From the Guidelines
Treatment for thoracic outlet syndrome typically begins with conservative approaches before considering surgery, focusing on physical therapy, pain management, and lifestyle modifications, as recommended by the American College of Radiology Appropriateness Criteria 1. The initial treatment includes physical therapy focusing on stretching and strengthening exercises for the neck, shoulder, and chest muscles to improve posture and reduce compression of the affected nerves and blood vessels. Pain management often involves nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (250-500mg twice daily) for 1-2 weeks. Muscle relaxants such as cyclobenzaprine (5-10mg three times daily) may help reduce muscle spasms. For severe pain, a short course of oral corticosteroids like prednisone (20mg daily for 5-7 days) might be prescribed. Some patients benefit from nerve blocks using lidocaine or bupivacaine injections administered by pain specialists. Lifestyle modifications are crucial, including avoiding activities that worsen symptoms, taking frequent breaks from repetitive arm movements, maintaining good posture, and weight management if needed. If conservative treatments fail after 3-6 months, surgical options may be considered, including first rib resection, scalenectomy (removal of scalene muscles), or arterial reconstruction for vascular forms of the syndrome, as outlined in the guidelines 1. Surgery aims to decompress the thoracic outlet by removing structures causing compression of the neurovascular bundle. Recovery typically requires post-surgical physical therapy for 2-3 months to restore full function and prevent recurrence. Imaging studies, such as MRI and MRA, may be used to evaluate the thoracic outlet and guide treatment decisions, particularly in cases where surgical intervention is being considered 1. The choice of imaging modality depends on the specific symptoms and clinical presentation of the patient, with MRI being useful for evaluating neurogenic and venous thoracic outlet syndrome, and MRA being useful for evaluating arterial thoracic outlet syndrome. Overall, a comprehensive treatment approach that incorporates conservative management, lifestyle modifications, and surgical intervention, as needed, can help improve outcomes and reduce morbidity and mortality in patients with thoracic outlet syndrome.
From the Research
Treatment Options for Thoracic Outlet Syndrome
- Nonsurgical treatment includes:
- Anti-inflammatory medication
- Weight loss
- Physical therapy/strengthening exercises
- Botulinum toxin injections 2
- Conservative management is generally recommended as the first stage treatment, and may include:
- Graded restoration of scapula control, movement, and positioning at rest and through movement
- Restoration of humeral head control
- Isolated strengthening of weak shoulder muscles
- Taping and other manual therapy techniques 3
- Postural correction
- Stretching exercises (e.g. upper trapezius, levator scapulae, suboccipitals, scalenes, sternocleidomastoid and pectoral muscles)
- Strengthening exercises of the lower scapular stabilizers 4, 5
- Surgical treatment options include:
- Brachial plexus decompression
- Neurolysis
- Scalenotomy with or without first rib resection 2
- Postoperative care for surgical treatment includes:
- Passive/assisted mobilization of the shoulder
- Resistance strength training by 8 weeks postoperatively 2
Complications and Outcomes
- Surgical treatment complications may include:
- Injury to the subclavian vessels
- Brachial plexus injury
- Hemothorax
- Pneumothorax 2
- Conservative treatment has been shown to be effective in relieving symptoms in many cases, with one study reporting good results in 75% of patients after an average follow-up of seven years 6