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Thoracic Outlet Syndrome Treatment & Management

  • Author: Daryl A Rosenbaum, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Sep 13, 2015
 

Acute Phase

Rehabilitation Program

Surgery in cases of thoracic outlet syndrome is indicated for acute vascular insufficiency and progressive neurologic dysfunction. For subclavian venous thrombosis, treatment addresses 3 problems: the clot, the extrinsic compression, and the intrinsic damage to the vein.[29, 30] Thrombolysis with urokinase is the most commonly recommended treatment, with continued anticoagulation for several months. The timing of surgical decompression is debated, but surgical decompression is needed for long-term improvement.[23, 31, 32] Patients with acute ischemia of the upper extremity require prompt diagnosis and surgical treatment.[33]

All other patients should receive nonoperative treatment that includes relative rest, nonsteroidal anti-inflammatory medications (NSAIDs), cervicoscapular strengthening exercises, and modalities such as ultrasound, transcutaneous nerve stimulation, and biofeedback. Conservative care has been shown to be successful in most patients.[34, 35] In those patients in whom pain is refractory to conservative care, surgery should be considered.

Physical Therapy

Physical therapy that addresses postural abnormalities and muscle imbalance relieves symptoms in most patients with thoracic outlet syndrome by relieving pressure on the thoracic outlet. This is based on 3 potential effects of abnormal static or repetitive postures and positions.

First, increased pressure directly around nerves at various entrapment points or increased tension on nerves creates chronic nerve compression. Second, certain postures maintain muscles in abnormally shortened positions, resulting in a new length. When these adapted muscles are stretched, pain occurs. Third, abnormal posture results in some muscles being stretched and others being shortened to new lengths, resulting in both being placed at a mechanical disadvantage and leading to muscle imbalance.[15] This is the basis for physical therapy.

Although, many conservative protocols for physical therapy are described, few outcome studies have been published. The few studies available demonstrate positive outcomes for most patients.[36, 37, 38]

Patient treatment includes several components that address the brachial plexus nerve compression and muscle imbalance in the cervicoscapular region. Key points emphasized in treatment begin with education. Postural correction focuses on positions of most risk and least risk for compression, with integration into the patient's activities of daily living at work, home, and sleep. For example, patients should avoid overhead arm positions while sleeping. Postural and position correction can be aided by wrist splints, elbow pads, soft neck rolls for nighttime use, and lumbar supports for sitting. In addition, the impact of body habitus and general physical conditioning should be evaluated and discussed (ie, obesity, breast hypertrophy).

Physiotherapy focuses on pain control and range of motion with specific stretching exercises. Stretching should begin with short, tight muscles (ie, upper trapezius, levator scapulae, scalenes, sternocleidomastoid, pectoralis major, pectoralis minor, suboccipitalis) and should not be aggressive. Once pain control and cervical motion are regained, strengthening exercises of the lower scapular stabilizers are begun, as is an aerobic conditioning program.[38, 39] The importance of patient compliance should not be overlooked.

Surgical Intervention

Little argument exists for the surgical treatment of a patient with severe compression or compromise of the subclavian vein or artery.[9, 13, 14, 30] However, less severe cases are more controversial. Likewise, patients with atrophy of the intrinsic muscles of the hand secondary to thoracic outlet syndrome with no distal sites of compression need surgical intervention.[15]

Because of the high prevalence of surgical complications and variable reports of success, many surgeons offer surgery to patients with disputed or nonspecific-type thoracic outlet syndrome only as a last resort after prolonged conservative management and a detailed discussion regarding the risks and complications of surgery. Potential complications from surgery can include pneumothorax, injury to the subclavian artery or vein, injury to the brachial plexus and long thoracic nerve, apical hematoma, intercostobrachial nerve injury, and injury to the thoracic duct.[40]

The surgical approach used varies and may be specialty dependent, with the transaxillary approach preferred by many thoracic and vascular surgeons and the anterior supraclavicular approach favored by most neurosurgeons.[10, 41] Both approaches allow for supraclavicular decompression, which consists of first rib (and cervical rib if present) removal and part or total scalene muscle removal.

For neurogenic thoracic outlet syndrome with examination findings of tenderness or reproduction of symptoms on palpation of the coracoid space only, isolated pectoralis minor tenotomy may be sufficient.[42]

Success rates for surgery vary dramatically in the literature. One review of 47 patients with thoracic outlet syndrome revealed 75% lower plexus and 50% upper plexus compressions remained asymptomatic at 4.6 years.[43] Morbidity in this study involved 17% of patients and was most frequently the result of incisional pain. However, not all studies have been so impressive. One retrospective analysis of patients with nonspecific neurogenic thoracic outlet syndrome demonstrated work disability at 1 year after surgery in 60% of patients. At 4.8 years of follow-up, 72.5% patients were limited in activities.[44]

This has led many surgeons to agree with Wood et al, who empathically stated in 1988 that some errors always occur in diagnosis, and, therefore, surgery should be advised "on a basis of exclusion and with great reservation."[24] This is especially true for disputed or nonspecific-type thoracic outlet syndrome.[10]

A study that evaluated the outcomes of patients who underwent first rib resection (FRR) for all 3 forms of thoracic outlet syndrome (TOS) during a period of 10 years reported that excellent results were seen in this surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, use of a standard protocol for venous patients, and expedient intervention in arterial patients.[45]

Consultations

Consultation with a sports medicine specialist and surgeon is recommended.

Other Treatment

Injection of botulinum toxin into the muscles of the thoracic outlet (scalenes, pectoralis minor, subclavius) has potential for obtaining long-term symptom relief, but further research is needed.[46]

A 2014 Cochrane review looked to evaluate outcome studies of treatments of TOS that took place at a minimum of 6 months after the intervention.[47] The review found that there was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty, and found no randomized evidence that either treatments is better than no treatment at all. The review also reported that there is moderate evidence to suggest that treatment with botulinum toxin injections yielded no great improvements over placebo injections of saline. There is no evidence from randomized controlled trials for the use of other currently used treatments. The review concluded that there is a need for an agreed definition for the diagnosis of TOS, agreed outcome measures, and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.[47]

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Recovery Phase

Rehabilitation Program

Physical Therapy

Postoperative physical therapy is essential for strengthening and range of motion.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

Continued regular stretching of the muscles around the cervical girdle (eg, scalene, pectoralis major and minor, trapezius, levator scapulae, and sternocleidomastoid muscles) is essential.

Recommended exercises for thoracic outlet syndrome include neck stretching, abdominal breathing, and postural exercises. Ineffective therapies include shoulder shrugs (useful for prevention), weight lifting, and neck traction. Exercises should be performed at home at least twice a day.

Medical Issues/Complications

See the list below:

  • Patients may require continued postoperative anticoagulation with warfarin.
  • To help prevent recurrence of thoracic outlet syndrome, the patient should avoid sleeping with his or her arms in an overhead position.
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Contributor Information and Disclosures
Author

Daryl A Rosenbaum, MD Associate Professor, Director of Sports Medicine Fellowship, Department of Family and Community Medicine, Wake Forest University School of Medicine

Daryl A Rosenbaum, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, North Carolina Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Matt Thornburg, MD Staff Physician, Department of Family and Community Medicine, University of Missouri Health Care at Columbia

Matt Thornburg, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association

Disclosure: Nothing to disclose.

Matthew L Silvis, MD Assistant Professor, Departments of Family and Community Medicine and Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine

Matthew L Silvis, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

Ajay Kalra, MD Consulting Surgeon, Surgical Specialists

Ajay Kalra, MD is a member of the following medical societies: Missouri State Medical Association

Disclosure: Nothing to disclose.

Donald Spadone, MD Assistant Professor, Department of Surgery, Division of Vascular Surgery, University of Missouri Health Sciences Center

Donald Spadone, MD is a member of the following medical societies: American College of Surgeons, American Institute of Ultrasound in Medicine, Association for Academic Surgery, Association for Surgical Education, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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Thoracic outlet syndrome in a 16-year-old volleyball player with a stenotic right subclavian vein (arrow) secondary to fibrosis.
 
 
 
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