous and arterial are similarly done. We need to resect the rib that is surrounding that same area. We need to free up the vein if it's for venous thoracic outlet and remove external scar tissue. The artery, I do the same approach, supraclavicular.

Often they're associated with cervical ribs. I'll remove that portion of the cervical rib as well as reconstruct the artery as needed in those senses. Surgery is generally well tolerated if we select the right patients. Most patients do really well with a low reoccurrence risk after surgery.

Host: This is such an interesting discussion, Dr. Rowse. So you've mentioned that many of your patients are referred from your sports medicine colleagues and you mentioned the addition of pain management colleagues and how they come in in first line and conservative measures if the patients are refractory to physical therapy.

So I'd like you to kind of summarize that multidisciplinary approach, the how that's evolved in managing these patients and what further collaboration could enhance that care delivery as you see it down the line for better outcomes.

Jarrad Rowse, M.D.: Yeah, so I think it's, I mean, it's extremely important that it's not just one physician in isolation treating these patients, you know. There's lots of collaboration that is required, you know, not only in the pre operative during physical therapy phases, I work very closely with physical therapists and interacting and engaging with them and trying to help our patients really thrive through physical therapy. My goal for most of the patients is not to need surgery, although a lot of patients ultimately do and a lot of them do well with surgery, but if we don't have to operate on a patient, that's is really great news for them and it doesn't provide any long term negative side effects when you don't have to have surgery.

So I work well with pain management as well. They provide not only preoperative help with diagnosis, but also often if we have patients that have trigger points or other things that develop along the way, they're great at integrating them and getting them in quickly to, take care of those other aspects of the care that is beyond my expertise. The other areas that we work well with is within orthopedic surgery, as well as peripheral neuro surgery. Here at UAB, we're actually working to develop a complex peripheral nerve center with thoracic alley being part of that. But I think it's great to have other surgical specialties that have expertise in this area and can help really people deliver the best care to each of our patients. Not every patient that I see that's referred for neurogenic thoracic outlet has thoracic outlet syndrome. A lot of them will have carpal tunnel syndrome, cubital tunnel syndrome, lots of these other nerve compression syndromes. And so it's great to have other colleagues who can help take care of those patients as well and get them expeditious care.

So I think it's extremely important for our patients with thoracic outlet to have a multidisciplinary team.

Host: As we get ready to wrap up, Dr. Rowse, what are the typical outcomes for these patients? Are there specific factors that influence prognosis and what would you like the key takeaways to be? What would you like other providers, primary care, internal medicine, orthopedic, sports medicine, listening to this podcast to know about thoracic outlet syndrome and those outcomes?

Jarrad Rowse, M.D.: Yeah, so I think a diagnosis that's getting more attention, particularly in the setting that we often see imaging testing not being positive. It's more of a clinical diagnosis and I think we have to be attuned to that. So I think just really listening to our patients and not dismissing some of their concerns is really of utmost importance in this diagnosis.

I think continuing to just think about this and the treatment of patients with upper extremity diseases is really important. Most patients, the recurrance risk with surgery after neurogenic thoracic outlet is quite low in the single digits; somewhere between 5 to 10 percent is what's been published in multiple studies.

So, the outcomes are quite good and venous and arterial have even better outcomes when we treat these patients expeditiously and don't ignore the fact that we need to remove the clot, and restore flow whether that's arterial or venous flow. So it's extremely important that when we see these that we get the patient in to see vascular surgery quickly so that we can give them the best long term outcomes, and we know that opening the vein and artery quickly leads to better outcomes.

Host: Thank you so much, Dr. Rowse, for giving us such great information and sharing your incredible expertise with us today. For more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast.

I'm Melanie Cole. Thanks so much for joining us today.