Treatment of TOS

Treatment of Neurogenic TOS

Treatment of neurogenic TOS remains challenging

The primary focus of treatment in patients with neurogenic TOS is to relieve compression or stretching of the brachial plexus. Many doctors begin with conservative therapy, including physical therapy, occupational therapy, massage or acupuncture. A minority of patients with neurogenic TOS will eventually require surgery. Surgical results are variable, but depending on the surgeon and the selected technique the results may be quite good.

No matter the modality, treatment of neurogenic TOS remains quite challenging. It is important to understand that no single treatment modality has been proven superior in all patients. Understand that there are a large number of underlying mechanisms that cause neurogenic TOS. Thus, it would be unrealistic to expect one treatment to work in all patients. It is wise to remain cautious of any provider who uses the same approach in all patients.

Many patients experience improvement with a progressive or multi-modality treatment plan. A progressive treatment plan would include one type of conservative therapy, gradually increasing in intensity, or a sequence of different conservative modalities. A multi-modality plan would combine various conservative treatment modalities at one time, which may change over time. In either of these patient groups, surgery would remain a treatment option if conservative treatment fails.

Neurogenic TOS rarely presents as a surgical emergency. However, a minority of patients with neurogenic TOS eventually require surgical treatment. Therefore, it is useful to include an early surgical consult in most treatment plans. This allows the surgeon to observe the progress or lack of progress in a patient.

For these reasons, TOS specialists and patients should consider all forms of treatment. The patient and doctor should work together to build a successful treatment program, with frequent review of progress and consideration of all options.

Medical team 5 specialists with stethoscopes smiling

Treatment of neurogenic TOS is often controversial

Optimal treatment of patients with neurogenic TOS remains the subject of active and lively discussion among TOS specialists. Providers and patients can choose from a broad array of treatment options. Many of these options are not well-proven or objectively compared with other treatment options. Many TOS specialists strongly prefer one option, often to the exclusion of others. These specialists may have little or no experience with other treatment modalities. For these reasons, patients often find it difficult to gather useful information about their treatment choices. They may have to take their doctor’s advice on faith, often without awareness or detailed knowledge of other options.

Our goal is to provide the reader with a broad outline of treatment options first, followed by more detailed discussions of each modality. We will also consider alternative treatment modalities that hold promise for improving outcomes.

To begin with, treatment choices for patients with neurogenic TOS can be divided into two broad groups:

Conservative Treatment of Neurogenic Thoracic Outlet Syndrome
Surgical Treatment of Neurogenic Thoracic Outlet Syndrome

Conservative Treatment of Neurogenic TOS

All treatment that does not involve surgery is referred to as conservative treatment. Conservative treatment for patients with neurogenic TOS may include one or more of the following modalities:

Physical Therapy

Physical therapy and physical therapists resolve physical impairments, and promote mobility and normal musculoskeletal function.

Learn more about physical therapy.

Chiropractic

Chiropractors restore normal spinal structure and alignment in order to restore normal body function.

Learn more about chiropractic.

Drugs

Several drugs are used as a first-line component in the conservative treatment of patients with neurogenic TOS.

Learn more about drugs that are used to treat neurogenic TOS.

Occupational Therapy

Occupational therapists help patients to accomplish normal activities within the limits of a disability or temporary physical injury.

Learn more about occupational therapy.

Acupuncture

Acupuncture has grown into an effective method of pain relief for many people, especially in conjunction with other conservative methods.

Learn more about acupuncture.

Massage therapy

Many patients find massage therapy helpful, especially in combination with other forms of conservative therapy. Several states license massage therapists to ensure high standards are maintained.

Learn more about massage therapy.

Scalene block

Many patients inquire about scalene blocks. This procedure was first performed in 1947, and many surgeons rely on this test to help make surgical decisions.

Learn more about scalene blocks.

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Surgical Treatment of Neurogenic TOS

All treatment that does not involve surgery is referred to as conservative treatment. Conservative treatment for patients with neurogenic TOS may include one or more of the following modalities:

Supraclavicular approach

The supraclavicular incision starts with an incision above the collarbone. Since the 1980s, the supraclavicular approach has become the preferred approach in many academic centers. This approach provides good access to the soft tissues of the scalene triangle and to the lateral aspect of the first rib.

Learn more about the supraclavicular approach.

Infraclavicular approach

The infraclavicular approach starts with an incision below the collarbone. The infraclavicular approach is not as widely used as the supraclavicular approach. However, the infraclavicular approach provides better access to the anterior aspect of the first rib, and to the subclavian vein.

Learn more about the infraclavicular approach.

Posterior approach

Dr. O. Theron Claggett introduced the posterior approach to the thoracic outlet in the 1960s. Dr. Clagett focused on the first rib as a cause of thoracic outlet syndrome, contrary to prevailing thought that the anterior scalene muscle was the most important underlying factor. Unfortunately, the procedure may have significant complications. Surgeons rarely use the posterior approach today.

Learn more about the posterior approach.

Transaxillary approach

Dr. David Roos of Denver pioneered the transaxillary approach in the 1960s. Through this approach, Dr. Roos was able to view selected areas of the anatomy that he felt were the most important to address for treatment of TOS. The transaxillary approach provides access to the lateral aspect of the first rib and to the insertions of the scalene muscles. However, the procedure can be challenging, as it is performed through a small and deep incision.

Learn more about the transaxillary approach.

Combined approach

Some surgeons advocate a combined supraclavicular and infraclavicular approach. While this approach has the advantages of each separate approach, it is more time consuming, and requires a larger sterile field.

Learn more about the combined approach.

New Surgical Innovations

Some pioneering surgeons are developing and refining radical new approaches to the thoracic outlet, including robotic surgery and modifications of the standard techniques used in the past.

Learn more about new surgical innovations.

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Do you have questions about thoracic outlet syndrome?

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Alternative Treatment of Neurogenic TOS

Treatment modalities that are recently developed or outside of the traditional conservative or surgical approaches are referred to as alternative treatments. Alternative treatment modalities for patients with neurogenic TOS may include one or more of the following modalities:

Selective injections

Since the 1970s, some TOS specialists have performed specialized injections to help diagnose and guide treatment decisions. Specifically, doctors started by injecting a local anesthetic in the anterior scalene muscle on the symptomatic side. These doctors believed that a reduction in symptoms would be a good indicator towards surgical success. However, the injections were performed initially without imaging guidance, and the validity of the conclusions has been questioned.

Currently, many centers use ultrasound or CT for guided injections. Additionally, doctors inject into the anterior or middle scalene muscle, and sometimes the pectoralis minor muscle. Finally, injected agents include local anesthetics, paralyzing agents such as Botox®, or anti-inflammatory agents around the brachial plexus.

The current medical literature remains inconclusive regarding the effectiveness of these injections for reduction of symptoms. In addition, there remains little agreed-upon evidence regarding the use of injections to ensure good surgical outcome.

We consider injections such as these to have significant value in selected patients, even if the mechanism of their action remains unclear. The injections are safe when performed by experienced TOS specialists. We remain hopeful that evidence will continue to accrue to guide TOS specialists in their best applications.

Alternative Drugs

We have all read or heard about medical marijuana recently. Although there remains considerable research on the use of marijuana to treat pain, researchers have published some early promising results.

When used in combination with opiates, marijuana reduces pain at the same level compared to a significantly lower opiate dose. While opiates present significant risks of addiction and overdose, marijuana does not present these risks. Therefore, a patient can achieve the same pain relief with a much lower risk. That is promising news!

Orthotics

Some people are born with anatomic variations, such as fibrous bands or unusual scalene muscles. However, many of these people never experience symptoms. In those people who do get symptoms, we know that a secondary process combined with the underlying anatomic variations. Since there are two additive factors, treatment can begin by addressing one of these factors.

Therefore, instead of surgery, we can address the secondary process. Specifically, we can treat by altering posture, correcting shoulder position, and assuming better spine position.

A number of people have developed orthotic devices specifically targeted to help patients with thoracic outlet syndrome.

Ergonomics

In the computer age, we face constant demands to assume unnatural positions. Most people do not work with computers in an optimal position. Outside of work, the issues only worsen, which you can easily see by watching somebody use their phone or tablet in all sorts of positions.

Diet

Some authorities have suggested that the adoption of an anti-inflammatory diet may help decrease chronic pain. Proposed dietary changes often involve increased servings of foods high in Omega-3 fats, such as salmon or avocado. Supplements containing fish oil or Omega-3 fats are used by many people, and may provide some of the same benefits.

Learn more about surgical treatment of neurogenic TOS