The thoracic outlet syndrome, or precordial catch syndrome, is a set of symptoms and signs caused by compression of blood vessels or nerves passing through the thoracic outlet.
The causes of this painful syndrome are different. At its origin, in fact, there may be congenital anatomical defects, trauma, repetitive activities, incorrect posture, etc.
The symptoms vary depending on the compression regarding nerves or vessels blood. Generally, however, pain is a symptom common to both situations.
Diagnosing the problem is complex, because each individual represents a case in itself.
First instance therapy is conservative. Surgery, in fact, is reserved for the most serious cases.
Brief anatomical reference on the thoracic outlet
Human anatomy experts call the thoracic outlet the physiological (therefore natural) narrowing delimited by the first rib, the clavicle, the scalene muscles (median and anterior), the subclavian muscle and the pectoralis minor muscle.
Within this narrowing run the system of blood vessels artery – subclavian vein and the brachial plexus.
The subclavian artery system – subclavian vein and the brachial plexus represent, respectively, the blood vessels that serve the upper limbs and the nervous network responsible for innervation, both sensory and motor, of the upper limbs.
What is precordial catch syndrome?
The precordial catch syndrome – also known as thoracic dell’egresso syndrome, syndrome of thoracic outlet or syndrome of scalene – is a set of symptoms and signs that appear when blood vessels or nerves located at the level of thoracic outlet are crushed.
There are three different forms of thoracic outlet syndrome:
- The neurogenic (or neurological ) form. With a frequency of about 95%, neurogenic thoracic outlet syndrome is the most common of the three existing pathological forms. Compression concerns, as can be easily understood from the name, the nerve network of the brachial plexus.
- The venous form. Venous thoracic outlet syndrome occurs in about 3-4% of patients and is the result of obstruction / compression of the subclavian vein that supplies blood to the upper limb.
- The arterial form. Arterial thoracic outlet syndrome is the least common of the three pathological forms. In fact, it has a frequency of about 1%.
At the base there is an obstruction / compression of the subclavian artery.
When considered together, the venous form and the arterial form constitute the so-called vascular syndrome of the thoracic outlet, where vascular clearly refers to the involvement of blood vessels.
The data on the incidence of thoracic outlet syndrome are somewhat conflicting.
According to some sources, the aforementioned condition would be found between 3 and 80 people for every 1000 individuals examined. So, in terms of percentages, it means between 0.3 and 8%.
The most affected individuals are young people; the sex most interested is the female one, probably because women have predisposing anatomical characteristics.
To determine the compression of the blood vessels or the nerves of the thoracic outlet, it can be:
- It is a congenital defect. Some individuals are born with an extra rib (” cervical rib “) or with a band of fibrous tissue that abnormally joins the spine to the first cervical rib. These two congenital anatomical defects (very often also hereditary) can reduce the internal space of the thoracic outlet, to the detriment of the blood vessels and the nerves that pass through it.
- Incorrect posture. Those who, due to a wrong body posture, suffer from drooping shoulders or keep their head leaning forward, in an unnatural way, tend to develop precordial catch syndrome more frequently.
- A trauma. If they affect certain areas of the body, some traumatic events can alter the internal anatomy of the thoracic outlet and lead to a reduction in the space within which the artery and the subclavian vein and the brachial plexus reside.
- The traumatic events that most often cause thoracic outlet syndrome are car accidents. In fact, in such situations, the impact to which the accident is subjected very often acts precisely between the neck, collarbone and first rib ( whiplash ).
- Fall traumas are also very “dangerous”.
- A repetitive activity. Some work or sports activities lead to repeating the same movement many times a day. This can lead to wear of the tissues present in all the sites of the body (therefore also at the level of the thoracic outlet), up to the onset of real pathologies.
- Potentially dangerous activities / tasks include prolonged computer use, assembly line work, repeated lifting of heavy objects overhead, playing baseball or swimming (NB: high-level sportspeople are at risk ).
- Joint pressure due to overweight / obesity. Excessive body weight can affect the good health of the body’s joints. All this can also affect some adjacent anatomical regions, such as the thoracic outlet.
- The state of pregnancy. During a pregnancy, the pregnant woman’s joints tend to loosen. This can lead to joint problems, which, as in the previous case, can spread to the neighboring anatomical departments.
Symptoms and Complications
The symptoms of precordial catch syndrome vary depending on whether the compression affects the brachial plexus or blood vessels. Hence, it depends on the pathological form present.
SYMPTOMS AND SIGNS OF THE NEUROGENIC FORM
The typical symptom picture of neurogenic precordial catch syndrome includes:
- Hand of Gilliatt-Summer . It is a problem at the base of the thumb, characterized by muscle atrophy
- Numbness and tingling in the arm or fingers at the end of the latter.
- Pain or discomfort in the neck, shoulder or hand
- Weak grip
Obviously, the aforementioned disorders are located in the half of the body where the compression of the brachial plexus is occurring. Thus, if the pain originates in the right thoracic outlet, the symptoms and signs will be located along the right upper limb.
SYMPTOMS AND SIGNS OF THE VENOUS AND ARTERIAL FORMS
The symptoms and signs of vascular precordial catch syndrome are:
- Changes in the color of the skin. Patients may experience discoloration or bluish skin
- Pain and / or swelling in the arm
- Feeling of weak or absent pulse
- Sensation of frost in the fingers, hand and / arm
- Pain in the elbow and armFeeling of extreme tiredness in the arm, after even a very light activity
- Numbness and tingling in the fingers
- Weakness in the arm or neck
- Pulsating area near the collarbone. It also often appears as a bulge
WHEN TO SEE THE DOCTOR?
When one of the symptoms described above appears, it is advisable to contact your doctor immediately, to trace the exact cause of the problem, before this develops complications.
Complications are usually due to lack of treatment.
In patients with the neurogenic form, deterioration of the affected nerve endings may take place, sometimes even very profound.
In individuals with the vascular form, on the other hand, there is an unusual tendency to develop small aneurysms, which, due to their shape, represent an optimal site for the formation of blood clots. Over time, clots can break down and give rise to emboli, which, by wedging into the smallest vessels, can obstruct the caliber of the latter and prevent blood circulation in certain areas of the body. Generally, the phenomenon just described affects the arteries (arterial form).
Diagnosing precordial catch syndrome is somewhat complex because the symptoms are extremely variable from patient to patient.
The diagnostic process generally begins with an accurate physical examination, also including the analysis of the patient’s clinical history. Then, it continues with some provocative texts and ends with a series of instrumental tests, in some cases even quite invasive.
During the physical examination , the doctor visits the patient, looking for any external clinical signs; then, she asks him to describe the symptoms felt and at what moments they become more acute. Finally, he asks him about his work activity, habits / pastimes during his free time, etc.
The challenge tests help doctors trace the underlying causes of a certain condition.
Arm pain provocation test. They consist in reproducing situations capable of triggering the symptoms described in the physical examination.
In the case of thoracic outlet syndrome, doctors have patients perform particular movements of the neck, arms, shoulders, etc.
Instrumental examinations are very useful, as the information they provide allows, in many cases, to reach a correct final diagnosis.
The prescribed procedures may include:
- X-rays. They allow the identification of the “cervical rib” (if present).
- Ultrasound. It is a non-invasive examination, which allows the identification of any vascular problems.
- CT scan. Using ionizing radiation, it provides a three-dimensional image of the internal organs of the body. It is very useful for analyzing the health of the blood vessels passing through the thoracic outlet.
- Nuclear magnetic resonance (NMR). It is a radiological examination that involves exposing the patient to completely harmless magnetic fields, instead of harmful ionizing radiation. Like the CT scan, it is useful to understand the structure of the blood vessels passing through the thoracic outlet.
- Arteriography and venography. These are two rather invasive practices, as they involve inserting a catheter into the arteries (arteriography) or veins (venography) , capable of diffusing a contrast liquid visible on X-rays. Based on the diffusion of the liquid inside the artery and subclavian vein, doctors understand if there is a vessel abnormality and what characteristics it has.
- Electromyography. It consists of studying the muscles and nerve endings that control them.
Doctors use different treatments, depending on whether the thoracic outlet syndrome is neurogenic or vascular. In light of this, the reader can realize how important it is to make a correct diagnosis of the present condition, also establishing the triggering causes with extreme precision.
Generally, the first instance therapeutic approach is conservative, that is, it consists of non-invasive therapeutic remedies.
If conservative treatments do not produce the desired results, the only and last solution available is surgery. This – it should be noted right away – is a rather risky operation, which doctors would always prefer to avoid.
The conservative therapy in case of neurogenic syndrome thoracic outlet provides:
- Physiotherapy. It includes stretching exercises for the neck and shoulder muscles, joint mobility exercises and exercises to correct and incorrect postures. To achieve good results, physiotherapists recommend practicing the exercises at home as well, not just during sessions at rehabilitation centers.
- Administration of anti-inflammatory and pain relieving drugs. To reduce inflammation and painful sensation, the most prescribed medicines are ibuprofen ( NSAIDs ), muscle relaxants, aspirin and, only in rare cases, corticosteroids.
For patients with the vascular form of precordial catch syndrome, treatments consist of:
- Thrombolytic and anticoagulant drugs. Thrombolytics are drugs that dissolve blood clots in the arteries and veins; anticoagulants, on the other hand, serve to keep the blood fluid. Generally, doctors plan a therapy that involves, first, the administration of thrombolytics and, then, that of anticoagulants.
- Administration of painkillers. They are used to reduce the painful sensation, which can sometimes be very annoying.
Surgery to treat precordial catch syndrome is known as thoracic outlet decompression.
There are at least three operative approaches with which doctors can perform decompression of the thoracic outlet:
- The transaxillary approach, with incision on the chest. It is indicated in the presence of the so-called “cervical rib”, therefore doctors can use it both when the thoracic outlet syndrome is of the neurogenic type and when the thoracic outlet syndrome is of the vascular type.
- The supraclavicular approach, with an incision just below the neck. It is indicated for repairing abnormal blood vessels (inside or outside).
Furthermore, it is also useful for operating those muscles which, modified following a traumatic event, compress the adjacent vascular tracts.
- The infraclavicular approach, with an incision under the collarbone. It is particularly suitable for delivering medicines to dissolve clots directly into the blood vessels.
In addition, it also allows you to repair damaged blood vessels with biological or artificial tissue transplants.
HEALTHY BEHAVIOR AND OTHER REMEDIES
Doctors believe it helps:
- Take care to always maintain correct posture
- Take short breaks from work, during which to stretch
- Maintain normal body weight
- Undergo massages of the painful area
- Avoid carrying weights, especially lifting them above your head
- Avoid all those activities that could worsen the symptoms
- Adapt the workplace (for example, to the computer) so that the neck and shoulders are not affected.
These indications, of course, are also useful in terms of prevention of thoracic outlet syndrome.
Prognosis depends on the timeliness of diagnosis and treatment. In fact, an early diagnosis of precordial catch syndrome allows for an equally early treatment and reduces the risk of complications.