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Treatment of thoracic outlet syndrome depends on which structure is compressed. Neurogenic TOS is usually treated first with physiotherapy, while venous and arterial TOS often need urgent vascular treatment followed by surgery.

Match treatment to the problem

For many people with neurogenic TOS, conservative care comes first, with reassessment of symptoms and function. Significant weakness or wasting of the hand muscles changes the discussion toward earlier surgery1. A clot in the arm vein, or damage to the artery, follows a vascular pathway that may include clot treatment or repair of the vessel as well as decompression23. These vascular problems shouldn't wait on a timetable designed for nerve symptoms.

Conservative care for neurogenic TOS

Physiotherapy aims to improve posture, shoulder-blade control and the movements that bring on symptoms, and activities that provoke symptoms are adjusted. The 2024 INTOS consensus supports conservative care for many patients, with the type, duration and response interpreted in the clinical context1.

Decompression surgery

When symptoms persist despite good conservative care, or when there is weakness or muscle wasting, surgery decompresses the outlet. Operations may remove the first rib or a cervical rib, release the scalene muscles or fibrous bands, or address another site of compression1.

Surgeons reach the outlet in three main ways:

  • Supraclavicular, through a cut above the collarbone
  • Transaxillary, through the armpit
  • Posterior, from behind, as in the PURED approach

Practice varies. The INTOS group didn't reach consensus that the first rib should be removed in every first operation for neurogenic TOS1, and a 2026 study of case scenarios found that experts proposed different plans for the same patients4. In a long-term cohort, the length of rib left behind after surgery wasn't associated with outcome5.

The PURED approach

PURED, Posterior Upper Rib Excision and Decompression, is a posterior approach to the thoracic outlet developed by Dr. Kamran Aghayev, who edits Thoracic Outlet Syndrome Wiki. The surgeon reaches the first rib and the brachial plexus from behind, through a gap between the muscles of the upper back, then removes the first rib, or a cervical rib, and frees the nerves and vessels.

Older posterior approaches cut through large back muscles, which limited their use. An anatomical study in 11 cadavers, co-authored by Dr. Aghayev, described a muscle-sparing route through a triangle of muscles beneath the trapezius that gives direct access to the brachial plexus6. The author reports that the posterior view allows the first rib to be removed fully and the nerves and vessels decompressed along their length7.

Published results

The first report, in 2018, described nine patients (10 operations). Average arm pain fell from 7.8 to 1.1 out of 10 at six months, and all returned to full-time work8. Dr. Aghayev's 2023 series reports every patient with neurogenic TOS he operated on with PURED from 2015 to 2023: 80 operations in 61 patients, with an average follow-up of 1,153 days (just over three years, range 87 to 3,048 days)7.

  • 55 patients rated their improvement as excellent (more than 75%) and 6 as good (50 to 75%). None reported a fair, poor or worse result.
  • The mean improvement reported by patients was 91.5%.
  • In 11 patients (18%), a bony abnormality such as a cervical rib was the cause.
  • Complications were opening of the pleura (the lining of the lung), Horner syndrome and bleeding at the top of the lung. None was permanent.

As with most surgical evidence on TOS, this is a retrospective series from a single surgeon, with improvement rated by patients themselves and no comparison group. It shows what was achieved in these patients, not how PURED compares with other approaches.

Venous TOS

Venous TOS with a clot in the subclavian vein is treated in phases: blood thinners and often clot-dissolving treatment first, then decompression of the outlet to remove the compression that caused the clot, and sometimes treatment of a narrowed vein afterward2. See venous TOS.

Arterial TOS

Arterial TOS can damage the subclavian artery and send clots to the hand. Treatment combines decompression with repair of the artery and removal of clots where needed, and repeat procedures are sometimes necessary3. See arterial TOS.

Questions before treatment

  • Which form of TOS do I have, and what findings support it?
  • What has conservative care achieved, and what would count as a meaningful improvement?
  • Which surgical approach do you recommend for me, and why?
  • Will the first rib or a cervical rib be removed?
  • How often do you see persistent or returning symptoms, and how are they managed?

References

  1. Chim H, Hagan RR. Plast Reconstr Surg Glob Open. 2024;12:e6107. doi:10.1097/GOX.0000000000006107. Source ↩
  2. Davies MG, Hart JP. Front Surg. 2024;11:1302568. doi:10.3389/fsurg.2024.1302568. Source ↩
  3. de Kleijn RJCMF et al. Front Surg. 2023;9:1072536. doi:10.3389/fsurg.2022.1072536. Source ↩
  4. Chim H; INTOS Workgroup. J Hand Surg Am. 2026;51:982.e1–982.e9. doi:10.1016/j.jhsa.2026.03.014. PubMed ↩
  5. Nuutinen H et al. Interact Cardiovasc Thorac Surg. 2021;33:734–740. doi:10.1093/icvts/ivab172. PubMed ↩
  6. Akaslan I, Ertas A, Uzel M, Ozdol C, Aghayev K. Surgical anatomy of the posterior intermuscular approach to the brachial plexus. Hand (N Y). 2021;16(6):759-764. doi:10.1177/1558944719895619 PubMed ↩
  7. Aghayev K. World Neurosurg. 2023;180:e739–e748. doi:10.1016/j.wneu.2023.10.017. PubMed ↩
  8. Aghayev K, Ciklatekerlio O. Posterior upper rib excision for neurogenic thoracic outlet syndrome: feasibility and early outcomes. Oper Neurosurg. 2018;14(5):532-537. doi:10.1093/ons/opx143 PubMed ↩