Thoracic Outlet Syndrome Case Report: Appropriate Diagnosis Can Expedite Patient Treatment and Prevent Negative Outcomes

Abstract

Introduction: Thoracic outlet syndrome (TOS) is a diagnosis classifying upper extremity symptoms caused by compression of the neurogenic and vascular structures between the clavicle and first rib. It is important to promptly decompress these structures to prevent long-term deficits and poor patient outcomes. However, TOS often presents in unique ways with substantial symptom variance, making it difficult to identify, diagnose, and promptly treat. Compounding this, common diagnostic tools such as magnetic resonance imaging are not independently appropriate for a conclusive diagnosis of TOS. Patients with TOS can initially present acutely due to symptom exacerbations or emergent situations, necessitating multimodal diagnostic methods and early TOS recognition to improve patient outcomes, particularly in emergency department (ED) settings.

Case report: A 22-year-old male presented with chronic symptoms of numbness and weakness in his right hand in addition to chest pain that radiated into his right elbow, along with a diminished right radial pulse. The patient also suffered from acute symptomatic exacerbations of total arm asthenia, paresthesia, and what the patient described as "an intensely cold hand" during football practice. He was eventually treated with a right first-rib resection to decompress the brachial plexus, which resulted in complete symptom resolution and recovery.

Conclusion: Due to the serious long-term complications associated with uncorrected brachial plexus compression and the fact that TOS patients can initially present to ED settings with acute exacerbations, it is important for emergency clinicians to be able to recognize and either treat or appropriately refer patients for treatment. The ED is equipped to enable physicians to perform a comprehensive diagnostic assessment because they often have access to the diagnostic modalities necessary for diagnosing thoracic outlet syndrome.

Figure

Representation of the Roos test. Circles on each arm represent regions where a diminished pulse can be felt in a positive Roos test. The circle in the right axillary region represents possible compression of the thoracic outlet. The lines around the hands exemplify rapid opening and closing of hands during the Roos test. Reprinted with permission.

Image 1

Diagnostic imaging findings for thoracic outlet syndrome: A) demonstrates a radiograph displaying bilateral cervical ribs (arrows); B) points out the fibrous band from the cervical rib to the first thoracic rib near the inferior trunk (arrows); and C) is a T2-weighted magnetic resonance image showing increased signal near the inferior trunk (asterisk). Reprinted with permission, with arrows added to the image in section A.

Image 2

Ultrasound of the brachial plexus with and without Doppler: B) normal and C) injured side. Compare the cross-sectional view of the brachial plexus (BP) in these images. The BP is larger on the injured side. D) Longitudinal axis showing compression of the lateral trunk (LT) by the middle scalene (MS) muscle as is denoted by the measuring markers labeled 1; and E) short-axis view of the LT compression by the scalenus minimus (SM). SCA, subclavian artery; AS, anterior scalene. Reprinted with permission.