From the Guidelines
Thoracic outlet syndrome (TOS) should be managed with a multidisciplinary approach, prioritizing conservative treatment with physical therapy and anti-inflammatory medications, reserving surgery for cases with persistent symptoms or vascular complications, 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, numbness, and weakness in the neck, shoulder, arm, or hand. The condition occurs in three main types: neurogenic, venous, and arterial, each with distinct symptoms and treatment approaches.
- Neurogenic TOS is the most common type, affecting nerves, and is typically managed with physical therapy, anti-inflammatory medications, and muscle relaxants for short-term use 1.
- Venous TOS affects veins and may require imaging studies such as MRI or CT scans to evaluate the thoracic outlet and assess for venous compression or thrombosis 1.
- Arterial TOS affects arteries and may require imaging studies such as angiography or CT scans to evaluate the thoracic outlet and assess for arterial compression or stenosis 1.
Imaging Studies
Imaging studies play a crucial role in diagnosing and managing TOS. The choice of imaging study depends on the type of TOS and the clinical symptoms.
- MRI is a useful modality for evaluating neurogenic TOS, as it can delineate anatomy and evaluate the brachial plexus, muscular attachments, and sites of compression 1.
- CT scans can be used to evaluate the thoracic outlet and assess for bony abnormalities, muscular hypertrophy, or other causative lesions 1.
- Angiography or CT scans can be used to evaluate arterial TOS and assess for arterial compression or stenosis 1.
Prevention and Recurrence
Maintaining good posture, taking regular breaks from repetitive activities, and performing specific stretching exercises can help prevent recurrence after treatment.
- Patients with TOS should avoid activities that exacerbate symptoms and take regular breaks to stretch and move their arms and shoulders.
- Physical therapy can help improve posture, strengthen chest muscles, and create more space in the thoracic outlet, reducing the risk of recurrence.
Morbidity, Mortality, and Quality of Life
The goal of treatment is to improve symptoms, reduce morbidity, and improve quality of life. Conservative treatment with physical therapy and anti-inflammatory medications can improve symptoms in most patients within 3-6 months.
- Surgery is reserved for cases with persistent symptoms despite conservative management or for those with vascular complications, and can improve symptoms and reduce morbidity in these patients 1.
From the Research
Definition and Classification of Thoracic Outlet Syndrome
- Thoracic outlet syndrome (TOS) is a rare condition caused by neurovascular compression at the thoracic outlet, presenting with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand 2.
- TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s) 2, 3.
Diagnosis of Thoracic Outlet Syndrome
- The diagnosis of TOS is often made in the presence of symptoms with physical examination findings, and is not a diagnosis of exclusion 2.
- A thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis 4.
- Diagnosis 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 2.
Treatment Options for Thoracic Outlet Syndrome
- Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections 2.
- Conservative management is generally recommended as the first stage treatment, and may include physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids 5, 6, 4.
- Surgical treatment options include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection, and may be considered for patients who have failed conservative therapy 2, 3.
Rehabilitation and Management
- The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement 5.
- Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques 5.
- Patient education, compliance to an exercise program, and behavioral modification at home and work are critical to successful conservative management 6.