Thoracic Outlet Syndrome in Emergency Medicine Treatment & Management

Updated: Aug 25, 2020
  • Author: Andrew K Chang, MD, MS; Chief Editor: Erik D Schraga, MD  more...
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Approach Considerations

A Cochrane review concluded that despite many reports on conservative and surgical intervention, complications, outcomes, and success rates, rigorous scientific investigation and management is lacking. [10]

For most patients, conservative treatment for thoracic outlet syndrome (TOS) is generally recommended. Stress avoidance, work simplification, and job site modification are also recommended to avoid sustained contraction and repetitive or overhead work that exacerbate symptoms.

Myofascial or chronic pain elements can be addressed through exercise programs, good posture, and self-management.

The potential outlet space can be maximized through a program of stretching and strengthening of the shoulder-elevating mechanism, such as with the following:

  • 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)


Emergency Department Care

Most presentations of thoracic outlet syndrome (TOS) to the ED are nonemergent and require only symptomatic treatment and referral. Vascular TOS, although much less common than neurologic TOS, requires more urgent care.

Management of vascular (arterial and venous) TOS includes the following:

  • Immediate heparinization

  • Vascular surgery consultation

  • Color flow duplex scanning

  • Angiography or venography

Neurologic TOS is generally managed with conservative outpatient physiotherapy.


Patients with vascular TOS may be admitted for the following:

  • 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

Operative therapy is indicated for neurologic TOS if conservative approach fails. [11]

Supraclavicular decompression techniques may include anterior and middle scalenectomy, excision of a cervical rib if present and first rib resection. [1, 12]

Using a prospectively maintained database, Orlando et al. retrospectively evaluated the outcomes of 538 patients who underwent first rib resection (FRR) for indications of neurogenic, venous, and arterial TOS from August 2003 through July 2013. A comparison of the second 5-year period with the first 5-year period showed that improved or fully resolved symptoms increased from 93% to 96%. The mean length of stay was 1 day. [13]

A retrospective survey of 158 workers' compensation patients undergoing surgery for TOS showed that 60% were still work-disabled 1 year after surgery. [14]


Neurologic, orthopedic, or vascular surgery consultation(s) may be indicated depending on the type of pathologic condition.

Physical medicine and rehabilitation physicians are needed for outpatient workup.


For patients with vascular TOS, transfer to a center with experience in such cases for definitive diagnosis and treatment is indicated if it is unavailable at the current institution.