Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a group of conditions caused by compression of the nerves or blood vessels that pass from the base of the neck to the arm. They run through the thoracic outlet, a narrow space bounded by the collarbone, the first rib and the scalene muscles of the neck. An extra rib growing from the lowest neck vertebra (a cervical rib), tight muscles or fibrous bands can narrow the space further.

Three forms

TOS takes three forms, depending on what is compressed1:

Neurogenic TOS is by far the most common form. The forms can overlap, but each is assessed and treated differently.

Symptoms that need urgent attention

A newly swollen, painful, warm or discolored arm needs urgent medical assessment, because a clot in the arm vein is one possible cause. Sudden breathlessness, chest pain or coughing blood needs emergency care2. A suddenly painful, cold or pale arm or hand, especially with numbness or difficulty moving it, can mean the blood supply is blocked and also needs emergency care3.

Diagnosis

Neurogenic TOS is diagnosed mainly from the history and examination: symptoms in the pattern of the nerves of the brachial plexus, tenderness above or below the collarbone, symptoms brought on by raising the arms, and the exclusion of other causes such as a trapped nerve in the neck or at the elbow or wrist4. Imaging looks for a cervical rib and, in the vascular forms, shows the vein or artery and any clot5. See symptoms and diagnosis.

Treatment

Neurogenic TOS is usually treated first with physiotherapy and activity changes. Surgery is considered when symptoms persist despite good conservative care, or sooner when there is muscle weakness or wasting4. The operation decompresses the outlet by removing the first rib or a cervical rib and releasing the scalene muscles and fibrous bands.

Venous TOS with a clot is treated with blood thinners and, often, clot-dissolving treatment, followed by decompression of the outlet to stop it recurring5. Arterial TOS may need repair of the damaged artery as well as decompression6. See treatment and PURED.

Surgical approaches

Surgeons reach the thoracic outlet from above the collarbone (supraclavicular), from the armpit (transaxillary), or from behind. The PURED operation, Posterior Upper Rib Excision and Decompression, is a posterior, muscle-sparing approach developed by Dr. Kamran Aghayev, who edits Thoracic Outlet Syndrome Wiki. In his series of 80 operations in 61 patients with neurogenic TOS, followed for an average of just over three years, 55 patients rated their improvement as excellent and 6 as good, and no complication was permanent7.

Pages on each form

The neurogenic, venous and arterial pages cover each form in detail, and recovery and recurrent TOS covers what happens after surgery and when symptoms return.

About the editor

Dr. Kamran Aghayev

Neurosurgeon, Associate Professor of Neurosurgery · Istanbul

Dr. Kamran Aghayev is a neurosurgeon in Istanbul and an associate professor of neurosurgery, with more than 20 years in practice. He trained in neurosurgery at Hacettepe University in Ankara, completed spinal oncology and neuro-oncology fellowships at the H. Lee Moffitt Cancer Center in Tampa, Florida, and taught there as a clinical instructor before returning to Turkey. He chaired the neurosurgery department at Biruni University in Istanbul from 2017 to 2020. His published work includes a surgical technique for jugular vein decompression in atlanto-styloid compression and the PURED operation for thoracic outlet syndrome, and he is a named inventor on 13 U.S. patents for spinal devices.

How this site is editedkamranaghayev.com

References

1. Illig KA et al. J Vasc Surg. 2016;64:e23–e35. doi:10.1016/j.jvs.2016.04.039. PubMed ↩
2. NHS. Thoracic outlet syndrome. Reviewed 14 December 2023. Source ↩
3. Society for Vascular Surgery. Acute Limb Ischemia. Source ↩
4. Chim H, Hagan RR. Plast Reconstr Surg Glob Open. 2024;12:e6107. doi:10.1097/GOX.0000000000006107. Source ↩
5. Davies MG, Hart JP. Front Surg. 2024;11:1302568. doi:10.3389/fsurg.2024.1302568. Source ↩
6. de Kleijn RJCMF et al. Front Surg. 2023;9:1072536. doi:10.3389/fsurg.2022.1072536. Source ↩
7. Aghayev K. World Neurosurg. 2023;180:e739–e748. doi:10.1016/j.wneu.2023.10.017. PubMed ↩

Related pages

• Symptoms and diagnosisWhy a pattern of symptoms matters more than a single maneuver, scan finding or subtype label.
• Neurogenic thoracic outlet syndromeThe brachial plexus, diagnostic uncertainty, and the role of conservative and specialist pathways.
• Venous thoracic outlet syndromeCompression of the subclavian vein, effort thrombosis, and why clot assessment has its own pathway.
• Treatment and PUREDTreatment of thoracic outlet syndrome: physiotherapy, decompression through the neck, armpit or back, the PURED approach, and venous and arterial TOS.