Neurogenic Neurogenic Thoracic Outlet (TOS)- The Existence Killer – Yet Poorly Recognized

Neck and/or arm pain/numbness with progressive disability and many negative evaluations is typical of the disease. Emotional decompensation from pain and poor treatment from others, forms an integral part of the disease. Evaluation is actually quite simple – treatment often only palliative. Situation reminds me of people laughing at a joke – when they hear it, when they tell it, and when they finally get it. I had plenty of knowledge on TOS but the perspective and wisdom from Dr. Togut made it all clear (went to his talk twice)…

Neurogenic Thoracic Outlet Syndrome
Allen Togut
Painweek 2013 Presentation

  • Part of the problem is the overlap with other issues – It can be a result of whiplash so ignored – thinking it`s all from neck.¬† It can co-exist with carpal tunnel and shoulder issues and without good evaluation can be easily missed
  • 95% of TOS is neurogenic¬† and the standard TOS test for vascular compression (Adson`s test) will be negative
  • Only 30% of time will nerve studies be helpful. – a newer form of testing involving A Delta fibers with a 250 hertz signal being ramped up.
  • MRI`s are worthless – even the fibromuscular bands that can complicate this disorder are not visible


The journey that victims go through with this problem is akin to an odyssey to becoming one of the damned. Without good clinician assessment, and with negative electrodiagnosis and imaging –¬† they will be spurred by all others. Worse, they could have carpal tunnel and shoulder surgery without benefit. I tell my patients with chronic pain they will become a Rodney Dangerfield – “get no respect” but this is much worse. If there was an ice flow – they would be set adrift on one of them. It appears that psychological decompensation is universal with this condition – its absence would make you wonder..

Here is a presentation of 3 cases treated as nuts until successful treatment with surgery:
Pain. 1985 Jun;22(2):195-200.
Representation of the thoracic outlet syndrome as a problem in chronic pain and psychiatric management.
Jamieson WG, Merskey H.

Initiating factors include:

  • Motor Vehicle accidents – even a Canadian article on this subject:
    Mailis, Angela, et al.
    Thoracic Outlet Syndrome after Motor Vehicle Accidents in a Canadian Pain Clinic Population.
    The Clinical journal of pain 11.4 (1995): 316-324.

  • cumulative trauma – beauticians (short with arms up), musicians (eg violin players), video terminal operators, certain sports (baseball)
  • Heavy breasted women don’t usually get it unless they have repetitive or accident issues as well
  • Prior dislocated shoulder

What I found very interesting is getting the narrative of the story – and during exam as well. huarache homme huarache homme

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