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. [36, 37] 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. [18, 38, 39] Patients with acute ischemia of the upper extremity require prompt diagnosis and surgical treatment. [40]
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. [41, 42] 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. [12] 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. [43, 44, 45]
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. [45, 46] The importance of patient compliance should not be overlooked.
Surgical Intervention
Little argument exists against the surgical treatment of a patient with severe compression or compromise of the subclavian vein or artery. [19, 24, 25, 37, 47] 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. [12] However, less severe cases are more controversial.
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. [48]
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. [20, 49] Both approaches allow for supraclavicular decompression, which consists of first rib (and cervical rib if present) removal and part or total scalene muscle removal. In a study of 33 patients with venous thoracic outlet syndrome, Siracuse et al reported good results with an infraclavicular surgical approach. [50]
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. [51]
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. [52] Morbidity in this study involved 17% of patients and was most frequently the result of incisional pain.
A literature review by Peek et al found evidence that most patients who undergo surgery for thoracic outlet syndrome benefit from the treatment. The investigators reported that postoperatively, 90% of the study's patients with arterial or venous thoracic outlet syndrome improved under Derkash’s classification to an excellent/good rating, while patients with neurogenic thoracic outlet syndrome showed a 28.3-point improvement in their Disabilities of the Arm, Shoulder and Hand scores. [53]
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. [54]
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." [29] This is especially true for disputed or nonspecific-type thoracic outlet syndrome. [20]
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. [55]
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. [56]
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. [57] 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. [57]
Recovery Phase
Rehabilitation Program
Physical therapy
Postoperative physical therapy is essential for strengthening and range of motion.
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
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.
Return to Play
Return to play following treatment of thoracic outlet syndrome is difficult to generalize and depends on multiple variables, including the type of thoracic outlet syndrome, the presence of contributing factors, the treatment plan, the response to treatment, and the sport played.
A retrospective review by Talutis et al, which included 60 adolescent athletes, found that about 94% of the patients with venous thoracic outlet syndrome were able to return to play after operative decompression, compared with nearly 74% of those with neurogenic thoracic outlet syndrome. Of the patients with neurogenic thoracic outlet syndrome, 10% had other injuries and 5% had medical disorders that prevented their return to play. [58]
Prevention
The patient should avoid repetitive motions, stressful lifting, and overhead work. Performing a regular exercise program for improving flexibility and strength is beneficial. Shoulder-elevating movements (eg, shrugs, hand circles) increase range of motion and aid in prevention, but they are not a treatment modality.
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Thoracic outlet syndrome in a 16-year-old volleyball player with a stenotic right subclavian vein (arrow) secondary to fibrosis.
