Treatment For TOS

Options exist in the management of Thoracic Outlet Syndrome.

For each type of problem- venous, arterial and nerve impingement– there are non-surgical and surgical options.

When the subclavian artery has been injured by the bony and non-bony structures at the thoracic outlet the best treatment is surgery. It is important to decompress the artery removing the first and cervical ribs as well as any constricting connective and muscle tissue. The subclavian artery itself may need to be replaced or repaired so that no further clot forms. It is also necessary to consider removing any clot that has floated into the arm or hand.

When the subclavian vein is compressed it is at risk for thrombosis or clotting. The obstructing clot could break loose and travel to the lung causing a pulmonary embolus. Additionally, blockage of the subclavian vein lessens the channel through which blood returns from the arm to the heart. Just like a dam causes the river above the dam to swell, the blocked vein results in swelling of the arm. Collateral channels (other veins) enlarge over time to help empty the arm, but they are far less efficient than the large caliber subclavian vein. Thus, the arm remains swollen, and swelling worsens with use. With the passage of time, the clot in the vein changes from a Jell-O-like dissolvable substance to dense tissue which adheres to the vein wall and which may cause permanent blockage.

If recognized early, the fresh clot in the vein can be removed or lysed by placing a catheter into the vein and either removing the clot mechanically or chemically dissolving the clot with medicines dripped into the vein. If doctors are successful in opening up the vein, there still remains the extrinsic tissue which caused the compression of the vein in the first place. It has been our experience that surgical removal of the first rib along with muscular and connective tissue which compresses the vein from the outside provides the best chance of returning normal venous drainage to the affected arm. After successfully decompressing the subclavian vein, webs inside the vein caused by the clot or injury of the vein may have to be treated with a balloon to fully open up the inside the vein.

You are an important part of your treatment, and a successful outcome requires hard work on your part. Almost all patients are eager to do whatever they can to help their recovery. Since TOS symptoms begin at a definite point in time, it stands to reason that prior to that time sufficient space existed at the thoracic outlet to allow normal unimpeded nerve movement.

Therefore in the absence of something like a fractured rib or collar bone it may be possible to relax and stretch the muscular structures around the nerves and make the symptoms go away. This is done by physical and occupational therapists. The goal of therapy is:

1) To balance the muscles which pull the shoulder back with those that pull the shoulders forward.

2) To teach the patient ways of moving that do not further injure or strain the injured muscles.

3) To increase “core strength” improving the way one carries the shoulders neck and head.

4) To teach the patient to recognize tight muscles and to learn to relax them.

5) To slowly increase range of motion in a way so as not to irritate the nerves.

Treatment may include, massages by a trained therapist, a TENS unit to block the pain messages from the arm, and medicines to help relax tight muscles, to allow sleep, to combat swelling and inflammation, to lessen pain, and to treat depression. Patients have sought improvement through other means such as: biofeedback, acupuncture, meditation, chiropractic care, yoga, Pilates, and other therapies. We will try to help you find a therapist who is an expert in the treatment of brachial plexus disorders. Not all therapy is beneficial; some therapy can actually worsen symptoms. It should be given a thorough trial of at least 12 solid weeks and should include home exercises. When appropriate therapy has failed and when symptoms are intolerable, surgical decompression of the brachial plexus becomes a reasonable option.

Many surgical approaches to decompress the brachial plexus have been proposed. I will describe the technique used at the Vascular Institute of the Rockies and tell you why we believe it is the optimal surgical approach. We remove the first rib through a transaxillary approach (under the arm pit) as described by Dr. Roos.

If a cervical rib exists, it is also completely removed. We completely detach the anterior scalene muscle from the first rib as well as from the subclavian vein, artery, and attachments to the fascia beneath the subclavian artery, vein and brachial plexus. This allows the anterior scalene muscle to become completely relaxed, like a rubber band taken off stretch.

We believe that this complete dis-insertion of the anterior scalene muscle reduces the likelihood of recurrent symptoms to due scarring of the muscle. This is based on our observation when performing re-operations on patients in whom the muscle was not disconnected. At the back of the rib, we sew the cut end of the middle scalene muscle over the cut end of the first rib. This covers the rib and attaches the middle scalene muscle so it will not grow into the lower nerves of the plexus. We then carefully remove any impinging structures around the lower two or three nerve roots and the lower one or two trunks of the brachial plexus. We make every attempt not to disrupt the smooth surface of the scalene muscles adjacent to the nerves. We recognize that those surfaces facilitate nerve glide, and their dissection may lead to scar formation. We always use a mechanical arm holder so that no stretch injury occurs on the nerve.

Following surgery we emphasize rest and adequate pain control to allow the patient to relax. Gradually, physical therapy is implemented.

Patients are educated as to avoid future injury. Though complications can arise from this surgery, this is a safe and effective procedure when performed by surgeons who are experienced in treating TOS.

In some patients’ improvement is only temporary due to recurrent scar formation, which again entraps the plexus. The surgery is designed to limit scar formation by releasing the anterior and middle scalene muscles while still keeping the smooth surface of those muscles intact thus allowing nerve glide to continue. We believe that leaving the muscles in place while taking them off stretch is vital to achieving the best result from the surgery and makes our surgery different from others. Though few become completely symptom free after our TOS procedure, our goal is to lessen pain and discomfort, improve movement and function so that our patients can return to a productive and satisfying life.