The patient had been in unrelenting pain for more than 20 of his 78 years. Despite multiple nerve blocks, rounds of physical therapy, visits to different doctors and a wide range of pain relievers and anti-inflammatories, nothing seemed to help. Even more discouraging, none of the imaging or testing could find anything likely to be the source of the pain. Finally, when a specialist couldn't find any orthopedic problems, he referred the patient to David Whitley, MD at Vascular Institute of Birmingham for an evaluation.
"In reviewing tests and talking with the patient about his history, it was soon clear that thoracic outlet syndrome was likely to be the root cause of his pain. An echo confirmed it," Whitley said.
After undergoing corrective surgery at Ascension St. Vincent's Medical Center, the patient was so happy with the relief that he was asking how soon he could have the other side done when he was barely out of recovery.
"Thoracic Outlet Syndrome often presents with symptoms similar to the pain of an orthopedic condition or the numbness of a neurological problem," Whitley said. "It can go misdiagnosed for a long time until someone realizes that the lack of positive test results could be an indication that the source of the problem lies elsewhere."
Symptoms arise when spacing is too tight to allow adequate blood flow through the vein and artery exiting over the top rib in the clavicle area. It can develop on one side of the body or to a greater or lesser degree in both. Left untreated, symptoms can range from pain and numbness to the possibility of a blood clot if a vein is damaged, or rarely, an aneurysm if there is enough wear on the artery.
"We can make any necessary vascular repairs when we do the surgery," Whitley said. "In mild cases, physical therapy may be enough to stretch the space to offer some relief, depending on the individual anatomy. However, when patients can't live with the discomfort any more, we start looking at whether surgery offers the best option."
To open up space for adequate blood flow during the surgical procedure, it may be necessary to remove a section of the top rib and possibly release some of the muscle tissue.
What causes thoracic outlet syndrome and who is most likely to develop the problem?
"I'm seeing more young, athletic people lately, particularly those involved in sports that require a lot of throwing or repetitive motion," Whitley said. "Occupational risks also include repetitive motion and carrying heavy loads can also contribute to the problem. If a person is involved in an accident, injuries to bone structures may change spacing. Basic anatomy and posture also play a role. People with sloped shoulders tend to be at higher risk."
Whitley is one of the most highly regarded vascular surgeons in the nation who performs the corrective procedure for thoracic outlet syndrome. He is also one of the busiest and finds this type of surgery especially rewarding.
"Some of my happiest patients are those who have had thoracic outlet surgery," he said. "The relief from pain makes such a difference. I just wish more practitioners would remember to consider whether it might be a possibility earlier in the diagnostic process so patients didn't have to wait so long for the correct diagnosis and the relief it can bring. No one should have to live with pain when relief is available."
A Thoracic Outlet Syndrome Patient Discusses Her Experience
When Sarah Beth Roberson was in high school and college studying to become an elementary school teacher, she loved being active and playing sports.
"Then one day, out of the blue, I tried throwing a ball and a pain shot through me. I thought I'd torn or sprained something. I couldn't even raise my arms without it hurting," she said.
She tried the usual locker room remedies for sports injuries, but nothing helped. So she made an appointment with a doctor and went through the usual treatments and medications. Physical therapy actually seemed to make it worse.
Then, hoping to get to the root of the problem, she went to a sports medicine orthopedic specialist.
"When nothing showed up on the imaging, I couldn't believe it," Roberson said. "Something had to be wrong, considering the pain I was in. The specialist said it might be Thoracic Outlet Syndrome, so he referred me to Dr. Whitley. My mom is a surgical nurse and she had worked on several procedures so she knew what it was.
"It only took Dr. Whitley a couple of minutes to figure it out and the echo he ordered confirmed it. Then we talked about surgery. I was a little worried about having a scar with summer coming. He said he only needed a tiny incision and he had a special way of doing stitches so they didn't show much.
"It was amazing. Now you can barely see it. Best of all, my shoulder doesn't hurt."