eMedicine Specialties > Neurology > Headache and Pain

Thoracic Outlet Syndrome: Treatment & Medication

Author: Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University hospital
Coauthor(s): Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Contributor Information and Disclosures

Updated: Nov 29, 2007

Treatment

Medical Care

Most patients with TOS require only symptomatic treatment and appropriate consultation. Arterial, venous, and neurologic features may coexist; treatment should be directed toward the dominant component.

  • Common neurologic-type TOS requires conservative management that commonly includes pharmacologic therapy and gentle physiotherapy.
    • Patients with common neurologic-type TOS may respond to physical therapy, which increases the range of motion of the neck and shoulders, strengthens the rhomboid and trapezius muscles, and induces a more erect posture.
    • Aggressive physiotherapy, particularly traction, should be avoided, because it may worsen brachial plexus symptoms.
    • For true neurologic TOS, sectioning of the congenital band is an appropriate option.
  • Vascular (arterial and venous) TOS is less common and often requires surgical treatment.
    • Patients with vascular-type TOS need immediate heparinization and vascular surgery consultation.
    • Anticoagulant therapy (ie, warfarin) may be needed for a minimum of 3 months in vascular-type TOS to prevent recurrent or ongoing thromboembolic occlusion.
  • Analgesic drug therapy for TOS can be divided into the following categories:
    • Nonopioid analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen): NSAIDs commonly are used in patients with mild to moderately severe pain. They inhibit inflammatory reactions and pain by decreasing prostaglandin synthesis. Acetaminophen is a safe choice for treatment of pain during pregnancy and breastfeeding.
    • Opioid analgesics: Opioids are used commonly as an analgesic for many pain syndromes. Opioid therapy can be a safe and effective option in patients with intractable nonmalignant pain and no history of drug abuse.6 Quang-Cantagrel et al report that failure of one opioid cannot predict the patient's response to another opioid.7 High doses of tramadol may provide effective and safe relief in neuropathic pain.
    • Antidepressants: Antidepressant medications play a major role in treatment of neuropathic pain.
      • Tricyclic antidepressants - Amitriptyline (Elavil), nortriptyline (Pamelor)
      • Selective serotonin reuptake inhibitor (SSRI) antidepressants - Paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft)
      • Other antidepressants - Nefazodone (Serzone), venlafaxine (Effexor)
    • Anticonvulsants
      • Sodium channel antagonists have been used in the management of neuropathic pain for several years. These medications are started slowly and administered as needed. Monitor the patient carefully.
      • Several anticonvulsant drugs (eg, clonazepam, topiramate, gabapentin, lamotrigine, tiagabine, zonisamide) have been tried in treatment of TOS.
      • In studies by Nicholson and Rowbothan, gabapentin has been reported to be effective in the management of chronic neuropathic pain syndromes.
      • Controlled studies for the effect of lamotrigine are not yet available, but Jain noted that the drug has demonstrated effect in neuropathic pain.
    • Other adjunct analgesics: Muscle relaxants (eg, metaxalone [Skelaxin], cyclobenzaprine [Flexeril], benzodiazepines, tizanidine) may be helpful to decrease spasm and provide pain relief.

Surgical Care

Careful evaluation and selection of the patient is very important.

  • Surgical management of TOS commonly includes supraclavicular and transaxillary approaches for anatomic decompression.8
  • For classic neurologic TOS, sectioning of the congenital band with a supraclavicular approach is the appropriate option. If necessary, the tip of the rudimentary cervical rib can be removed.
  • Spinal cord stimulation may be considered carefully for management of severe chronic pain that has been refractory to other conservative modalities.9
  • Cherington et al reported on 5 patients who suffered serious injuries after surgery for TOS. These patients had few or no clinical abnormalities on examination prior to the surgery.
  • Other studies, including one of 8 patients who sustained brachial plexus injuries resulting in clinical and electrophysiologic deficits after TOS surgery, have been reported.10

Consultations

Consultation may be needed depending on the type of TOS and pathology, as follows:

  • Neurology
  • Orthopedic surgery
  • Vascular surgery
  • Physical medicine and rehabilitation

Activity

Aggressive physiotherapy, particularly traction, should be avoided, because it may worsen brachial plexus symptoms.

Medication

Drug therapy for TOS can be divided into the following categories:

Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. NSAIDs may provide pain relief in the patient with TOS.


Naproxen sodium (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderately severe pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.

Adult

275 mg PO tid or 550 mg PO bid

Pediatric

Not established

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug


Ibuprofen (Motrin, Advil)

NSAIDs used commonly for patients with mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

400-800 mg PO q8h; not to exceed 3200 mg/d

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Probenecid may increase toxicity; may decrease effects of loop diuretics; may increase serum lithium levels; may prolong PT in patients taking anticoagulants

Documented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, or decreased renal or hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.


Acetaminophen (Tylenol, Feverall, Tempra, Aspirin Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Adult

650-1000 mg PO initially; may be repeated if necessary at same dose after 6h

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d (3-6 y: not to exceed 720 mg/d; 6-12 y: not to exceed 2.6 g/d)
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Documented hypersensitivity; known G-6-PD deficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose


Oxycodone (OxyContin)

Long-acting form of opioid currently used commonly for severe pain. Start with small dose and increase gradually.

Adult

10-160 mg PO q12h

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity

Documented hypersensitivity; presence of intracranial lesion associated with impaired intracranial pressure (hydromorphone); concurrent or recent use of MAOIs; poor respiratory function (eg, COPD, cor pulmonale, emphysema, status asthmaticus, kyphoscoliosis)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in COPD, emphysema, renal insufficiency, impaired respiratory and cardiac function, and severe renal disease


Morphine sulfate (MS Contin, Duramorph, Astramorph)

Effective analgesic with good safety profile and ease of reversibility with naloxone. Various IV doses used; commonly titrated until desired effect obtained.
Oral morphine sulfate includes Avinza, Kadian, and MS Contin. These medications are available in multiple different strengths (15-120 mg).

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose

Pediatric

Infants and children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose

Phenothiazines may antagonize analgesic effects; TCAs, MAOIs, and other CNS depressants may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing airway control rapidly would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate


Fentanyl transdermal patch (Duragesic)

Potent narcotic analgesic with much shorter half-life than morphine sulfate. Excellent choice for pain management and sedation with short duration (30-60 min); easy to titrate. Easily and quickly reversed by naloxone. When using transdermal dosage form, most patients' pain controlled with 72-h dosing intervals; however, some patients may require dosing intervals of 48 h.

Adult

12 mcg/h TD; replace q48-72h
25 mcg/h (10 cm2) TD; replace q48-72h
50 mcg/h (20 cm2) TD; replace q48-72h
75 mcg/h (75 cm2) TD; replace q48-72h
100 mcg/h (100 cm2) TD; replace q48-72h

Pediatric

Not established

Phenothiazines may antagonize analgesic effects; TCAs may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with hypotension, respiratory depression, constipation, nausea, emesis, or urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation

Antidepressants

This complex group of drugs has central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission. They increase synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.

Other options include duloxetine hydrochloride (Cymbalta), venlafaxine (Effexor), and bupropion (Wellbutrin).


Nortriptyline (Pamelor)

Has demonstrated effectiveness in treatment of chronic and neuropathic pain.

Adult

25-100 mg PO hs; not to exceed 200 mg/d

Pediatric

Children: 0.1 mg/kg PO hs initially; increase, as tolerated, up to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO; increase gradually to 100 mg/d

Cimetidine may increase levels; may increase PT in patients whose PT is stabilized with warfarin

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency, MAOIs within 14 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances, history of hyperthyroidism, or renal or hepatic impairment; because of pronounced effects in cardiovascular system, best to avoid in elderly


Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Adult

25-100 mg PO hs; not to exceed 150 mg/d

Pediatric

Not established

Phenobarbital may decrease effects; CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Documented hypersensitivity; MAOIs within 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances, history of hyperthyroidism, or renal or hepatic impairment; avoid using in elderly patients

Selective serotonin reuptake inhibitors

These agents may be considered as alternative to TCAs.


Fluoxetine (Prozac)

Antidepressant with potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult

10 mg PO on waking initially; can be increased every 2 wk, not to exceed 60 mg/d

Pediatric

Not established

Increases toxicity of diazepam and trazodone by decreasing clearance; increases toxicity of MAOIs and highly protein-bound drugs; other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan) may cause serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death); discontinue other serotonergic agents at least 2 wk prior to SSRIs

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease; MAOIs within last 2 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted (resolve within 1-2 wk); caution in hepatic impairment and history of seizures; discontinue MAOIs inhibitors at least 14 d before initiating fluoxetine therapy


Sertraline (Zoloft)

Antidepressant with potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult

50 mg/d PO initially, increased at weekly intervals after several wk; not to exceed 200 mg/d

Pediatric

Not established

Increases toxicity of diazepam and trazodone by decreasing clearance; increases toxicity of MAOIs and highly protein-bound drugs; other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan) may cause serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death); discontinue other serotonergic agents at least 2 wk prior to SSRIs

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease; MAOIs within last 2 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted (resolve within 1-2 wk); caution in hepatic impairment and history of seizures; discontinue MAOIs inhibitors at least 14 d before initiating fluoxetine therapy


Paroxetine (Paxil)

Antidepressant with potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult

Start at 10 mg/d PO and titrate upward; not to exceed 50 mg/d

Pediatric

Not established

Increases toxicity of diazepam and trazodone by decreasing clearance; increases toxicity of MAOIs and highly protein-bound drugs; other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan) may cause serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death); discontinue other serotonergic agents at least 2 wk prior to SSRIs

Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease; MAOIs within last 2 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted (resolve within 1-2 wk); caution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating paroxetine therapy

Benzodiazepines

By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. They may act in the spinal cord to induce muscle relaxation.


Clonazepam (Klonopin)

Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters.

Adult

0.5-1 mg PO tid, for short course

Pediatric

Not established

Phenytoin and barbiturates may reduce effects; CNS depressants increase toxicity

Documented hypersensitivity; severe liver disease; acute narrow-angle glaucoma

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in chronic respiratory disease or impaired renal function; withdrawal symptoms can result from abrupt discontinuation of the medication

Anticonvulsants

Use of certain antiepileptic drugs, such as the GABA analogue gabapentin (Neurontin), has proven helpful in some patients with neuropathic pain. Other anticonvulsants (eg, clonazepam, topiramate, lamotrigine, zonisamide, tiagabine) also have been tried in chronic pain.

Pregabalin (Lyrica) can be effective, tolerable, and easy to titrate compared to gabapentin.


Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action unknown. Structurally related to GABA but does not interact with GABA receptors.

Adult

100 mg PO hs to 1200 mg PO tid

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Antacids may reduce bioavailability significantly (administer at least 2 h following antacids); may increase norethindrone levels significantly

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt withdrawal of this medication may precipitate seizures; caution in severe renal disease

More on Thoracic Outlet Syndrome

Overview: Thoracic Outlet Syndrome
Differential Diagnoses & Workup: Thoracic Outlet Syndrome
Treatment & Medication: Thoracic Outlet Syndrome
Follow-up: Thoracic Outlet Syndrome
References
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Further Reading

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Keywords

TOS, thoracic outlet syndrome, brachial plexus, neurologic TOS, vascular TOS, compression of the subclavian artery, compression of the subclavian vein, brachial plexus compression, congenital anomaly, arterial TOS, venous TOS, combined neurovascular TOS

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Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University hospital
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Jashvant Patel, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Jorge E Mendizabal, MD, Consulting Staff, Corpus Christi Neurology
Jorge E Mendizabal, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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