Thoracic Outlet Syndrome, A Case Report

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Thoracic Outlet Syndrome, A Case Report

Shawn M Neff, DC, MAS, Casey S. Okamoto

Published:

Journal of the Academy of Chiropractic Orthopedists
March 2015, Volume 12, Issue 1

The original article copyright belongs to the original publisher. This review is available from: http://www.dcorthoacademy.org © 2015 Neff and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction: This paper presents a case report of chiropractic management of a patient with thoracic outlet syndrome.

Case Presentation: A 65 year old male was treated with spinal manipulation for intermittent bilateral hand numbness and paresthesia.

Management and Outcome: The patient’s pain was measured utilizing a Numeric Rating Scale and orthopedic testing was used to monitor for arterial insufficiency. Manipulation of the cervical spine was performed manually. Following the fourth visit, the patient reported complete resolution of pain and paresthesia in the extremities.

Conclusion: In this case a patient with thoracic outlet syndrome was successfully treated with chiropractic care. In light of multiple anecdotal reports showing positive outcomes further study is warranted to evaluate the treatment of this common disorder.

Keywords: Spinal Manipulation, Chiropractic, Thoracic Outlet Syndrome

Background

Thoracic outlet syndrome (TOS) can be divided into three subtypes: neurogenic, venous, and arterial. Neurogenic is the most common and is responsible for approximately 90 percent of cases.1,2 Cases of neurogenic TOS are caused by compression of the brachial plexus and present with pain, numbness, paresthesia, or muscle weakness in the arm or hand. Neurogenic TOS is further divided into true neurogenic TOS, which can be objectively demonstrated utilizing diagnostic instruments, and non-specific neurogenic TOS, which cannot.2 Venous TOS is the second most common, and represents 3-5% of TOS. Venous TOS is caused by congenital narrowing, and subsequent thrombosis, at the junction of the subclavian and jugular veins. Venous TOS presents with pain, paresthesia, and a feeling of heaviness in the affected arm, each of which may be exacerbated or precipitated by activity. The arm may appear swollen or cyanotic, with enlarged collateral veins in the shoulder and ipsilateral chest wall. Arterial TOS is the least common, and represents less than 1% of all TOS. Most cases of arterial TOS are caused by stenosis of the subclavian artery, usually secondary to obstruction by anatomy. Cervical ribs, calloused clavicle fractures, and hypertrophic C7 transverse processes can all cause partial occlusion of the subclavian artery. A less common cause of arterial TOS is thromboembolism, broken from atherosclerotic plaque in the subclavian artery, and lodged in a distal artery or arteriole. Arterial TOS may present with pain, paresthesia, and motor weakness in the affected arm and hand. The finger nails may exhibit splinter hemorrhaging, secondary to an embolism. If the TOS is longstanding, the patient may exhibit ischemic ulceration.1,2

Though a number of studies have been conducted to measure post-surgical outcomes in patients with TOS few have been done to measure the efficacy of conservative care. Fewer still have been done specifically regarding the treatment of TOS with chiropractic manipulation. TOS is most reliably diagnosed and categorized based on history and clinical presentation, as recent studies show commonly used provocative tests like Adson’s and modified Adson’s to be unspecific. At this juncture, there is no “gold standard” test for rendering a diagnosis of TOS. 2 For this reason, it is difficult to determine the incidence. Compounding the problem is poor interdisciplinary reliability in diagnosing TOS. For instance, one study found that orthopedic surgeons were 100 times more likely to diagnose TOS than were neurologists.4,5

Case Presentation

A 65 year old Caucasian male presented to the chiropractic clinic for intermittent bilateral hand numbness and tingling. The paresthesia was diffuse in both hands and arms, but was worse in the left extremity. He reported a history of whiplash following a motor vehicle accident, after which the symptoms began to occur. Lying down in the supine position was listed as provocative for his symptoms and regular changes in position were palliative. He described the sensation as tingling accompanied by pain, which he rated at 5/10 on the Numerical Rating Scale (NRS). The patient’s medical/surgical history was significant for ankle surgery, healed T12 compression fracture, and hypertension. The patient had seen a chiropractor for carpal tunnel syndrome approximately ten years prior, with good results.

Examination revealed positive modified Adson’s tests bilaterally, with the pulse diminished more markedly on the left than right. Modified Adson’s created ipsilateral non-dermatomal tingling and numbness. Allen’s test was positive on the right for radial artery insufficiency. Adson’s test was negative bilaterally. Though the patient reported a history of contralateral paresthesia while side lying, we were unable to recreate the condition during examination. Moderate muscle spasm and pain was noted on palpation of the posterior and middle scalenes bilaterally. Motion palpation revealed intersegmental hypomobility in the cervical spine. There was no noted sensory deficit in the absence of provocative testing. A review of available imaging revealed a grade I spondylolisthesis of L5, a healed compression fracture of T12, and degenerative changes, including posterior joint sclerosis and enthesopathic changes, at L3, L4, and L5. Cervical radiographs revealed ostephytosis, posterior joint sclerosis, decreased disc space, and bilateral foraminal stenosis at the levels of C5, C6, and C7. The patient was diagnosed with intermittent thoracic outlet syndrome (TOS) and somatic dysfunction as well as degenerative disc disease of the lumbar and cervical spine, history of compression fracture, and muscle spasm.

Management and Outcome

As the patient’s symptoms were reproduced with provocative testing and skeletal imaging did not reveal a cervical rib, it was not considered necessary to perform any initial vascular imaging. It was explained to the patient that if the symptoms did not change as expected with treatment further studies may be obtained.

The patient underwent a course of cervical spinal manipulation for five treatments over the course of seven weeks. In addition, the patient received instructions regarding stretches for the scalene, trapezius, pectoralis, levator scapulae, and sternocleidomastoid muscles. All manipulations were performed with manual adjusting techniques.

Prior to each treatment the patient was asked to rate his pain associated with paresthesia on the NRS. At the initial consult, the patient rated his pain at 5/10. At the second visit, the patient reported 0/10 pain, but noted occasional tingling in the left hand. Pretreatment NRS on the third visit was recorded at 0/10 with one instance of right hand paresthesia while sleeping. At the fourth visit, the patient reported with 0/10 pain and no instances of paresthesia. On the fifth and final visit, the patient reported 0/10 pain, without paresthesia, and reported only one instance of paresthesia since his the fourth visit.

Orthopedic exams for TOS were repeated. Left Adson’s and modified Adson’s were negative. The patient was advised to continue with his home exercise program, including stretches, and was discharged from the clinic with remission of symptoms.

Conclusion

In this case a patient was successfully treated to a resolution of symptoms with chiropractic care. Following the course of treatment the symptoms could not be recreated with provocative testing and there was no detectable reduction in arterial flow. As mentioned these provocative tests are unspecific in the diagnosis of TOS of various types and there is no consistent testing for this condition, therefore TOS is most reliably diagnosed and categorized based on history and clinical presentation. The resolution of the TOS symptoms indicates clinical success.

As the world continues to demand more time working on computers and doing repetitive tasks the incidence of this already common condition is likely to increase. 6 Surgical treatment is effective but costly and riskier than conservative care.7 If conservative care is shown to be as effective in most cases this could mean a substantial decrease in risk related to iatrogenic injury as well as significant savings in health care costs.

Although several studies have shown improvement with conservative care and surgical care, uncertain diagnostic criteria and the lack of a “gold standard” limit the generalizability and clinical utility of the studies. Further and higher level study is needed to establish reliable, evidence-based protocols for the diagnosis and conservative treatment of this common condition.

Limitations have not been explored.

Consent

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

Supported by the Department of Veteran Affairs. The contents do not represent the views of the Department of Veterans Affairs or the United States Government.

References
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