Treatment Options for Thoracic Outlet Syndrome

Treatment Options for Neurogenic Thoracic Outlet Syndrome

Treatment options for neurogenic thoracic outlet syndrome (TOS) include:

  • Conservative therapy
  • Drug therapy
  • Surgery

Conservative Treatment

Conservative treatment has been found to be increasingly effective resulting in a decreased need for surgical intervention. This trend comes with the realization that often symptoms of TOS are related to muscular involvement secondary to postural changes.

The goals of conservative treatment include:

  • Decreasing compression on the brachial plexus

  • Correcting muscle imbalance in the cervicoscapular region through:

    • patient education
    • behavior modification
    • appropriate exercises

  • Stretching muscles

  • Increasing mobility and range of motion of cervical and scapular muscles and strengthening these muscles

Most experts agree that a conservative approach is the first-line treatment in the management of patients with neurogenic TOS unless the patient is experiencing significant neurologic impairment or acute vascular insufficiency due to neurovascular compression in which case surgery may be necessary. Approximately 85% or more of patients with TOS will improve with conservative treatment and only a small percentage of patients actually require surgery.

Patient education plays a crucial role in conservative therapy for thoracic outlet syndrome. The patient must be aware of:

  • Positions and postures that relieve or exacerbate pain
  • The extent to which their actions can control their symptoms
  • Behavior modification to develop healthy posture and careful movement at home, work, and during daily activities
  • Obesity can also contribute to the severity of symptoms in TOS and has been associated with poor treatment outcome. Proper diet and exercise with resulting weight loss may not eliminate TOS but will boost the efficacy of other treatments.

Conservative treatments for neurogenic TOS include:

  • Physical therapy
  • Postural training
Physical Therapy
  • Muscle strengthening and lengthening exercises
  • Stretching/isometric exercises
  • Aerobic exercise for cardiovascular health
  • Orthotics to help keep posture upright
  • Osteopathic manipulation of the scalene and trapezius muscles
  • Extra-supportive bra that crosses at the back to help support posture in women with very large breasts
  • Heat treatments with ultrasound
  • Transcutaneous Electrical Nerve Stimulation (TENS) to control pain
  • Swimming - may be beneficial, however, some authorities recommend avoiding the "backstroke" and "breaststroke"

Physical therapists can also advise patients with TOS regarding arm placement and body support during sleep which are especially important since so much time is spent in bed or sleeping. Helpful measures include:

  • Soft neck rolls which immobilize and support the cervical spine
  • Refraining from resting the arm elongated above the head
  • Some health care professionals recommend the use of cervical supports and pillows but these may cause excessive cervical extension and in some cases, increase pain
Postural Training

The goal of postural training is to correct poor posture such as drooping or sagging shoulders. Proper posture is essential in the treatment of TOS. Compression resulting from poor posture and positioning affects soft tissue and eventually causes hyperextension of the cervical spine due to continued head forward position. Some important aspects of muscular rehabilitation in the cervicoscapular region include:

  • Stretching to improve range of motion - Improved range of motion is best achieved through gentle stretching and repetitive motions to gain full cervical movement. This stretches tight muscles of the upper chest that attach to the cervical spine. These muscles include:

    • scalene muscles
    • pectoralis major and minor
    • upper trapezius
    • levator scapulae

To provide the greatest support and least exacerbation of pain, exercises are typically done on the floor with a pillow or towel roll supporting the cervical spine. Exercise intensifies gradually until full cervical extension is achieved and exercises can be done with no extra support of the head or neck. The patient then progresses to doing these exercises in a sitting position. As the tolerance for exercises increases, more aggressive stretching techniques can be initiated. If exercises are too intense for the level of the patient or if they progress too rapidly, symptoms can worsen.

When carrying out a treatment program for increasing the range of motion in the cervicoscapular area, the patient must be careful not to overstretch nerves (neural stretching) which can result in symptoms in the entire arm.

  • Restoring muscle strength - Restoration of muscle strength in the cervicoscapular region proceeds only after patients have achieved pain-free range of motion. Initially strengthening exercises are done with gravity assistance (i.e., minimum resistance) and then progressive resistance is introduced. Among the muscles targeted are the middle/lower trapezius muscles and the serratus anterior muscles.

The objective of muscle strengthening activity is endurance, not power, so progressive stages of exercise are introduced gradually. Stretching and range of motion exercises must be maintained during the strengthening stage.

  • Improving muscles involved with respiratory function - Poor posture puts a strain on accessory respiratory muscles, those muscles that are not normally involved directly in inhaling and exhaling. Over time, poor posture causes muscles involved in breathing to shorten resulting in the first rib being pulled out of place and elevated which leads to greater compression on the brachial plexus. Accessory respiratory muscles are then used to assist with respiration and chest expansion which puts an added burden on them.

Breathing exercises that promote proper muscle use while maintaining good posture improve chest expansion during breathing resulting in decreased use of accessory breathing muscles.

Drug Therapy

Drug therapy for controlling pain in neurogenic TOS may be accomplished with:

  • Analgesics and non-steroidal anti-inflammatory drugs (NSAID's)- may be used to reduce pain and inflammation

  • Muscle relaxants - may be used to control muscle spasms (e.g., metaxalone)

  • Antidepressants - may be necessary for TOS patients to treat pain:

    • tricyclic antidepressants (Elavil, Pamelor)
    • selective serotonin reuptake inhibitors (Paxil, Zoloft)

  • Anticonvulsants (e.g., clonazepam, gabapentin, topiramate)

  • Scalene injections with local anesthetic/steroid solutions - may be used to reduce pain

  • Stellate ganglion block - may be given to patients with TOS who also have symptoms of reflex sympathetic dystrophy (RSD)

Surgery

As mentioned above, most patients with thoracic outlet syndrome improve with conservative treatment and only a small percentage will actually require surgery for anatomic decompression. Surgery may be considered as an option in certain situations including:

  • Patients who have failed to respond to conservative therapy after a minimum of at least 3 months and continue to have severe pain or neurologic deficits

  • Patients with acute vascular problems resulting in reduced blood flow to the area

  • Patients with true neurologic TOS caused by congenital anomalies (fibromuscular bands) that cause compression of the brachial plexus. Surgery is done to relieve the compression by resecting the first rib and all anomalous fibromuscular tissue around the brachial plexus and subclavian vessels.

  • Patients who are experiencing progressive sensory loss or muscle wasting

  • Patients with fractures of the clavicle who develop excessive callus formation that causes compression of the brachial plexus

  • In rare cases, breast reduction surgery has been recommended for women with extremely large breasts (hypertrophy) to relieve the excess weight load to the anterior chest wall.

Types of Surgical Procedures

There are several types of surgical procedures for the treatment of TOS including:

  • Transaxillary First Rib Resection - This involves surgical resection of the first rib using a transaxillary approach (incision is made under the armpit to gain access to the first rib. It is recommended for lower TOS involving C8-T1 nerve root symptoms. The most common complication is paresthesia with reduced sensation along the upper arm. Rare complications include injury to the brachial plexus and pneumothorax (punctured lung).

  • Cervical Scalenectomy - This surgical procedure involves severing the scalene muscle at the point of attachment to the first rib. It is recommended for upper TOS involving C5-C7 nerve root symptoms. Complications may include:

    • neck hematoma (a collection of blood)
    • chylus drainage (leakage of a fluid that is usually drained through the lymphatic system)
    • Horner's syndrome (injury to the nerves of the neck resulting in a constricted pupil and drooping eyelid involving one side of the face)

  • Resection of Fibrous Bands - This surgical procedure involves surgically removing bands of fibrous tissue in the costoclavicular region.

Although results of surgery for TOS may vary from patient to patient, an overall improvement of about 70% has been reported with a follow-up of 3-5 years in patients with true neurologic TOS following first rib resection or scalenectomy (Orthop. Clin. North America, Vol. 27(2):265-303, April 1996).

Postsurgical recurrence of TOS after rib resection is estimated at 2-30% of patients, typically secondary to significant scarring. The best outcome is typically in patients with occupations not requiring labor while the worst outcome is in obese patients and patients with other nerve entrapments in affected arm.

Recuperation Following Surgery

Within a short time after surgery, the patient commences range-of-motion exercises for the shoulder and cervical spine under the direction of a physical therapist. The patient typically achieves full range of motion within 3-4 weeks and then may begin muscle strengthening exercises. The surgery does not correct muscle imbalance which may have developed due to improper posture so strengthening and stretching these affected muscles is part of the postoperative treatment plan.

Regarding the long term results of surgery for treatment of thoracic outlet syndrome, some studies reported that 90% of patients who underwent surgery had good results and 65% of these patients maintained the benefit of surgery after 15 years. However, another study followed patients diagnosed with TOS who either elected to undergo surgery or were treated with conservative measures. The data indicated that return to work and symptoms severity were not significantly different between the two groups.

It is clear, however, that if one chooses to undergo surgery, it is of the utmost important to choose the surgeon very carefully and to verify that he/she has extensive experience doing these types of surgical procedure.

Most patients with TOS undergo one or more types of treatments and achieve relief, but for some patients the pain remains refractory and unabating. Patients in this situation usually require chronic pain management and may benefit from evaluation at a pain clinic.