Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

neurogenic TOS (NTOS)

1st line – conservative management

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ACUTE
|
neurogenic TOS (NTOS)
|
without electrodiagnostic abnormalities or hand muscle atrophy
1st line – 

conservative management

Presents with pain, numbness, and tingling with no hand muscle atrophy or electrodiagnostic abnormalities.

Initially treated conservatively with rest, work restrictions, and physical therapy.[139][140]

Core strengthening therapies help to improve posture and realign musculoskeletal structures.

Physical therapy is used to open up the space between the clavicle and first rib, improve posture, strengthen the shoulder girdle, and loosen the neck muscles.[142]​ This is accomplished by pectoralis stretching, strengthening the muscles between the shoulder blades, good posture advice, and active neck exercises (including chin tuck, flexion, rotation, lateral bending, circumduction).[139]

Ergonomics are also a key factor in rehabilitation and the ability of the patient to return to work.

Consider – pharmacotherapy

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ACUTE
|
neurogenic TOS (NTOS)
|
without electrodiagnostic abnormalities or hand muscle atrophy
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Pharmacotherapy should be limited to oral analgesics such as nonsteroidal anti-inflammatory drugs and muscle relaxants (e.g., cyclobenzaprine).

Local anesthetic muscle injections are largely used for aiding diagnosis and prognosis, but do not provide sustainable pain control.

Botulinum toxin injections into the suspected abnormal muscle (e.g., scalene and pectoralis minor) may be used; however, this treatment has not shown long-term efficacy.[32][143][144][145][146]

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 3200 mg/day

OR

cyclobenzaprine: 5-10 mg orally (immediate-release) three times daily when required for up to 3 weeks

2nd line – surgery

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ACUTE
|
neurogenic TOS (NTOS)
|
without electrodiagnostic abnormalities or hand muscle atrophy
2nd line – 

surgery

Usual indications for surgery are a sound clinical diagnosis, a disabling level of symptoms, and ineffective results with appropriate conservative therapy, after eliminating other possible etiologies for the symptoms.

A good prognosis for surgery may be more predictable in patients with a positive response to anterior scalene muscle anesthetic injection and relief of symptoms by injecting into the pectoralis minor.[118][136]​​

Surgical decompression of the thoracic outlet (e.g., removal of cervical rib, removal of first rib, removal or sectioning of the anterior and middle scalene muscles, neurolysis of the brachial plexus, release of the pectoralis minor muscle) is recommended.

The most commonly used surgical approaches are the supraclavicular and transaxillary approaches. The approach used is generally based on surgeon preference.

The advantage of the supraclavicular approach is the relative ease of access to the scalene muscles and clear visualization of the neural and vascular anatomy. Disadvantages include the need to manipulate the brachial plexus and vessels, as well as potential injury to the phrenic nerve.

The main advantage of the transaxillary approach is that the brachial plexus and subclavian vessels do not need to be retracted. A disadvantage is limited exposure and potential injury to the intercostobrachial nerve.

Isolated pectoralis minor tenotomy can be considered in cases of NTOS where the area of nerve compression is felt to be confined to the subcoracoid space.[118][136]

Complications include injury to the neural structures (i.e., brachial plexus, intercostobrachial nerve, phrenic nerve), bleeding, infection, pneumothorax, pleural effusion, chylothorax, and incomplete nerve release.

Plus – postoperative rehabilitation and pain control

Back
ACUTE
|
neurogenic TOS (NTOS)
|
without electrodiagnostic abnormalities or hand muscle atrophy
Plus – 

postoperative rehabilitation and pain control

Treatment recommended for ALL patients in selected patient group

Physical therapy is paramount, focusing on posture modifications, stretching and muscle relaxation, shoulder girdle strengthening, and ergonomics.

Pain control with oral and/or intravenous analgesics is appropriate in the immediate postoperative period, with the selection of the specific analgesic agent depending on physician preference. Oral analgesics often need to be continued after the immediate postoperative period.

Rest and work restrictions are also recommended.

1st line – surgery

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ACUTE
|
neurogenic TOS (NTOS)
|
with electrodiagnostic abnormalities or hand muscle atrophy
1st line – 

surgery

Patient objective signs of nerve compression: specifically, motor deficits such as weakness and atrophy of the involved muscle groups, and abnormalities on electrodiagnostic testing. Hand muscle atrophy is most pronounced in the thenar eminence and interosseous muscles (Gilliatt-Sumner hand). A bony abnormality (e.g., cervical rib) is often present.

Early surgery is the preferred approach as many patients will not respond to conservative management.[31][140]​​

Surgical decompression of the thoracic outlet (e.g., removal of cervical rib, removal of first rib, removal or sectioning of the anterior and middle scalene muscles, neurolysis of the brachial plexus, release of the pectoralis minor muscle) is recommended.

The most commonly used surgical approaches are the supraclavicular and transaxillary approaches. The approach used is generally based on surgeon preference.

The advantage of the supraclavicular approach is the relative ease of access to the scalene muscles and clear visualization of the neural and vascular anatomy. Disadvantages include the need to manipulate the brachial plexus and vessels, as well as potential injury to the phrenic nerve.

The main advantage of the transaxillary approach is that the brachial plexus and subclavian vessels do not need to be retracted. A disadvantage is limited exposure and potential injury of the intercostobrachial nerve.

Complications include injury to the neural structures (i.e., brachial plexus, intercostobrachial nerve, phrenic nerve), bleeding, infection, pneumothorax, pleural effusion, chylothorax, and incomplete nerve release.

Prognosis for full neural and functional recovery is more guarded given longstanding nerve compression with objective findings of nerve injury.

Plus – postoperative rehabilitation and pain control

Back
ACUTE
|
neurogenic TOS (NTOS)
|
with electrodiagnostic abnormalities or hand muscle atrophy
Plus – 

postoperative rehabilitation and pain control

Treatment recommended for ALL patients in selected patient group

Physical therapy is paramount, focusing on posture modifications, stretching and muscle relaxation, shoulder girdle strengthening, and ergonomics.

Pain control with oral and/or intravenous analgesics is appropriate in the immediate postoperative period, with the selection of the specific analgesic agent depending on physician preference. Oral analgesics often need to be continued after the immediate postoperative period.

Rest and work restrictions are also recommended.

venous TOS (vTOS)

1st line – catheter-directed thrombolysis

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ACUTE
|
venous TOS (vTOS)
|
surgical candidate
1st line – 

catheter-directed thrombolysis

Immediate venography and catheter-directed treatment is recommended within 2 weeks of diagnosis of subclavian vein thrombosis, but intervention may still be effective if performed up to 6-8 weeks after the onset of arm swelling symptoms.[113] If acute thrombosis is present, venography and catheter-directed therapy is recommended with thrombolysis, suction thrombectomy, and/or balloon angioplasty. Placement of stents in the subclavian vein is contraindicated in the absence of surgical decompression.[155]

Venography is performed through an antecubital, basilic, or brachial vein catheter and thrombolytic treatment or suction thrombectomy are initiated. The thrombolytic agent chosen and method of clot disruption is determined by the treating physician.

Surgical treatment may be performed immediately after catheter-directed therapy, within days during the same hospital stay, or after an interval of 4-6 weeks with the patient remaining on anticoagulation treatment.[156][157][158][159]​​​

Plus – surgery

Back
ACUTE
|
venous TOS (vTOS)
|
surgical candidate
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

The surgical approach selected should ensure decompression at the costoclavicular space, with resection of the anterior scalene muscle, the subclavius muscle and costoclavicular ligament, and the anteromedial first rib. This can be accomplished by transaxillary, infraclavicular, or paraclavicular approaches. The approach used is generally based on surgeon experience and preference.[79][91][160][161][162]​​​​[163][164][165]

Intraoperative venography can help define the degree of vein obstruction present at the time of surgery and immediately after decompression. Intravascular ultrasound may be another option for assessing the subclavian vein. In some cases, intraoperative balloon angioplasty may be considered for residual vein stenosis.

Direct axillary-subclavian vein reconstruction can be accomplished at the time of surgery when the infraclavicular or paraclavicular approaches are used, with either patch angioplasty or bypass grafting. With the transaxillary approach, venography is often deferred for several weeks after surgery and endovascular approaches (e.g., balloon angioplasty) are used to treat any residual vein stenosis.

Complications include injury to neural structures (i.e., brachial plexus, intercostobrachial nerve, phrenic nerve), bleeding, infection, pneumothorax, pleural effusion, chylothorax, and postoperative subclavian vein thrombosis.

Plus – postoperative rehabilitation and pain control

Back
ACUTE
|
venous TOS (vTOS)
|
surgical candidate
Plus – 

postoperative rehabilitation and pain control

Treatment recommended for ALL patients in selected patient group

Physical therapy is paramount, focusing on posture modifications, stretching and muscle relaxation, shoulder girdle strengthening, and ergonomics.

Pain control with oral and/or intravenous analgesics is appropriate in the immediate postoperative period, with the selection of the specific analgesic agent depending on physician preference. Oral analgesics often need to be continued after the immediate postoperative period.

Rest and work restrictions are also recommended.

Consider – anticoagulation

Back
ACUTE
|
venous TOS (vTOS)
|
surgical candidate
Consider – 

anticoagulation

Treatment recommended for SOME patients in selected patient group

Patients are typically discharged from hospital on anticoagulation following surgery, for periods of 1-3 months.

Anticoagulation is most frequently accomplished with a direct oral anticoagulant. Other options include warfarin or a low-molecular-weight heparin (e.g., enoxaparin). Antiplatelet agents (e.g., aspirin, clopidogrel) may be used in some cases. Consult your local protocols for further guidance on suitable anticoagulation/antiplatelet options and doses.

1st line – catheter-directed thrombolysis

Back
ACUTE
|
venous TOS (vTOS)
|
nonsurgical candidate
1st line – 

catheter-directed thrombolysis

Patients who are not deemed to be surgical candidates (i.e., patients with significant medical comorbidities that would not tolerate extensive surgical intervention or prolonged anesthesia) can still undergo catheter-directed therapy with thrombolysis, suction thrombectomy, and balloon angioplasty to remove the venous obstruction. However, thrombolysis should not be considered in patients with ongoing contraindications to thrombolytic therapy (e.g., active bleeding).

Placement of stents in the subclavian vein is contraindicated in the absence of surgical decompression.

Venography is performed through an antecubital, basilic, or brachial vein catheter and thrombolytic treatment or suction thrombectomy are initiated. The thrombolytic agent chosen and method of clot disruption is determined by the treating physician.

Patients with compromised hemodialysis access due to venous thoracic outlet syndrome are at considerably higher risk for surgery, so initial treatment with endovascular approaches is preferred. If there are repeated occurrences of access thrombosis or persistent arm swelling, thoracic outlet decompression is considered. This may be performed by an infraclavicular approach with limited anterior first rib resection, or by resection of the medial clavicle as an alternative.[81][82]​​[83][84]​​[85][86]​​[87]​​​​

Plus – postoperative rehabilitation and pain control

Back
ACUTE
|
venous TOS (vTOS)
|
nonsurgical candidate
Plus – 

postoperative rehabilitation and pain control

Treatment recommended for ALL patients in selected patient group

Physical therapy is paramount, focusing on posture modifications, stretching and muscle relaxation, shoulder girdle strengthening, and ergonomics.

Pain control with oral and/or intravenous analgesics is appropriate in the immediate postoperative period, with the selection of the specific analgesic agent depending on physician preference. Oral analgesics often need to be continued after the immediate postoperative period.

Rest and work restrictions are also recommended.

Plus – arm elevation and compression

Back
ACUTE
|
venous TOS (vTOS)
|
nonsurgical candidate
Plus – 

arm elevation and compression

Treatment recommended for ALL patients in selected patient group

Arm elevation and use of a compression sleeve are recommended to help minimize arm swelling.

Consider – anticoagulation

Back
ACUTE
|
venous TOS (vTOS)
|
nonsurgical candidate
Consider – 

anticoagulation

Treatment recommended for SOME patients in selected patient group

Patients are typically discharged from hospital on anticoagulation following surgery, for periods of 1-3 months.

Anticoagulation is most frequently accomplished with a direct oral anticoagulant. Other options include warfarin or a low-molecular-weight heparin (e.g., enoxaparin). Antiplatelet agents (e.g., aspirin, clopidogrel) may be used in some cases. Consult your local protocols for further guidance on suitable anticoagulation/antiplatelet options and doses.

arterial TOS (ATOS)

1st line – surgery

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ACUTE
|
arterial TOS (ATOS)
1st line – 

surgery

Immediate surgical intervention is required if there is concern about acute limb ischemia.

Emergency surgical treatment may include initial exploration at the brachial artery level for thromboembolectomy.[56]​ Intraoperative adjuncts include systemic anticoagulation and possible infusion of thrombolytic agents into the distal artery branches.

Once acute limb ischemia is resolved, thoracic outlet decompression should be undertaken either at the same setting or within days to weeks, while the patient is maintained on anticoagulation treatment.

For patients with a cervical rib, decompression can be accomplished by either transaxillary or supraclavicular approaches with resection of the cervical rib and first rib, resection of the anterior and middle scalene muscles, and removal of congenital bands and accessory muscles. The subclavian artery must be assessed for the presence of aneurysmal dilatation.

Intraoperative assessment of the subclavian artery can include direct observation, intraoperative arteriography, or intravascular ultrasound. The presence of aneurysmal dilatation (diameter greater than twice normal) or mural thrombus is an indication for arterial repair. Milder degrees of post-stenotic dilatation may be observed without direct arterial repair.

Subclavian artery reconstruction should be performed with a supraclavicular approach, with or without an infraclavicular incision for exposure of the distal artery. The aneurysmal segment of subclavian artery is excised with interposition bypass graft repair. Conduits may include prosthetic grafts, autologous reversed saphenous vein, or cryopreserved femoral artery or vein allografts.

Postoperative evaluation of arterial patency is essential. Perfusion of the limb and pulses should be routinely tested clinically. In cases where clinical assessment is in question, assessment of arterial patency with arteriography or CT angiography may be necessary. Arteriography also allows for diagnosis and immediate treatment of complications, such as dissection, thrombosis, or pseudoaneurysm.

Complications include injury to neural structures (i.e., brachial plexus, intercostobrachial nerve, phrenic nerve), bleeding, infection, pneumothorax, pleural effusion, chylothorax, and postoperative arterial thrombosis.

Plus – consider catheter-directed thrombolysis

Back
ACUTE
|
arterial TOS (ATOS)
Plus – 

consider catheter-directed thrombolysis

Treatment recommended for ALL patients in selected patient group

If thrombosis is present, catheter-directed thrombolysis is a recommended treatment option.

Plus – postoperative rehabilitation and pain control

Back
ACUTE
|
arterial TOS (ATOS)
Plus – 

postoperative rehabilitation and pain control

Treatment recommended for ALL patients in selected patient group

Physical therapy is paramount, focusing on posture modifications, stretching and muscle relaxation, shoulder girdle strengthening, and ergonomics.

Pain control with oral and/or intravenous analgesics is appropriate in the immediate postoperative period, with the selection of the specific analgesic agent depending on physician preference. Oral analgesics often need to be continued after the immediate postoperative period.

Rest and work restrictions are also recommended.

Consider – anticoagulation

Back
ACUTE
|
arterial TOS (ATOS)
Consider – 

anticoagulation

Treatment recommended for SOME patients in selected patient group

Postoperative anticoagulation is necessary after surgical treatment with thromboembolectomy, direct arterial repair, if residual ischemia is present during postoperative evaluation, or if the patient is deemed to have a hypercoagulable state.

Anticoagulation is most frequently accomplished with a direct oral anticoagulant. Other options include warfarin or a low-molecular-weight heparin (e.g., enoxaparin). Antiplatelet agents (e.g., aspirin, clopidogrel) may be used in some cases. Consult your local protocols for further guidance on suitable anticoagulation/antiplatelet options and doses.

neurovascular (combined)

1st line – surgery

Back
ACUTE
|
neurovascular (combined)
1st line – 

surgery

Immediate surgical intervention is required for both the vascular and neurogenic components of combined thoracic outlet syndrome.

Techniques include catheter-directed thrombolysis and surgical decompression of the thoracic outlet. The method selected depends on the pathology and type of thoracic outlet syndrome and surgeon preference. See Management approach.

Complications include injury to the neural structures (i.e., plexus, intercostal nerve, phrenic nerve), bleeding, infection, pneumothorax, and incomplete nerve release.

Plus – postoperative rehabilitation and pain control

Back
ACUTE
|
neurovascular (combined)
Plus – 

postoperative rehabilitation and pain control

Treatment recommended for ALL patients in selected patient group

Physical therapy is paramount, focusing on posture modifications, shoulder girdle strengthening, and ergonomics.

Pain control with oral and/or intravenous analgesics is appropriate in the immediate postoperative period, with the selection of the specific analgesic agent depending on physician preference. Oral analgesics often need to be continued after the immediate postoperative period.

Rest and work restrictions are also recommended.

Consider – anticoagulation

Back
ACUTE
|
neurovascular (combined)
Consider – 

anticoagulation

Treatment recommended for SOME patients in selected patient group

Postoperative anticoagulants are necessary if residual ischemia is seen on postoperative evaluation or if the patient is deemed to have a hypercoagulable state.

Anticoagulation is most frequently accomplished with a direct oral anticoagulant. Other options include warfarin or a low-molecular-weight heparin (e.g., enoxaparin). Antiplatelet agents (e.g., aspirin, clopidogrel) may be used in some cases. Consult your local protocols for further guidance on suitable anticoagulation/antiplatelet options and doses.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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