eMedicine Specialties > Emergency Medicine > Cardiovascular

Thoracic Outlet Syndrome: Follow-up

Author: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
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
Contributor Information and Disclosures

Updated: Oct 30, 2009

Follow-up

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

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)

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.

Transfer

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

Complications

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

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.
 


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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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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Further Reading

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Keywords

thoracic outlet syndrome, nerve compression syndrome, thoracic outlet syndrome causes, thoracic outlet syndrome symptoms, TOS, vascular thoracic outlet syndrome, neurologic thoracic outlet syndrome, arterial thoracic outlet syndrome, venous thoracic outlet syndrome, compression of neurovascular structures, neurovascular entrapment

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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.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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.

 
 
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