Selected Podcast
Thoracic Outlet Syndrome (TOS)
Dr. Gregory Pearl discusses Thoracic Outlet Syndrome (aka First Rib Resection).
Featuring:
Gregory Pearl, MD, FACS
Gregory J. Pearl, MD, FACS, Co-Medical Director for Vascular Surgery at Baylor Scott & White Heart and Vascular Hospital - Dallas and Baylor University Medical Center. National speaker for many professional athletic organizations on thoracic outlet syndrome. Involvement in numerous clinical trials and studies across the vascular surgery spectrum. Widely published in professional medical journals. Transcription:
Caitlin Whyte: Today we welcome Dr. Gregory Pearl to the show. He is the Co-Medical Director for Vascular Surgery at Baylor Scott and White Heart and Vascular Hospital in Dallas. And he's going to tell us a bit about the Thoracic Outlet Syndrome or first rib resection. This is Heart Speak, the podcast from Baylor Scott and White Heart and Vascular Hospital, Dallas Fort Worth. I'm your host, Caitlin Whyte. So Thoracic Outlet Syndrome or TOS, sounds very, you know, like a specific syndrome. Can you tell us exactly what that means?
Dr. Pearl: It's a condition it's most commonly seen in young active individuals and it's typically caused by some type of injury and it can be a specific injury, like a lifting injury or a fall or a whiplash injury, or it can be just a cumulative type injury from overuse. And that's what we see in the athletes, especially the throwing athletes, which is from Reddit, repetitive overuse of the upper extremity or even somebody that's working in an office or in a job where they're doing a lot of repetitive activities with the upper extremity, especially reaching out away from their body or overhead repetitively. And what's occurring is that some muscles up in the neck that run down and attached to the top rib, from that repetitive overstimulation, start to shorten and get very tight and because of the anatomic configuration of everything up there, the nerve artery and vein, passes behind that muscle over the top of the first rip and behind the collarbone. And so the space between the collarbone and the top rib is a tight space anyway.
And if you add this very tight muscle, that's getting tighter and shortened more over time from the overstimulation, it compresses and traps and irritates the nerve artery and vein as they pass through that space. Anytime nerves get compressed or pinched or irritated anywhere in the body it's going to cause pain, numbness, tingling, weakness, fatigue, heaviness, etcetera. And that's related to the nerve irritation. If the vein gets compressed or pinched, it can cause a blood clot and cause a big swollen arm. And if the artery is being compressed and becomes damage, it can cause a blood clot in the artery that can impair the circulation, the arm and hand. So it can be any where from a sort of a nuisance kind of a thing of some occasional numbness and tingling in the arm and hand to a true life or limb threat issue with the development of blood clots.
Host: So, what are some of the symptoms and diagnostic tests that are used to confirm this syndrome?
Dr. Pearl: So again, the condition is kind of divided up into neurogenic venous or arterial. And the classification is really upon the predominance of the symptoms or whether or not the patient has a blood clot. So the vast majority of patients that have thoracic outlet syndrome present with the neurogenic type and so that's where their symptoms are predominantly related to the nerve irritation. And that's probably 95% of patients that present with thoracic outlet, will present with the neurogenic type symptoms and that's it's pain and tightness in the neck, upper back, upper chest. They may have referred pain out into the shoulder or into the elbow or arm. And then there's some numbness and tingling so-called paresthesia that extend through the arm and hand. And the patients complain of a lot of fatigue and heaviness and weakness and extremity with use, just cause those nerves aren't able to fire to the muscles normally because of the compression.
And then those muscles get weak and they can't do the work of moving the arm as they would otherwise, if they were able to file a fire normally. With the venous type, again, they'll present with a big swollen, painful arm from the blood clot in the vein, where there's impaired blood return up out of the arm. And in the arterial, they can present with a lot of pain and sensitivity in their fingertips of their hand, usually from a little blood breaking off a clot in the artery, lodging down into the arteries of the hand and causing problems with tissue perfusion. And when they can actually get little ulcers and, or thick, painful callous over the tips of the fingers from the lack of the circulation. So they're different presentations, but again, the vast majority of patients present with the neurogenic type symptoms.
Host: So, what are some things that people can do, especially those young athletes to prevent developing this?
Dr. Pearl: Well, if it's the neurogenic type it's really all about postural correction, proper posture and for the athletes, proper mechanics. And for them, we do a lot of repetitive activities at work. It's again, proper pasture and posture correction, and then proper ergonomics. For example, if they work at a desk working at a computer all day, they need to make sure their desk height is appropriate. And that's where the standing or adjustable desks are very helpful. Proper chair height have the keyboard and mouse ergonomically appropriate set up, or there are actually ergonomic keyboards, and mouse to use. Patients that may be predisposed to that. Again, for patients that work at a desk or computer throughout the day, I have recommended they stand frequently and stretch and take short walks and things to really get everything kind of up, and stretched out. Again for the athletes is especially the throwing athletes. They just need to really be aware of proper mechanics, especially the baseball pitchers. That's really the best they can do because in most patients, it's more of a functional disorder in that there's not any anatomic abnormality per se. Unless the patient has an extra rib or some type of bony anomaly of like an abnormal first rib or clinical deformity from a fractured clavicle in the past. And that's the vast minority of patients that would have that. So the majority of patients that develop this again, don't really have any anatomic issues. It's mainly just a functional issue of, again, repetitive use, overuse, that's causing depression of the nerve artery and vein within the outlet.
Host: So, when it comes to surgery for TOS, who is a good candidate?
Dr. Pearl: So, it's really all about the symptoms. And so for the neurogenic, the nerve type, again, which is by far and away, the most common type it's really based on the severity and the duration of their symptoms. What their daily physical activities typically require them to do, and how disruptive or disabling the symptoms are to those daily activities. For example, in the athlete, they typically can't perform, they're bored, and all the things related to their sport. It's certainly not performing at an elite level like they would like based on the symptoms. So most of the athletes will give them a period of rehab trying to work and make these corrective rehabilitation. But in some of those athletes it'll help, but most athletes because of the daily physical demands of what they're doing with the workouts and throwing and everything related to their sport, it's such a physically demanding, rigorous, repetitive use kind of activities with their sport. They usually require surgery to decompress the nerve neurovascular bundle, to get rid of the symptoms. The non-athletes have more options. And again, we get them into a physical therapy program working on postural correction, muscular stretching muscular strengthening, core strengthening, things like that.
And then of course, just as we talked about a few minutes ago making any ergonomic or mechanical adjustments that would be helpful within their workplace or with what they're doing with their job, are they able to restrict or modify the activities that they're doing that minimize those causative mechanisms. And for those patients that don't respond well to the conservative treatment in any way, where the patient symptoms are still of such severity that they're really causing them daily misery, and they're truly life altering and disruptive to them on a daily basis. They simply just can't do what they otherwise need to be doing or want to be doing. And the therapy and these other corrective measures haven't helped, then they'll consider having surgery to fix it, to decompress the neurovascular bundle and get rid of the symptoms. For the vascular type, if they have a blood clot, most of those patients will require surgery to fix it, so they can have their arm improved related to the swelling from the blood clot in the vein, or remove that source of a blood clot in the artery that could cause problems with circulation and even potentially tissue loss in the hand.
Host: And wrapping up here, what does recovery time look like post-Surgery?
Dr. Pearl: So, what we do with the procedure itself is we're basically going in and removing those points of compression, where the nerve artery and vein are being compressed. So the procedure can be done in a couple of different approaches. I do it through an approach. That's a make a short incision just above the collarbone at the base of the neck, and then go in and detach and exercise that muscle that we were talking about that gets so tight and short, called the anterior scalene muscle. And then we free up any adhesive bands or adhesions that we see around the nerves and the vessels, it's called a neural isis, and an isis of the vessels. And then we take out that top rib. And the top rib is actually a very short curved rib people think of, you know, their ribs that they filled out along their side is a gripping long thing. And they are in that location. But up at the top and at the first drip, it's a very short, maybe four or five inch long curved rib that just is tucked up under the collarbone. You can't see it or feel it, it doesn't really provide any specific function that's irreplaceable. The patient will never miss it. And the muscle is mainly a stabilizer. It doesn't really move anything like most muscles move bones across joints. The scalene is more of kind of a stabilizer muscle, which in fact is the reason that it's more predisposed to being, to shortening and compressing cause that's what it's built to do.
So, there's no visible change in somebody's appearance. There's no change or alteration and their ability to move a certain way or they're weaker in a certain way or something by removing these things, to the contrary the purpose of the procedure and the intent of the procedure is to rid the patients of all of their symptoms and get them back doing whatever they want without restrictions. For example, the athletes, our goal is to get them back performing very high level under daily physically demanding circumstances. And all other patients that have such severity of symptoms that are unable to just do typical daily, normal, everyday things due to the disruptive and stabling nature of the symptoms. Our goal is to get them back doing whatever they want, again, without any symptoms or, or restrictions. So the surgery itself takes about an hour and a half hour and 45 minutes. It's not a really long procedure. We keep the patients to the hospital for a couple of nights, mainly to manage their postoperative discomfort and get them transitioned over to an oral pain medication regimen that they'll be on for a week or two after the surgery.
They're not immobilized in any way, like there's no splint or brace. Like there is in some upper procedures like elbow surgery or shoulder surgery where the patient has to be immobilized for awhile. There's no immobilization in this procedure, went with the patients to be up and using their extremity for normal everyday stuff, eating, bathing, brushing their teeth, to help keep a lot of these muscles up around the neck and upper back and upper chest kind of worked out and keep it from getting too tight and sore. Let everything kind of settle down for a week or 10 days after the surgery and then we get back into a rehab program with physical therapy, and it's a very similar to the therapy that we work on before the surgery to try to avoid the patient having to have surgery. And it's all about postural correction, scaling stretches, pectoral stretches, neural glide exercises, what we call scapulothoracic stabilization, and strengthening exercises, generalized stretching and strengthening program just in general. And that goes on for about six to eight weeks and kind of a progressive fashion under the direction of a physical therapist. And usually by a couple of months after surgery, the patients are feeling pretty good.
They still won't be a hundred percent because they'll still be regaining strength and things. As far as the return to a hundred percent recovery, get all their strength back and everything. Give me anywhere from three to six months, it's very much dependent on what kind of shape the patient was in before the surgery and how severe their symptoms were and how long the symptoms have been going on beforehand. Because patients that have had really prolonged severe symptoms can get fairly what we call deconditioned, where it takes them a little bit longer time to recover, to get over all their deconditioning related to their debilitation prior to the surgery. But usually by anywhere from three to six months, the patients are feeling good, in good shape, and full strength and getting back to whatever they want to do.
Host: Well, thank you for being with us and for breaking this topic down Dr. Pearl. That was Dr. Gregory Pearl, he is the co medical director of vascular surgery at Baylor Scott and White Heart and Vascular Hospital Dallas. Find out more about TOS at baylorhearthospital.com/TOS. This has been Heart Speak. I'm your host, Caitlin Whyte, stay well.
Caitlin Whyte: Today we welcome Dr. Gregory Pearl to the show. He is the Co-Medical Director for Vascular Surgery at Baylor Scott and White Heart and Vascular Hospital in Dallas. And he's going to tell us a bit about the Thoracic Outlet Syndrome or first rib resection. This is Heart Speak, the podcast from Baylor Scott and White Heart and Vascular Hospital, Dallas Fort Worth. I'm your host, Caitlin Whyte. So Thoracic Outlet Syndrome or TOS, sounds very, you know, like a specific syndrome. Can you tell us exactly what that means?
Dr. Pearl: It's a condition it's most commonly seen in young active individuals and it's typically caused by some type of injury and it can be a specific injury, like a lifting injury or a fall or a whiplash injury, or it can be just a cumulative type injury from overuse. And that's what we see in the athletes, especially the throwing athletes, which is from Reddit, repetitive overuse of the upper extremity or even somebody that's working in an office or in a job where they're doing a lot of repetitive activities with the upper extremity, especially reaching out away from their body or overhead repetitively. And what's occurring is that some muscles up in the neck that run down and attached to the top rib, from that repetitive overstimulation, start to shorten and get very tight and because of the anatomic configuration of everything up there, the nerve artery and vein, passes behind that muscle over the top of the first rip and behind the collarbone. And so the space between the collarbone and the top rib is a tight space anyway.
And if you add this very tight muscle, that's getting tighter and shortened more over time from the overstimulation, it compresses and traps and irritates the nerve artery and vein as they pass through that space. Anytime nerves get compressed or pinched or irritated anywhere in the body it's going to cause pain, numbness, tingling, weakness, fatigue, heaviness, etcetera. And that's related to the nerve irritation. If the vein gets compressed or pinched, it can cause a blood clot and cause a big swollen arm. And if the artery is being compressed and becomes damage, it can cause a blood clot in the artery that can impair the circulation, the arm and hand. So it can be any where from a sort of a nuisance kind of a thing of some occasional numbness and tingling in the arm and hand to a true life or limb threat issue with the development of blood clots.
Host: So, what are some of the symptoms and diagnostic tests that are used to confirm this syndrome?
Dr. Pearl: So again, the condition is kind of divided up into neurogenic venous or arterial. And the classification is really upon the predominance of the symptoms or whether or not the patient has a blood clot. So the vast majority of patients that have thoracic outlet syndrome present with the neurogenic type and so that's where their symptoms are predominantly related to the nerve irritation. And that's probably 95% of patients that present with thoracic outlet, will present with the neurogenic type symptoms and that's it's pain and tightness in the neck, upper back, upper chest. They may have referred pain out into the shoulder or into the elbow or arm. And then there's some numbness and tingling so-called paresthesia that extend through the arm and hand. And the patients complain of a lot of fatigue and heaviness and weakness and extremity with use, just cause those nerves aren't able to fire to the muscles normally because of the compression.
And then those muscles get weak and they can't do the work of moving the arm as they would otherwise, if they were able to file a fire normally. With the venous type, again, they'll present with a big swollen, painful arm from the blood clot in the vein, where there's impaired blood return up out of the arm. And in the arterial, they can present with a lot of pain and sensitivity in their fingertips of their hand, usually from a little blood breaking off a clot in the artery, lodging down into the arteries of the hand and causing problems with tissue perfusion. And when they can actually get little ulcers and, or thick, painful callous over the tips of the fingers from the lack of the circulation. So they're different presentations, but again, the vast majority of patients present with the neurogenic type symptoms.
Host: So, what are some things that people can do, especially those young athletes to prevent developing this?
Dr. Pearl: Well, if it's the neurogenic type it's really all about postural correction, proper posture and for the athletes, proper mechanics. And for them, we do a lot of repetitive activities at work. It's again, proper pasture and posture correction, and then proper ergonomics. For example, if they work at a desk working at a computer all day, they need to make sure their desk height is appropriate. And that's where the standing or adjustable desks are very helpful. Proper chair height have the keyboard and mouse ergonomically appropriate set up, or there are actually ergonomic keyboards, and mouse to use. Patients that may be predisposed to that. Again, for patients that work at a desk or computer throughout the day, I have recommended they stand frequently and stretch and take short walks and things to really get everything kind of up, and stretched out. Again for the athletes is especially the throwing athletes. They just need to really be aware of proper mechanics, especially the baseball pitchers. That's really the best they can do because in most patients, it's more of a functional disorder in that there's not any anatomic abnormality per se. Unless the patient has an extra rib or some type of bony anomaly of like an abnormal first rib or clinical deformity from a fractured clavicle in the past. And that's the vast minority of patients that would have that. So the majority of patients that develop this again, don't really have any anatomic issues. It's mainly just a functional issue of, again, repetitive use, overuse, that's causing depression of the nerve artery and vein within the outlet.
Host: So, when it comes to surgery for TOS, who is a good candidate?
Dr. Pearl: So, it's really all about the symptoms. And so for the neurogenic, the nerve type, again, which is by far and away, the most common type it's really based on the severity and the duration of their symptoms. What their daily physical activities typically require them to do, and how disruptive or disabling the symptoms are to those daily activities. For example, in the athlete, they typically can't perform, they're bored, and all the things related to their sport. It's certainly not performing at an elite level like they would like based on the symptoms. So most of the athletes will give them a period of rehab trying to work and make these corrective rehabilitation. But in some of those athletes it'll help, but most athletes because of the daily physical demands of what they're doing with the workouts and throwing and everything related to their sport, it's such a physically demanding, rigorous, repetitive use kind of activities with their sport. They usually require surgery to decompress the nerve neurovascular bundle, to get rid of the symptoms. The non-athletes have more options. And again, we get them into a physical therapy program working on postural correction, muscular stretching muscular strengthening, core strengthening, things like that.
And then of course, just as we talked about a few minutes ago making any ergonomic or mechanical adjustments that would be helpful within their workplace or with what they're doing with their job, are they able to restrict or modify the activities that they're doing that minimize those causative mechanisms. And for those patients that don't respond well to the conservative treatment in any way, where the patient symptoms are still of such severity that they're really causing them daily misery, and they're truly life altering and disruptive to them on a daily basis. They simply just can't do what they otherwise need to be doing or want to be doing. And the therapy and these other corrective measures haven't helped, then they'll consider having surgery to fix it, to decompress the neurovascular bundle and get rid of the symptoms. For the vascular type, if they have a blood clot, most of those patients will require surgery to fix it, so they can have their arm improved related to the swelling from the blood clot in the vein, or remove that source of a blood clot in the artery that could cause problems with circulation and even potentially tissue loss in the hand.
Host: And wrapping up here, what does recovery time look like post-Surgery?
Dr. Pearl: So, what we do with the procedure itself is we're basically going in and removing those points of compression, where the nerve artery and vein are being compressed. So the procedure can be done in a couple of different approaches. I do it through an approach. That's a make a short incision just above the collarbone at the base of the neck, and then go in and detach and exercise that muscle that we were talking about that gets so tight and short, called the anterior scalene muscle. And then we free up any adhesive bands or adhesions that we see around the nerves and the vessels, it's called a neural isis, and an isis of the vessels. And then we take out that top rib. And the top rib is actually a very short curved rib people think of, you know, their ribs that they filled out along their side is a gripping long thing. And they are in that location. But up at the top and at the first drip, it's a very short, maybe four or five inch long curved rib that just is tucked up under the collarbone. You can't see it or feel it, it doesn't really provide any specific function that's irreplaceable. The patient will never miss it. And the muscle is mainly a stabilizer. It doesn't really move anything like most muscles move bones across joints. The scalene is more of kind of a stabilizer muscle, which in fact is the reason that it's more predisposed to being, to shortening and compressing cause that's what it's built to do.
So, there's no visible change in somebody's appearance. There's no change or alteration and their ability to move a certain way or they're weaker in a certain way or something by removing these things, to the contrary the purpose of the procedure and the intent of the procedure is to rid the patients of all of their symptoms and get them back doing whatever they want without restrictions. For example, the athletes, our goal is to get them back performing very high level under daily physically demanding circumstances. And all other patients that have such severity of symptoms that are unable to just do typical daily, normal, everyday things due to the disruptive and stabling nature of the symptoms. Our goal is to get them back doing whatever they want, again, without any symptoms or, or restrictions. So the surgery itself takes about an hour and a half hour and 45 minutes. It's not a really long procedure. We keep the patients to the hospital for a couple of nights, mainly to manage their postoperative discomfort and get them transitioned over to an oral pain medication regimen that they'll be on for a week or two after the surgery.
They're not immobilized in any way, like there's no splint or brace. Like there is in some upper procedures like elbow surgery or shoulder surgery where the patient has to be immobilized for awhile. There's no immobilization in this procedure, went with the patients to be up and using their extremity for normal everyday stuff, eating, bathing, brushing their teeth, to help keep a lot of these muscles up around the neck and upper back and upper chest kind of worked out and keep it from getting too tight and sore. Let everything kind of settle down for a week or 10 days after the surgery and then we get back into a rehab program with physical therapy, and it's a very similar to the therapy that we work on before the surgery to try to avoid the patient having to have surgery. And it's all about postural correction, scaling stretches, pectoral stretches, neural glide exercises, what we call scapulothoracic stabilization, and strengthening exercises, generalized stretching and strengthening program just in general. And that goes on for about six to eight weeks and kind of a progressive fashion under the direction of a physical therapist. And usually by a couple of months after surgery, the patients are feeling pretty good.
They still won't be a hundred percent because they'll still be regaining strength and things. As far as the return to a hundred percent recovery, get all their strength back and everything. Give me anywhere from three to six months, it's very much dependent on what kind of shape the patient was in before the surgery and how severe their symptoms were and how long the symptoms have been going on beforehand. Because patients that have had really prolonged severe symptoms can get fairly what we call deconditioned, where it takes them a little bit longer time to recover, to get over all their deconditioning related to their debilitation prior to the surgery. But usually by anywhere from three to six months, the patients are feeling good, in good shape, and full strength and getting back to whatever they want to do.
Host: Well, thank you for being with us and for breaking this topic down Dr. Pearl. That was Dr. Gregory Pearl, he is the co medical director of vascular surgery at Baylor Scott and White Heart and Vascular Hospital Dallas. Find out more about TOS at baylorhearthospital.com/TOS. This has been Heart Speak. I'm your host, Caitlin Whyte, stay well.