Learning Objectives
Understand the pathophysiology of TOS
Learn the provocative maneuvers to diagnose TOS
Understand treatment options for TOS

Case Presentation
EB is a 30 year old white female who presents with left upper extremity swelling and pain, which began while she was watching a movie in a theater. She says that when she left the movie, a couple of hours after the symptoms initially began, she noted that the swelling of her left arm was worse and there was pain in her shoulder region. She also could not get her ring off of her finger and her left hand was dusky. She did not have any shortness of breath or pleuritic chest pain. A few days before that the patient had been shoveling snow during a heavy snow storm and the day after that developed upper respiratory symptoms including sore throat, sharp chest pain, a sensation of her ears being plugged and swollen glands in her neck.
The patient had a Doppler evaluation which revealed clot in the subclavian and axillary veins. A CT scan of the chest revealed no evidence of pulmonary embolism. She had a hypercoagulable workup which was negative. She was treated with heparin and then started on Coumadin and consideration was given a couple of times to giving thrombolytics but this was not done. She was taken off her OCP.
Ultrasound of the left upper extremity was performed about 15 days after the onset of symptoms and revealed interval partial recanalization of the left subclavian vein and slight increase in flow within the left axillary vein in a patient with previous occlusive thrombus in these vessels.
MRI of the left upper extremity was performed to look for a compressive component to her vasculature in the left upper extremity as a cause for the DVT.

TOS – Differential Diagnosis
Cervical disc disease
Cervical facet disease
Malignancies (Pancoast/local tumors, spinal cord tumors)
Peripheral nerve entrapments (ulnar or median nerve)
Brachial plexitis
Rotator cuff injuries
Fibromyalgia, muscle spasm
Neurologic disorders (MS)
Chest pain, angina
Vasculitis
Vasospastic disorder (Raynaud’s)
Neuropathic syndromes of upper extremity

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