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Compression syndromes of the upper thoracic aperture
Last reviewed: 07.07.2025
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Thoracic outlet compression syndromes are a poorly defined group of neurological disorders characterized by pain and paresthesias in the hands, neck, shoulders, or arms. The disorder is thought to involve compression of the lower trunk of the brachial plexus (and possibly the subclavian vessels) where they pass under the scalene muscles above the 1st rib. There are no specific diagnostic methods. Treatment includes physical therapy, analgesics, and, in severe cases, surgery.
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Pathogenesis
The pathogenesis of the disease is often unknown. Sometimes compression is associated with the presence of a cervical rib, an atypical first thoracic rib, abnormal attachment or course of the scalene muscles, or improper healing of a clavicle fracture. It is more common in women aged 35-55 years.
Symptoms of upper thoracic aperture compression syndromes.
Pain and paresthesias usually begin in the neck or shoulder, spreading to the medial arm and hand, and sometimes to the adjacent anterior chest wall. Mild to moderate sensory loss at the C7-Th2 level is common on the side of pain, and sometimes there are marked vascular-vegetative changes in the hands (e.g., cyanosis, swelling). Weakness in the affected hand is sometimes present. Rare complications include Raynaud's syndrome and distal gangrene.
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Diagnostics of upper thoracic aperture compression syndromes.
The diagnosis is based on the distribution of symptoms. Various methods have been proposed to demonstrate compression of vascular structures (eg, brachial plexus traction), but their sensitivity and specificity have not been established. Auscultation reveals vascular bruit over the clavicle or in the axillary region, and radiography may reveal a cervical rib. Angiography may reveal kinking or partial obstruction of axillary arteries or veins, but neither result is definitive proof of the disease. Other diagnostic methods are also controversial. As with brachial plexopathy, instrumental examination (eg, electrodiagnostics and MRI) is warranted.
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Treatment of upper thoracic aperture compression syndromes.
In most cases, patients without objective neurological defects respond well to physical therapy, NSAIDs, and low doses of tricyclic antidepressants.
In the presence of a cervical rib or subclavian artery obstruction, the question of surgical treatment should be decided by an experienced specialist. With rare exceptions, surgery is indicated in cases of significant or progressive neurovascular disorders, as well as in cases resistant to conservative therapy.