Treatment Options for Thoracic Outlet Syndrome
The treatment of thoracic outlet syndrome (TOS) should begin with conservative management for 3-6 months before considering surgical intervention, except in cases with progressive symptoms, significant functional compromise, or vascular complications. 1
Types of Thoracic Outlet Syndrome
- TOS is classified into three main types based on the compressed structure 1:
- Neurogenic TOS (95% of cases) - compression of the brachial plexus
- Venous TOS (4-5% of cases) - compression of the subclavian vein
- Arterial TOS (1% of cases) - compression of the subclavian artery
Conservative Management
- Physical therapy with myofascial release manipulation and stretching exercises is the first-line treatment for TOS 2, 3
- Self-stretching exercises should be demonstrated hands-on with the patient and regularly reviewed and modified 2
- High-frequency, progressive stretching should be implemented initially, then tapered to maintenance level as symptoms diminish 2
- Additional conservative measures include 3:
- Anti-inflammatory medications
- Weight loss if applicable
- Activity modification to avoid provocative movements
- Botulinum toxin injections into scalene muscles
Diagnostic Imaging to Guide Treatment
- Chest radiography should be performed initially to identify osseous abnormalities such as cervical ribs or first rib anomalies 1
- MRI without and with IV contrast is recommended for neurogenic TOS diagnosis 1
- CTA with IV contrast, MRA, or US duplex Doppler is recommended for arterial TOS diagnosis 1
- Imaging findings should be correlated with clinical symptoms to avoid misdiagnosis 1
Surgical Management
Surgical intervention is indicated when 1, 4:
- Conservative management fails after 3-6 months
- Patient has progressive symptoms
- Significant functional compromise exists
- Vascular complications are present
- Patient has high-risk occupation where recurrence prevention is critical
Common surgical approaches include 5, 6:
- Supraclavicular exposure
- Transaxillary approach with first rib resection
- Posterior subscapular exposure in selected patients
Specific surgical procedures may include 3, 4:
- Brachial plexus decompression
- Neurolysis
- Scalenotomy with or without first rib resection
- Resection of cervical ribs or fibrous bands
- Subclavian artery reconstruction (for arterial TOS)
Postoperative Care
- Patients should begin passive/assisted mobilization of the shoulder immediately after surgery 3
- By 8 weeks postoperatively, patients can begin resistance strength training 3
- For patients on anticoagulation (venous TOS with thrombosis), anticoagulation should be restarted once adequate hemostasis is achieved, typically 12-24 hours after surgery 7
Potential Complications of Surgery
- Injury to subclavian vessels potentially leading to exsanguination 3
- Brachial plexus injury 3
- Hemothorax and pneumothorax 3, 6
- Temporary brachial paralysis 6
Treatment Outcomes
- With careful patient selection, surgical intervention typically yields satisfactory results 5, 6
- Studies report 82.6% complete relief and partial relief in remaining cases following first rib removal through transaxillary approach 6
- A multidisciplinary approach involving thoracic surgeons, neurologists, and physical therapists improves management outcomes 4, 6