From the Guidelines
Thoracic outlet syndrome (TOS) should be managed with a multidisciplinary approach, starting with physical therapy and anti-inflammatory medications, and considering surgical decompression if conservative treatments fail, as recommended by the American College of Radiology Appropriateness Criteria 1.
Diagnosis and Treatment
TOS is a condition where blood vessels or nerves in the space between the collarbone and first rib become compressed, causing pain in the shoulders and neck and numbness in the fingers. The condition occurs in three main types: neurogenic (affecting nerves, most common), venous (affecting veins), and arterial (affecting arteries, least common) 1.
- Symptoms vary by type but often include arm pain, numbness, weakness, and discoloration.
- Proper diagnosis requires a thorough physical examination and possibly imaging tests like MRI or ultrasound to rule out other conditions with similar symptoms.
- Treatment typically begins with physical therapy to strengthen chest muscles, improve posture, and create more space in the thoracic outlet.
- Anti-inflammatory medications like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) can help manage pain.
- For severe cases, muscle relaxants such as cyclobenzaprine (5-10mg three times daily) may be prescribed for short-term use.
Imaging Tests
Imaging tests such as MRI or CT scans can help diagnose TOS and rule out other conditions with similar symptoms 1.
- MRI is typically performed with high-resolution T1-weighted and T2-weighted sequences in sagittal and axial planes to delineate anatomy and evaluate cervical radiculopathy, the brachial plexus, muscular attachments, and sites of compression.
- CT scans can provide assessment of vascular patency, which is a potential complication in the postintervention setting for patients with vTOS.
Surgical Decompression
If conservative treatments fail after 3-6 months, surgical decompression might be necessary, which could involve removing the first rib or releasing tight muscles 1.
- Surgical decompression can help relieve compression on the blood vessels or nerves and improve symptoms.
- The decision to undergo surgical decompression should be made on a case-by-case basis, taking into account the severity of symptoms and the patient's overall health.
From the Research
Definition and Classification of Thoracic Outlet Syndrome
- Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet 2
- TOS can be classified into several sub-types, including neurogenic, arterial, or venous based on the compressed structure(s) 3
Symptoms of Thoracic Outlet Syndrome
- Symptoms of TOS include pain, paresthesia, pallor, and weakness depending upon the compromised structures 4
- Patients with TOS may also experience arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand 3
Diagnosis of Thoracic Outlet Syndrome
- Diagnosis of TOS is often made in the presence of symptoms with physical examination findings 3
- A thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis 4
- Diagnosis of TOS can be established through history, physical examination maneuvers, and imaging in patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression 3
Conservative Management of Thoracic Outlet Syndrome
- Conservative management is generally recommended as the first stage treatment in favor of surgical intervention 2
- Conservative management includes physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids 4
- Rehabilitation programs for TOS focus on the graded restoration of scapula control, movement, and positioning at rest and through movement, as well as adjunctive strategies such as restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques 2
- Patient education, compliance to an exercise program, and behavioral modification at home and work are critical to successful conservative management 5
Surgical Treatment of Thoracic Outlet Syndrome
- Patients who have failed conservative therapy are considered for surgical decompression 4
- Surgical treatments for TOS include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection 3
- Postoperative care for patients undergoing surgical treatment for TOS includes passive/assisted mobilization of the shoulder, with resistance strength training beginning at 8 weeks postoperatively 3