Thoracic Outlet Syndrome
Thoracic outlet syndrome is a condition whereby symptoms are produced from compression of nerves or blood vessels, or both, because of an inadequate passageway through an area (thoracic outlet) between the base of the neck and the armpit. The thoracic outlet is surrounded by muscle, bone, and other tissues. Any condition that results in enlargement or movement of the tissues of or near the thoracic outlet can cause the thoracic outlet syndrome. These conditions include muscle enlargement (such as from weight lifting), injuries, an extra rib from the neck at birth (cervical rib), weight gain, and tumors at the top of the lung (rare). Often no specific cause is found.
It is felt by some researchers that the evolution of the torso of primates from a four-legged to a two-legged position may predispose humans to the development of thoracic outlet syndrome. The resulting vertical posture produced flattening of the chest cage and a shift of the shoulder joint backward, both of which narrowed the thoracic outlet.
Thoracic outlet syndrome is a rare condition that involves pain in the neck and shoulder, numbness and tingling of the fingers, and a weak grip. The thoracic outlet is the area between the rib cage and collar bone.
By Structures affected & Symptomatology
There are three main types of TOS, named according to the cause of the symptoms; however these three classifications have been coming into disfavor because TOS can involve all three types of compression to various degrees: The compression occurs in three anatomical structures, arteries, veins and nerves; isolated, or more commonly two or three of the structures are compressed. Compression can be of different magnitude in each of these structures.
neurogenic TOS or NTOS, disorders produced by compression of the components of the brachial plexus nerves. The neurogenic form of TOS accounts for 95% of all cases of TOS.
arterial TOS or ATOS, caused by compression of the subclavian artery.
venous TOS or VTOS, caused by compression or blockage of the subclavian vein
There are many causes of TOS. The most frequent cause is trauma, either sudden, as in a clavicle fracture caused by a car accident, or repetitive trauma, as in a legal secretary who works with her hands, wrists, and arms at a fast paced desk station with non-ergonomic posture for many years. TOS is also found in certain occupations involving lots of lifting of the arms and repetitive use of the wrists and arms.
One cause of arterial compression is trauma, and a recent case involving fracture of the clavicle has been reported
The two groups of people most likely to develop TOS are those suffering from neck injuries from traffic collisions and those who use computers in non-ergonomic postures for extended periods of time. It is a frequent repetitive stress injury caused by certain types of work environments. Other groups which may develop TOS, are athletes who frequently raise their arms above the head (such as swimmers, volleyball players, shuttle players, baseball pitchers, and weightlifters), rock climbers, housewives who need to raise their arms to hang washing and clean windows and walls, electricians who work long hours with their hands above their heads and also some musicians.
By structure causing constriction
It is also possible to classify TOS by the location of the obstruction:
Scalenus anticus syndrome (compression on brachial plexus and/or subclavian artery caused by muscle growth) diagnosed by using Adson's sign with patient's head turned outward.
Cervical rib syndrome (compression on brachial plexus and/or subclavian artery caused by bone growth) diagnosed by using Adson's sign with patient's head turned inward.
Costoclavicular syndrome (narrowing between the clavicle and the first rib) – diagnosed with the costoclavicular maneuver.
Some people are born with an extra, incomplete and very small rib above the first rib, which protrudes out into the superior thoracic outlet space and this rib causes fibrous changes around the brachial plexus nerves and causes the symptoms of Thoracic Outlet Syndrome. This is called a Cervical Rib, and is attached to the C-7. The symptoms of Thoracic Outlet Syndrome can first appear in the early teen years as a child is becoming more athletic. Surgical removal of this rib is almost always recommended
Causes, incidence, and risk factors
Blood vessels and nerves coming from the spine or major blood vessels of the body pass through a narrow space near the shoulder and collarbone on their way to the arms. As they pass by or through the collarbone (clavicle) and upper ribs, they may not have enough space.
Pressure (compression) on these blood vessels or nerves can cause symptoms in the arms or hands. Problems with the nerves cause almost all cases of thoracic outlet syndrome.
Compression can be caused by an extra cervical rib (above the first rib) or an abnormal tight band connecting the spinal vertebra to the rib. Patients often have injured the area in the past or overused the shoulder.
People with long necks and droopy shoulders may be more likely to develop this condition because of extra pressure on the nerves and blood vessels.
Overhead athletes, such as swimmers and volleyball players, are known to be predisposed to the development of TOS.
Symptoms of thoracic outlet syndrome may include:
- Pain, numbness, and tingling in the pinky and ring fingers, and the inner forearm
- Pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse)
- Signs of poor circulation in the hand or forearm (a bluish color, cold hands, or a swollen arm)
- Weakness of the muscles in the hand
When thoracic outlet syndrome affects the nerves, the first treatment is always physical therapy. Physical therapy helps strengthen the shoulder muscles, improve range of motion, and promote better posture. Treatment may also include pain medication.
If there is pressure on the vein, your doctor may give you a blood thinner to dissolve the blood clot. This will help reduce swelling in your arm.
You may need surgery if physical therapy and changes in activity do not improve your symptoms. The surgeon may make a cut either under your armpit or just above your collarbone.
During surgery, the following may be done:
- An extra rib is removed and certain muscles are cut.
- A section of the first rib is removed to release pressure in the area.
- Bypass surgery is done to reroute blood around the compression or remove the area that is causing the symptoms.
Your doctor may also suggest other alternatives, including angioplasty if the artery is narrowed.
Continued and active postural changes along with osteopathic, acupuncture, physiotherapy or massage therapy may suffice. The recovery process however is long term, and a few days of poor posture can often set one back.
About 10 to 15% of patients undergo surgical decompression following an appropriate trial of conservative therapy, most often specific physical therapy directed towards the treatment of thoracic outlet syndrome, and usually lasting between 6 and 12 months. Surgical treatment may include removal of anomalous muscles, removal of the native anterior and/or middle scalene muscles, removal of the first rib or, if present, a cervical rib, or neurolysis (removal of fibrous tissue from the brachial plexus). Surgical treatment for Thoracic Outlet Syndrome does have serious life -long risk. A good number of individuals suffer moderate to severe post operative complications and worsening or returning of symptoms post first rib resection. This unfortunate portion of this patient population is often left out of most articles and abandoned by the TOS medical community.
The goal of self stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, and tendons causing the problem.
Moving shoulders forward (hunching) then back to neutral, followed by extending them back (arching) then back to neutral, followed by lifting shoulders then back to neutral.
Tilting and extending neck opposite to the side of injury while keeping the injured arm down or wrapped around the back.
This syndrome causes a compression of a large cluster of nerves, resulting in the impairment of nerves throughout the arm. By performing nerve gliding exercises one can stretch and mobilize the nerve fibers. Chronic and intermittent nerve compression has been studied in animal models, and has a well-described pathophysiology, as described by Susan Mackinnon, MD, currently at Washington University in St. Louis. Nerve gliding exercises have been studied by several authorities, including David Butler in Australia.
Extend your injured arm with fingers directly outwards to the side. Tilt your head to the otherside, and/or turn your head to the other side. A gentle pulling feeling is generally felt throughout the injured side. Initially, only do this and repeat. Once this exercise has been mastered and no extreme pain is felt, begin stretching your fingers back. Repeat with different variations, tilting your hand up, backwards, or downwards.
TOS is rapidly aggravated by poor posture. Active breathing exercises and ergonomic desk setup can both help maintain active posture. Often the muscles in the back become weak due to prolonged (years) of hunching.
Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving circulation to them. While the whole arm generally feels painful, some relief can be seen when ice/heat is applied to the thoracic region (collar bone, armpit, or shoulder blades).
Injected into a joint or muscle, cortisone can help relief and lower inflammation
Botox, short for Botulinum Toxin A, binds nerve endings and prevents the release of neurotransmitters that activate muscles. A small amount of Botox injected into the tight or spastic muscles (usually one or all three scalenes) found in TOS sufferers often provides months of relief while the muscle is temporarily paralyzed. This noncosmetic treatment is unfortunately not covered by most medical plans and costs upwards of $400. The relief of symptoms from a Botox injection generally lasts 3–4 months, at which point the Botox toxin is degraded by the affected muscles. Serious side effects have been reported, and are similarly long-lasting, so improved understanding of the mechanism of a 'scalene block' is vital to determining the benefit and risk of using Botox. Additionally, many patients report no relief of symptoms from Botox or scalene injections, which may indicate that the pain does not stem from the scalene muscle, and may not be TOS. Botox can be an effective treatment for neurogenic TOS. It may allow for the patient to apply physical therapy pain free and thereby be able to properly stretch and open up the compressed area.
Having the first rib removed and the fibrous bands broken may relieve symptoms in certain patients. Surgery can be successful in 50% to 80% of patients. Conservative approaches using physical therapy are helpful for many patients.
At least 5% of patients have symptoms that return after surgery.
Complications can occur with any surgery and relate to the type of procedure and anesthesia used.
Damage to nerves or blood vessels may occur during surgery. This could lead to weakness of the arm muscles, or weakness of the muscles that help control the diaphragm when you breathe.
Medical Marijuana/Cannabis Relieves TOS Symptoms:
The cannabinoids in marijuana are potent pain relievers. In a study reported in the 2009 issue of "Neurotherapeutics," Drs. Rahn and Hohmann tested several cannabinoids on nerve pain that is often associated with nerve damage, The researchers found that cannabinoids derived from the smoked plant, from synthetic compounds, and from plant extracts were all effective in treating pain.
Inflammation is at the root of many chronic diseases. A major active ingredient in marijuana is cannabidiol, which has anticonvulsant, anti-epileptic and anti-inflammatory properties. In a study published in the 2009 issue of "CNS Neuroscience and Therapeutics," lead author Dr. T. Iuvone notes that inflammation was a common symptom in many neurodegenerative diseases and actually contributed to the progressive degeneration of nerve cells. The researchers found that cannabidiol has neuroprotective and anti-inflammatory actions .
Indica dominant hybrid: extracts, tinctures, decoctions, salve/balm, vaporizer, edibles, cannabutter
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Indica (dominant) x Sativa hybrid
- Neurotherapeutics; "Cannabinoids as Pharmacotherapies for Neuropathic Pain: From the Bench to the Bedside"; Rahn, E.J. and Hohmann, A.G.; October 2009
- CNS Neuroscience and Therapeutics; "Cannabidiol: A Promising Drug for Neurodegenerative Disorders?"; Iuvone, T. et al; 2009
- Neuro Endocrinology Letters; "Clinical Endocannabinoid Deficiency (CECD): Can This Concept Explain Therapeutic Benefits of Cannabis in Migraine, Fibromyalgia, Irritable Bowel Syndrome and Other Treatment-Resistant Conditions?"; Russo, E.B.; April 2008
- The Journal of Pharmacology and Experimental Therapeutics; "Antitumor Activity of Plant Cannabinoids With Emphasis on the Effect of Cannabidiol on Human Breast Carcinoma"; Ligresti, A. et al; September 2006
- Molecular Cancer Therapeutics; "Cannabidiol Enhances the Inhibitory Effects of Delta9-Tetrahydrocannabinol on Human Glioblastoma Cell Proliferation and Survival"; Marcu, J.P. et al; January 2010
Read more: http://www.livestrong.com/article/92021-medicinal-uses-marijuana/#ixzz1RXpIulMPReferences
1. MeSH Thoracic+outlet+syndrome
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17. San Francisco Chronicle: Lowry's agent lashes out
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