How to treat Thoracic Outlet Syndrome (TOS)?

Treatment of Thoracic Outlet Syndrome

Conservative management with physical therapy should be the initial treatment for TOS for 3-6 months, with surgical intervention reserved for patients who fail conservative therapy or present with true neurogenic or vascular TOS with progressive symptoms, significant functional compromise, or vascular complications. 1

Initial Conservative Management (3-6 Months Trial)

Core Physical Therapy Components

• Postural correction in sitting, standing, and sleeping positions is essential to decompress the thoracic outlet 2
• Stretching exercises targeting the upper trapezius, levator scapulae, suboccipitals, scalenes, sternocleidomastoid, and pectoral muscles should be performed regularly 2
• Graded restoration of scapula control is the main rehabilitation component, addressing scapula positioning at rest and through movement 3
• Strengthening exercises of lower scapular stabilizers should begin in gravity-assisted positions to restore normal cervico-scapular movement patterns 2, 3
• Humeral head control restoration and isolated strengthening of weak shoulder muscles serve as adjunctive strategies 3

Additional Conservative Measures

• Anti-inflammatory medications can be used for symptom management 4
• Weight loss should be pursued when applicable 4
• Botulinum toxin injections may be considered in select cases 4
• Patient education, compliance to exercise programs, and behavioral modification at home and work are critical to success 2

Important Caveat

Physical therapy cannot replace surgery in severe or complicated forms of TOS with vascular or neurologic compromise 5. Degradation of symptoms or invalidating functional compromise indicates immediate referral to surgery 5.

Indications for Surgical Intervention

Absolute Indications (Bypass Conservative Management)

• Venous TOS (vTOS) with subclavian vein thrombosis (Paget-Schroetter syndrome) requires surgical decompression following initial endovascular treatment 1
• Arterial TOS (aTOS) with subclavian artery compression causing vascular complications 1
• True neurogenic TOS with progressive symptoms and significant functional compromise 1
• High-risk occupations where recurrence prevention is critical 1

Relative Indications (After Failed Conservative Trial)

• Failure of conservative management after adequate 3-6 month trial 1
• Diagnostic anterior scalene block with minimal improvement 6
• Documented neurovascular compression on imaging with persistent symptoms 1

Surgical Treatment Approach

Thoracic Outlet Decompression (TOD) Components

Complete first rib resection (cartilage to cartilage), transection of scalene muscles, and complete neurolysis/venolysis or arteriolysis constitute the standard TOD procedure. 7

Surgical Approach Selection

Four approaches exist for TOD surgery 7:

• Transaxillary (TA) approach: Can be used for all forms of TOS 7
• Supraclavicular (SC) approach: Can be used for all forms of TOS 7
• Paraclavicular (PC) approach: Mostly used for venous TOS 7
• Infraclavicular (IC) approach: Only used for venous TOS, no role in neurogenic or arterial TOS 7

The surgical approach should be based on surgeon preference and experience, as literature does not definitively favor one approach 7.

Specific Procedures by TOS Type

Neurogenic TOS

• Brachial plexus decompression 4
• Neurolysis 4
• Scalenotomy with or without first rib resection 4
• Complete first rib removal during initial operation prevents recurrent TOS 6

Venous TOS

• First rib resection and scalenectomy 1
• Vascular exploration is necessary given documented subclavian vein pathology 1
• Direct visualization and potential intervention on subclavian vein assesses for residual stenosis, webs, or intrinsic venous pathology 1

Arterial TOS

• First rib resection 1
• Arterial lysis 6
• Scalenectomy 1

Perioperative Management for Patients on Anticoagulation

Preoperative Anticoagulation Management

• Discontinue anticoagulation 12-24 hours before planned surgery to minimize bleeding risk 8
• Do not continue anticoagulation up to the time of surgery due to increased bleeding risk 8

Postoperative Anticoagulation Management

• Resume anticoagulation 12-24 hours after surgery once adequate hemostasis is achieved 8
• Do not delay resumption of anticoagulation for too long in patients with high thrombotic risk 8
• Long-term anticoagulation may not be necessary if TOS is surgically corrected or if the initial thrombotic event was provoked and has resolved 8

Postoperative Rehabilitation

Early Phase

• Begin passive/assisted mobilization of the shoulder immediately postoperatively 4

Late Phase (8 Weeks Postoperatively)

• Begin resistance strength training at 8 weeks postoperatively 4

Surgical Complications to Monitor

Critical complications include: 4

• Injury to subclavian vessels potentially leading to exsanguination and death
• Brachial plexus injury
• Hemothorax
• Pneumothorax

Common Pitfalls to Avoid

• Do not diagnose TOS as an exclusion diagnosis—there should be evidence for a physical anomaly that can be corrected 4
• Do not proceed to surgery without adequate conservative trial (3-6 months) unless absolute indications exist 1
• Do not overlook concomitant cervical spine pathology that may mimic or exacerbate TOS symptoms 1
• Do not rely solely on imaging findings—venous compression during arm abduction is commonly seen in both asymptomatic and symptomatic individuals, making clinical correlation essential 1
• Ensure imaging confirmation of etiology such as bony tubercle, clavicle fracture, congenital cervical rib, or first rib abnormality before surgical intervention 1