Arterial TOS

Dizziness was the differentiating factor as Bryan Bopp sought medical help for chronic neck and facial pain.

A quintessential weekend warrior who participated in football and softball games as a young adult and remained an avid weight lifter, Bopp said that by the time he was in his early 30s, he was experiencing chronic low back pain as well as neck and myofacial pain. “I just figured it was because I was getting older and not able to do the things I did when I was in my 20s,” he says. “But it kept getting worse. I started to feel numbness and tingling in one of my arms all the way down to my pinky. It went on for several years.”

Depressed and battling anxiety as a result of doctors being unable to diagnose the cause of his pain, Bopp stopped lifting weights in 2007. “It was a major letdown to have to stop doing what I loved,” he says. “Three years of physical therapy and pain medications didn’t work, and I was trying to figure out if I was crazy because of all the pain.”

Two years later, a doctor ordered nerve conduction velocity studies around Bopp’s neck and shoulder. “He told me something was blocking a signal from traveling along the nerve path,” recalls Bopp. “The speculation was that it was neurogenic thoracic outlet syndrome because the main cause for that was compression around the brachial plexus nerve bundle.”

Bopp was referred to Robert Thompson, MD, a vascular surgeon at Washington University School of Medicine who specializes in thoracic outlet syndrome and directs the Washington University Center for Thoracic Outlet Syndrome at Barnes-Jewish Hospital. After initial physical examination, he suspected that Bopp had an extra cervical rib, which was confirmed by X-ray. A congenital anomaly affecting only 0.5% of the population, a cervical rib typically attaches to the first thoracic rib with a thick band of fibrous tissue. Its presence can block or interfere with the small opening that nerves and blood vessels pass through from the neck to the arm, especially when the arm is raised.

Bopp mentioned to Dr. Thompson that he had symptoms of dizziness in addition to neck and arm pain. “He put his thumb on my neck and felt a prominent pulse through my right collarbone,” says Bopp. “When he elevated my arm, he would lose the pulse completely.”

Dr. Thompson diagnosed Bopp with arterial TOS, and a Doppler study and an MR angiogram demonstrated that blood flow through the subclavian artery was disrupted. “It’s the least common form of thoracic outlet syndrome and seen in less than two percent of TOS patients,” says Dr. Thompson. “It’s often brought about by repeated and strenuous arm movements, coupled with unusual anatomy, such as a cervical rib.”

In half of these cases, the cervical rib or other congenital rib malformation compresses the subclavian artery, causing the artery to thicken. Over time, the thickening can result in distorted flow and the formation of an aneurysm, which can lead to blood clots, creating a potentially limb- or life-threatening situation.

Dr. Thompson explains, “The critical concern is that small blood clots can break off and travel to the hand, blocking blood flow down the arm. Patients are at risk for gangrene or loss of limb if the condition isn’t treated before an aneurysm bursts or blood clots form. In Bryan’s case, he had already developed an aneurysm caused by the cervical rib rubbing against the subclavian artery. It could have deteriorated and ruptured at any time.”

“I was in pain for almost ten years total,” says Bopp. “Within 30 seconds of putting his finger to my neck to feel the pulse, Dr. Thompson had a strong opinion that I had arterial TOS. I was thrilled that someone finally said I wasn’t crazy and that there was a reason for all of my pain and suffering.”  Surgery was scheduled a week later. Within hours of surgery, Bopp said he felt like he had a new neck – and a new lease on life.

“I went bowling six months after the surgery, and I threw a strike with the first ball,” he says with a smile. “The old Bryan is back. I can go out and do things with my wife and two kids without pain.

“The message I’d like to give to others is, ‘don’t give up,’” he adds. “Get educated, keep looking for answers and find someone who will listen to all of the symptoms. I’m living life without the distraction of pain, and it’s a great feeling.”

For more information on the Washington University Center for Thoracic Outlet Syndrome at Barnes-Jewish Hospital, please call Della Brink at (314) 362-7410.