Diagnosis and Treatment of Neurogenic Thoracic Outlet Syndrome (TOS) – A Clinical Analysis of Scalene Syndrome

Case Analysis: Neurogenic Thoracic Outlet Syndrome (Neurogenic TOS)

1. Patient Basic Information

• Male patient, experiencing itching and burning sensation in the right forearm for over 10 years, with several episodes each year, and the episodes have become more frequent in recent years, lasting for several weeks each time.

• Symptoms immediately relieved by ice application, worsen in summer and improve in winter, severely affecting sleep.

• The patient has tried various treatments with no effect and recently came to the clinic through a friend’s recommendation.

2. Main Symptoms and Medical History Features

• Significant itching and burning sensation, lasting for a long time (10 years), with progressively worsening episodes.

• Symptoms relieved immediately by cold, indicating potential involvement of the sympathetic nervous system.

• Worse in summer, better in winter, possibly related to abnormal sympathetic nervous function and blood flow regulation.

• Initially occasional, lasting from a few days to weeks and self-relieving, but with increased frequency and duration of episodes in the later stages.

• Severely affecting sleep, indicating strong symptoms that affect quality of life.

3. Physical Examination

• Skin Examination: Local skin intact, no skin lesions, papules, or other skin changes.

• Neurological Examination:

  • Diminished sensation in the outer forearm and thenar area, slightly dull sensation on the ulnar side of the hand.

  • Slight flattening of the lower triceps, indicating mild muscle atrophy due to long-term nerve involvement.

  • Normal tendon reflexes, normal muscle strength, indicating no significant involvement of motor nerves.

• Provocative Test:

  • Pain in the upper arm, outer lower arm, forearm, and thenar area upon pressing the anterior scalene muscle.

  • Complete relief of itching and burning sensation after continuous pressure for 1 minute.

4. Diagnostic Analysis

• Initial Consideration of Nerve Involvement

  • Sensory abnormalities (burning sensation, itching, numbness)

  • No significant motor impairment in the distal areas, suggesting the problem may lie in the proximal brachial plexus.

  • Sympathetic nerve abnormalities (relief with ice, burning sensation).

• Symptom fluctuation with pressure on the anterior scalene muscle

  • Directly points to Thoracic Outlet Syndrome (TOS), especially Neurogenic TOS.

  • Tension in the scalene muscles compresses the brachial plexus, primarily affecting C5-C7 (radial nerve, part of the ulnar nerve).

• Abnormal sympathetic nerve excitation

  • Indicates that the problem involves not only nerve compression but also sympathetic nerve dysfunction.

5. Final Diagnosis

• Neurogenic Thoracic Outlet Syndrome (Neurogenic TOS) — Scalene Syndrome

  • Main Cause: Tension in the anterior scalene muscle, compressing the brachial plexus (mainly C5-C7).

  • Key Features:

    • Itching, burning sensation (affected sympathetic nerve).

    • Numbness (radial nerve, part of the ulnar nerve).

    • Flattening of the lower triceps (mild muscle atrophy due to long-term nerve involvement).

    • Symptoms worsened with pressure on the anterior scalene muscle, relieved after continuous pressure (typical of TOS).

6. Treatment Plan

• 1. Acupuncture Treatment

  • Release of anterior scalene muscle: Tian Ding, Fu Tu, Que Pen

  • Improve brachial plexus nerve pathways: Ji Quan, Qu Chi, He Gu

  • Regulate sympathetic nerves: Nei Guan, Shen Men, Zu San Li

  • Moxibustion: Promotes local blood circulation and alleviates sympathetic nerve overactivity.

• 2. Manual Therapy

  • Release the anterior scalene muscle (patient rotates and laterally bends the head to the opposite side, applying pressure to the anterior scalene muscle).

  • Thoracic outlet adjustment (correct posture, avoid long-term shoulder elevation and slouching).

  • Nerve mobilization techniques (e.g., radial nerve gliding).

• 3. Rehabilitation Training

  • Correct breathing patterns (avoid chronic chest breathing, encourage diaphragmatic breathing).

  • Postural correction (reduce prolonged head protrusion and shoulder tension).

  • Self-massage or gua sha (to assist in relaxing the scalene muscles).

7. Prognosis and Follow-up

• Symptoms are expected to significantly improve within 2-4 weeks.

• Regular follow-up to assess the condition of the anterior scalene muscle release and nerve function recovery.

• Long-term management: Improve lifestyle habits, avoid excessive force, and prevent poor posture to avoid recurrence.

Summary

This case involves a patient with long-term itching and burning sensations. Symptoms were provoked and relieved by pressing the anterior scalene muscle, suggesting Neurogenic Thoracic Outlet Syndrome (Neurogenic TOS), with the main cause being tension in the anterior scalene muscle, compressing C5-C7 brachial plexus nerves and sympathetic nerves. Acupuncture, manual release of the scalene muscle, and rehabilitation training are the primary treatment methods, with a good prognosis.