From the Guidelines
Thoracic outlet syndrome (TOS) resulting from right thoracic outlet injury requires prompt evaluation and treatment, with initial management focusing on conservative measures including physical therapy and NSAIDs, and potentially progressing to surgical decompression if symptoms persist or worsen 1.
Initial Management
Initial management should focus on conservative measures including:
- Physical therapy with specific exercises to strengthen the shoulder girdle muscles and improve posture
- NSAIDs such as ibuprofen 400-600mg three times daily for pain and inflammation
- Activity modification to avoid aggravating positions
- For moderate to severe pain, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime may be beneficial
Diagnostic Workup
Diagnostic workup should include:
- Provocative tests (Adson's, Wright's, and Roos tests)
- Chest X-ray to rule out cervical rib
- Potentially MRI or CT angiography to assess vascular compression
Surgical Decompression
Severe cases with significant neurological deficits, vascular compromise, or intractable pain may require surgical decompression through:
- First rib resection
- Scalenectomy
- Removal of fibrous bands
Post-Injury Monitoring
Post-injury monitoring for complications like thoracic outlet syndrome, brachial plexus injury, or vascular compromise is crucial as symptoms may develop gradually after the initial injury 1. Some key points to consider in the management of TOS include:
- Understanding the various anatomic spaces and causes of narrowing that can lead to TOS 1
- The use of imaging modalities such as MRI and CT angiography to assess vascular compression and guide treatment 1
- The importance of post-intervention monitoring to evaluate interval changes in the thoracic outlet and assess adequate decompression 1
From the Research
Right Thoracic Outlet Injury
- The 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), with neurogenic being the most common form 3.
- Symptoms of TOS include pain and paresthesias of the head, neck, and upper extremities, and can be caused by congenital abnormalities, neck trauma, or repeated work stress 2, 4.
- Diagnosis of TOS is often made through history, physical examination maneuvers, and imaging, with the upper limb tension test (ULTT) being a useful screening test 3.
- Treatment options for TOS include nonsurgical methods such as anti-inflammatory medication, weight loss, physical therapy, and botulinum toxin injections, as well as surgical treatments like brachial plexus decompression and scalenotomy 2, 4.
- Rehabilitation is a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations 5.
- Complications of surgical treatment for TOS can include injury to the subclavian vessels, brachial plexus injury, hemothorax, and pneumothorax 2.
Classification and Diagnosis
- TOS can be classified into three subcategories: neurogenic, arterial, and venous 5.
- Diagnosis of TOS is clinical, and the best screening test is the ULTT, followed by an elevated arm stress test (EAST) to further support the diagnosis 3.
- Additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) may be utilized to further distinguish the vascular or neurological etiologies of the symptoms 3.
Treatment Options
- Initial treatment for neurogenic TOS is often conservative, with data limited on the effectiveness of different treatment methods 3.
- Surgery is considered for refractory cases of neurogenic TOS, while anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS 3.
- Rehabilitation has been shown to be a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations 5.