Thoracic Outlet Syndrome in Emergency Medicine Follow-up

  • Author: Andrew K Chang, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Jan 25, 2010
 

Further Inpatient Care

  • Vascular
    • Angiography or venography
    • Color flow duplex scanning
    • Catheter-directed local infusion of thrombolytic agent
    • Thrombectomy (for total thrombotic obstruction)
    • Fogarty catheter embolectomy
    • Emergent or urgent surgical exploration
  • Neurologic: Operative therapy is indicated if conservative approach fails.[4]
    • Supraclavicular decompression techniques may include anterior and middle scalenectomy, excision of a cervical rib if present and first rib resection.[1, 5]
    • A retrospective survey of 158 workman's compensation patients undergoing surgery for thoracic outlet syndrome (TOS) showed that 60% were still work-disabled 1 year after surgery.[6]
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Further Outpatient Care

  • For most patients, conservative treatment is recommended. Stress avoidance, work simplification, and job site modification are recommended to avoid sustained contraction and repetitive or overhead work that exacerbate symptoms.
  • Address myofascial or chronic pain elements through exercise programs, good posture, and self-management.
  • Maximize the potential outlet space through a program of stretching and strengthening of the shoulder-elevating mechanism.
    • Trapezius and rhomboid strengthening (eg, shoulder shrugs and bilateral shoulder retraction while standing or lying prone)
    • Shoulder mobilization (eg, hand circles and standing corner pushups)
    • Postural exercises (eg, cervical and lumbar spine extension)
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Inpatient & Outpatient Medications

  • Coumadin: Anticoagulate for a minimum of 3 months for vascular TOS.
  • Analgesics are seldom helpful except to assist in the institution of a progressive exercise program.
  • Tricyclic antidepressants: A short-monitored course may be helpful if the time course and symptoms suggest a protracted pain syndrome.
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Transfer

  • Vascular - For definitive diagnosis and treatment if unavailable at current institution
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Complications

  • Neurologic - Chronic pain
  • Arterial
    • Thrombosis
    • Thromboembolism
    • Acute ischemia
    • Poststenotic aneurysm formation
  • Venous - Thrombosis
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Prognosis

  • Neurologic TOS is generally neither progressive nor likely to resolve spontaneously.
  • Arterial or venous TOS usually results in a good outcome with adequate treatment.
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Contributor Information and Disclosures
Author

Andrew K Chang, MD  Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

J Stephen Bohan, MD, FACP, FACEP  Director, Observation Medicine, Department of Emergency Medicine, Clinical Director, Harvard Medical School, Brigham and Women's Hospital

J Stephen Bohan, MD, FACP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

David Eitel, MD, MBA  Associate Professor, Department of Emergency Medicine, York Hospital

David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. Apr 2009;11(2):176-83. [Medline].

  2. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. Sep 2007;46(3):601-4. [Medline].

  3. Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. Nov-Dec 2006;26(6):1735-50. [Medline].

  4. Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. Oct 2004;55(4):897-902; discussion 902-3. [Medline].

  5. Barkhordarian S. First rib resection in thoracic outlet syndrome. J Hand Surg [Am]. Apr 2007;32(4):565-70. [Medline].

  6. Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet syndrome in Washington state workers' compensation. Neurology. Mar 28 2000;54(6):1252-7. [Medline].

  7. Aufderheide TP. Peripheral arteriovascular disease. Emerg Med: Concepts and Clinical Practice. 1998;2:1844-7.

  8. Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. Oct 1997;63(10):913-7. [Medline].

  9. Oates SD, Daley RA. Thoracic outlet syndrome. Hand Clin. Nov 1996;12(4):705-18. [Medline].

  10. Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med. Apr 1998;5(4):337-42. [Medline].

  11. Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. Neurologist. Nov 2008;14(6):365-73. [Medline].

  12. Weber RJ, Lebduskin S. Rehabilitation issues in plexopathies. Phys Med Rehabil. 1988;996-8.

 
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