Treatment

The appropriate treatment of patients with thoracic outlet syndrome depends on the clinical form of thoracic outlet syndrome, and the underlying anatomic cause of the syndrome.

Patients with venous thoracic outlet syndrome usually present with upper extremity thrombosis, which causes arm swelling, cyanosis, and visible collateral vessels.  Rarely, these patients can present with a pulmonary embolism. Urgent thrombolysis is usually initiated, after which definitive treatment is performed, including either angioplasty of the vein, or surgical decompression of the thoracic outlet, with removal of the structures that are causing the extrinsic compression of this vein.

Patients with arterial thoracic outlet syndrome usually present with upper extremity pallor, coldness and distal emboli to the hand and/or fingers.  Urgent thrombolysis is usually initiated, after which definitive treatment is performed, including surgical decompression of the thoracic outlet, with removal of the structures that are causing the extrinsic compression of the artery, as well as repair or bypass of the damaged artery, if necessary.  Cervical ribs are much more common in this subtype of thoracic outlet syndrome, and are usually resected.

Patients with neurogenic thoracic outlet syndrome usually present with an insidious and progressive course, as described above.  These patients almost always undergo a specialized and focused program of physical therapy for a period of weeks to months, which is aimed at rebalancing the muscles of the shoulder girdle and improving the patient's posture.  Patients with repetitive stress injury may also undergo occupational therapy and ergonomic evaluation of their work environment.  A small number of patients fail to respond to conservative therapy, at which point surgical decompression of the thoracic outlet is considered.  It should be noted that patients with long-standing disease, as indicated by muscle atrophy or weakness in the hands, should undergo surgical decompression as soon as reasonably possible, as muscle atrophy or weakness indicates advanced and likely permanent nerve damage.

Surgical outcomes have been published from numerous university and private practice sites, both in the United States and abroad (4, 8, 14, 22, 27, 63, 105-113).  Following surgical decompression of the thoracic outlet, 80 to 85% of patients report excellent or good results.  During the first two postoperative years, some of these patients experience recurrent symptoms. However, beyond the first two postoperative years, approximately 70% of patients report excellent or good results.  It should be noted that patients with long-standing symptoms and/or motor signs are less likely to experience symptomatic improvement or to regain motor function (38, 114).  These findings closely parallel those seen in other nerve decompression procedures, including neural foraminotomy, carpal tunnel release, and decompression of the ulnar nerve in the cubital tunnel (114).