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

Common neurologic-type 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.

For true neurologic TOS, sectioning of the congenital band is an appropriate option.

Consider surgical intervention when patients have true weakness, intrinsic muscle wasting, and/or fail conservative therapy with continued pain limiting activities of daily living and work.

Vascular (arterial and venous) TOS

Vascular (arterial and venous) TOS is less common and often requires surgical treatment.

Patients with vascular-type TOS need thrombolysis and vascular surgery consultation.

Analgesic drug therapy

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 in the short term for symptom "flares" or postsurgery.

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)
Serotonin and norepinephrine reuptake inhibitors (SNRIs) - venlafaxine (Effexor), duloxetine (Cymbalta)

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.

Gabapentin and pregabalin are effective in chronic neuropathic pain syndromes.^{[10, 11, 12]}

Other adjunct analgesics

Muscle relaxants (eg, metaxalone [Skelaxin], cyclobenzaprine [Flexeril], benzodiazepines, tizanidine) may be helpful to decrease spasm and provide pain relief. Botulinum injection into the scalene muscles has been shown to provide pain relief and decrease spasm.^[13]

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.^[14]

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.

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.^[15]

Consultations

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

Neurology
Orthopedic surgery
Vascular surgery
Physical medicine and rehabilitation

Medication

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Author

Joy Chan, MD Resident Physician, Department of Neurology, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nasheed I Jamal, MD Assistant Clinical Professor, Department of Neurology, Director, UCLA Neuromuscular Medicine Fellowship Program, University of California, Los Angeles, David Geffen School of Medicine; Acting Chief, Neurology Service, Associate Chief of Neurology, Los Angeles Ambulatory Care Center, Director, Multidisciplinary Clinic, Co-Director, Tele-Polyneuropathy Clinic, Department of Neurology, VA Greater Los Angeles Healthcare System

Nasheed I Jamal, MD is a member of the following medical societies: American Academy of Neurology, American Association for the Advancement of Science

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.

Chief Editor

Robert A Egan, MD NW Neuro-Ophthalmology

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

Disclosure: Received honoraria from Biogen Idec and Genentech for participation on Advisory Boards.

Additional Contributors

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, National Stroke Association, American Headache Society, Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

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 Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Jashvant Patel, MBBS, MS, MD

Jashvant Patel, MBBS, MS, 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, Medical Society of the State of New York

Disclosure: Nothing to disclose.