TOS is sometimes treatable through medical and physical therapy. Surgery may be recommended to relieve the compression. Once treated, there are usually no long-term effects and you should be able to return to an active lifestyle. Treatment will vary depending on the source and severity of the condition.
Neurogenic Thoracic Outlet Syndrome
Once the diagnosis of NTOS has been made, patients are sent for a trial of physical therapy that focuses on relaxation and stretching of the scalene muscles, stabilizing the neck, spine, and shoulder girdle, and deep breathing exercises to improve diaphragmatic function. Those patients with NTOS whose symptoms do not improve are offered surgical decompression.
The goal of surgical treatment of NTOS is to relieve the compression of the nerves of the brachial plexus. A small incision is made at the base of the neck and the thoracic outlet is exposed. The brachial plexus is then decompressed by removing the anterior and middle scalene muscles and the first rib. Neurolysis of the brachial plexus is then performed, where the nerves are released from surrounding scar tissue. After discharge from the hospital patients will complete a course of post-operative physical therapy and will be expected to return to full activity within 2-3 months of surgery.
Venous Thoracic Outlet Syndrome
The goals of treatment of VTOS are to restore flow through the axillosubclavian vein and to relieve the compression of the subclavian vein. For patients who present with an axillosubclavian DVT, the first step in treatment is to remove the clot. Clot removal is usually performed in a minimally invasive fashion using endovascular techniques including:
- Targeted administration of thrombolytic agents (medicines that dissolve clot).
- Percutaneous thrombectomy devices that physically remove clot.
- Balloon angioplasty of the subclavian vein after removal of the acute thrombus to increase the diameter of the scarred subclavian vein.
Once the thrombus has been removed, patients are placed on anticoagulants to prevent recurrent thrombosis and plans are made for surgical decompression of the subclavian vein. To decompress the vein, a small incision is made beneath the clavicle near its junction with the sternum. The clavicle, first rib, and the edge of the sternum are exposed. The costoclavicular ligament is excised and venolysis of the subclavian vein is performed, where the vein is freed from any surrounding scar tissue. The anterior portion of the first rib is then removed to finish opening the space of the anterior thoracic outlet. Once the space has been opened a venogram is frequently performed to see if there is any residual narrowing of the vein. If present, the residual narrowing may be treated by:
- Opening the vein, excising scar tissue from the vein, and sewing a patch to vein to increase its diameter.
- Dilating the vein with an angioplasty balloon and placing a stent in the vein if there is residual narrowing after angioplasty.
After discharge from the hospital patients will complete a course of post-operative physical therapy and will be expected to return to full activity within 2-3 months of surgery.
Arterial Thoracic Outlet Syndrome
The goals of treatment in ATOS are to relieve compression of and to replace the injured segment of the injured subclavian artery and to restore flow to the forearm and hand. Patients who present with acute ischemia of the upper extremity due to emboli from the injured artery will undergo a thrombectomy procedure, where an incision is made over the obstructed artery in the extremity. The artery is exposed and opened and the thrombus is removed with the help of a thrombectomy catheter. Once flow has been restored to the hand, decompression of the subclavian artery is performed through a small incision at the base of the neck as in the treatment of NTOS. Cervical or anomalous first ribs are then excised with the anterior and middle scalene muscles and the first rib. The injured subclavian artery is excised and replaced with an interposition graft. In patients who have chronic occlusion of the more peripheral arteries from chronic emboli, additional arterial replacement or bypasses may need to be performed to restore flow to the hand.