Conventional Treatments for Thoracic Outlet Syndrome

What is thoracic outlet system (TOS)?

Thoracic outlet syndrome (TOS) is a condition in which the nerves and/or blood vessels in the thoracic outlet become compressed, irritated or injured. The thoracic outlet is a narrow space located between the collarbone and the first rib. The nerves and blood vessels that move down the arm, and the muscles from the neck to the shoulder, run through the thoracic outlet.

Early diagnosis of TOS can improve the chances of a successful treatment plan. Reduction of pain and other symptoms is the typical treatment goal. A health care professional should be consulted about benefits, risks, and side effects prior to making a decision on a specific treatment option. Treatments vary depending on the type of TOS experienced.

Neurogenic thoracic outlet syndrome treatment options

Neurogenic TOS affects nerves and involves compression of the brachial plexus, which is a network of nerves in the shoulder that supplies sensation and movement of the arms and hands. Treatment options include physical therapy, medications, injections, or surgery.

Physical therapy for neurogenic TOS

A physical therapist can provide exercises to strengthen muscles in the shoulders, which helps to open the thoracic outlet. Benefits include improved posture and range of motion, and stronger muscles around the collarbone and thoracic outlet. Over time, less pressure on the blood vessels and nerves in the thoracic outlet can occur.

Medications for neurogenic TOS

A physician can prescribe medications, which include the following:

• Prescription non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen or ibuprofen, can reduce pain and inflammation.
• Muscle relaxants can decrease pain and relax the muscles in the affected area.

OnabotulinumtoxinA injections for neurogenic TOS

A health care professional may inject onabotulinumtoxinA into the base of the neck every three months as needed to relax the area and decrease pain.

Surgery for neurogenic TOS

If other treatment options fail, surgery may be necessary. An incision will be made in small muscles of the neck (anterior and middle scalene) to remove the cervical or first rib. Scar tissue at the surgical site may cause a recurrence of TOS several months or years post-treatment.

Venous thoracic outlet syndrome treatment options

Venous thoracic outlet syndrome affects veins and occurs due to compression or damage to one or more of the major veins under the clavicle (collarbone). It usually develops quickly and results in the formation of a blood clot. Treatment options include medication, catheter-directed thrombolysis, and surgery.

Medication for venous TOS

Medications to treat venous TOS include the following:

• Thrombolytic medications can dissolve blood clots and are generally given in hospital settings to closely monitor. Clots may be dissolved in hours or a few days, depending on the size.
• Anticoagulant medications are blood thinning medicines that help prevent blood clots from forming; however, they do not dissolve an existing clot.

Catheter-directed thrombolysis for venous TOS

This is a minimum invasive procedure to dissolve blood clots. A catheter is moved, with x-ray guidance, through a blood vessel to the clot. The clot is broken up by medications that are directly administered to it, a mechanical device that will break it up, or both. If administering medication, the catheter will be left in place for up to 72 hours to gradually deliver the medicine. If only implementing the mechanical device, individuals typically go home the same day.

Surgery for venous TOS

A venogram with balloon angioplasty or a similar procedure can prevent or correct narrowing of veins. This may also be performed to an area after a clot is removed or dissolved to prevent further blood clotting in that area

Arterial thoracic outlet syndrome treatment options

Arterial thoracic outlet syndrome affects arteries and is the most serious type of TOS. It occurs due to abnormalities in the upper chest and neck area and often results in an aneurysm. Treatment options for arterial thoracic outlet syndrome include medication and surgery.

Medication for arterial TOS

Thrombolytic medications can dissolve blood clots and are generally given in hospital settings to closely monitor. The clot may be dissolved in hours or a few days, depending on the size. Thrombolytic medications may be delivered via IV or catheter.

Surgery for arterial TOS

Surgery is frequently recommended as treatment of arterial TOS. Removal of both scalene muscles in the neck, the cervical rib (if present), and the first rib can make room for vessels and nerves in the thoracic outlet. It may also involve surgical reconstruction or replacement of an artery if it contains a blood clot or aneurysm. A balloon angioplasty can repair a damaged artery following the removal of a blood clot.

Additional sources: RadiologyInfo.org