Neurological Manifestations of Thoracic Outlet Syndrome Treatment & Management

  • Author: Manish K Singh, MD; Chief Editor: Robert A Egan, MD   more...
 
Updated: Feb 12, 2010
 

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.
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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.[10]
  • Other studies, including one of 8 patients who sustained brachial plexus injuries resulting in clinical and electrophysiologic deficits after TOS surgery, have been reported.[11]
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Consultations

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

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

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

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Contributor Information and Disclosures
Author

Manish K Singh, MD  Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

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: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Robert A Egan, MD  Director of Neuro-Ophthalmology, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association

Disclosure: Nothing to disclose.

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