This syndrome is much discussed for reasons that we will see later. It is called thoracic gorge syndrome a series of neurological and / or vascular symptoms due to the compression of these structures in a specific anatomical area that we call the thoracic gorge. This gorge is the space that exits from the nerves of the neck between the scalene muscles to its passage between the clavicle and the first rib to end up in the armpit. Along this path are the artery and the subclavian vein. Perhaps we understand better seeing the drawing below.
This syndrome can affect us in two ways. On the one hand, it is possible to compress the subclavian artery and / or vein passing through this area and give circulation problems. On the other hand, it can affect the nerves that leave the neck and go down this region to end up in the armpit. These nerve structures are the ones that will form the definitive nerves that are distributed by the arm. Then we will see what consequences it has.
Causes of Thoracic Gorge Syndrome
There are a number of anatomical alterations that have been associated with this syndrome and that have caused us to call this syndrome in many different ways. These are some of the other names and their explanation.
– The cervical rib. In the neck there are no ribs. The ribs that form the thorax come out of the twelve dorsal vertebrae. In some people there may be a small “rib” that comes out of the cervical area (an extension of the transverse process that may be of different sizes). This occurs mainly in women and predisposes to suffer this syndrome. What has been verified is that it is not the rib itself that causes the compression but a ligament that leaves the tip of this rib until the first true rib.
– The scalene syndrome. Sometimes the entrapment is caused by anomalies in the arrangement of the muscles that surround and cushion the exit of the nerves and blood vessels. There are described deformities such as the fusion of scalene muscles, for example. In some people there may be excessively developed muscles in this area (scalenes, subclavius and pectoralis minor) that favor this syndrome.
– There are other names for this syndrome such as costoclavicular syndrome or hyperabduction syndrome.
What are the symptoms of thoracic gorge syndrome?
Depending on the structure that is compressed we have some symptoms or others:
– Neurological impairment. When we compress the nerves that go down to the arm we will notice tingling, pain and possibly weakness in the arm that may be diffuse or in a specific nervous territory. When the nerves are compressed due to the ligament that we mentioned before leaving the cervical rib, the typical affection of the lower roots that compose the nerves of the arm (C8-T1). This causes tingling of the inside of the arm. Typically, these symptoms are more pronounced when we raise our arms above the shoulders and in certain forced neck postures. In rare cases severe affection can be seen with atrophy of the musculature. These types of symptoms are also typical of cervical disc hernias, which is why I talk about this syndrome.
– Vascular affectation. If the subclavian vein is compressed we will have edemas (fluid retention that we will notice as swelling) in the arm, especially in the hand. Compression of the artery is the least frequent. It produces symptoms of pain, tingling and coldness in the arm (because the blood is not well).
How is thoracic gland syndrome diagnosed?
This is where the problem and the discussion about this syndrome is. In many cases the diagnosis will be made by seeing the symptoms and by the physical examination in the consultation. Only the source of the problem will be confirmed when the patient undergoes surgery and the problem is proven.
In the exploration in consultation the best known is the maneuver of Adson. This maneuver is used to try to reproduce the symptoms. At the same time we take the patient’s pulse at the wrist, we take the raised arm back and turn the neck to the opposite side. In this maneuver the pulse decreases or the tingling in the arm begins. This test is very unreliable and should not be what the diagnosis determines.
In some cases where neurological involvement predominates, an electromyogram can demonstrate the nerve entrapment as it passes through the thoracic gorge. Although it can give negative despite the existence of the entrapment. Tests such as X-ray and CAT scan allow us to see structures such as the cervical rib but will not give us the diagnosis. MRI helps little when it comes to nerve involvement in this region.
Vascular studies are more varied and precise and may be of more help when there is an involvement of the subclavian artery or vein. Ultrasound and Doppler, CAT, MRI, and arteriography are tests that can guide the diagnosis.
In many cases we will have the suspicion that the patient is suffering from this syndrome without being able to prove it. This is where the discussion between the defenders and the detractors of the existence of these processes enters. It is true that it is a very rare syndrome compared to the other causes of pain and tingling in the arm such as a herniated disc, muscular contractures or a shoulder injury.
All the data I have given correspond to the true syndromes, which have proven their existence. There are many more who are in that limbo without a clear diagnosis and without sufficient gravity to undergo a surgical intervention.
What is the treatment of thoracic gorge syndrome?
The treatment will depend on the severity of the symptoms and the situation of the patient. Surgery will be the option when there is progressive neurological involvement or significant vascular symptoms.
If no severe symptoms can be treated initially with physical therapy and medication. It can help to lose weight, strengthen the muscles and improve the posture with our therapist. Infiltrations with corticoids or botulinum toxin have been tested with disparate results. In vascular complications there are other types of procedures that may be necessary such as catheterization or anticoagulant treatments.