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Removing Rib Relieves Pressure from Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is caused by compression of the principal nerves and/or blood vessels in the shoulder area. Because other conditions can create similar symptoms, patients may experience a variety of doctors and treatments before they are properly diagnosed.

Robert W. Thompson, MD, a vascular and general surgeon, is out to correct that situation. He has founded the Center for Thoracic Outlet Syndrome at Washington University and Barnes-Jewish Hospital.

The surgery he performs includes taking out all or part of a top rib to relieve compression symptoms and then fixing any damage to blood vessels. There are only a few centers in the country doing this innovative surgery, many of them influenced by Thompson’s leadership.

Nerve compression symptoms such as pain, numbness and tingling build up over time; patients with blood vessel compression may experience sudden vascular symptoms like blood clots or aneurysm requiring immediate evaluation and treatment. “Optimal treatment for all forms of TOS requires considerable experience, expertise, and a great deal of patience,” Thompson says.

Cervical ribs can add to compression. However, only 10 percent of those with cervical ribs ever develop symptoms, and TOS can develop without a cervical rib when the muscles surrounding the first
rib and collarbone pinch.

The surgery focuses on removing the top rib and any cervical rib adding to the compression. “For neurogenic and arterial TOS, we remove the first rib to within 1 or 2 inches of the sternum to relieve the compression. If the subclavian vein is compressed, we make a second incision near the sternum to take out the rest of the rib,” Thompson says. When compression of the artery results in a ballooning or aneurysm, the surgery must also include doing a bypass around the aneurysm with a donated vein from another area.

Another variation on arterial compression is compression below the pectoralis minor muscle, where the axillary artery can become occluded or develop an aneurysm. Thompson sees this condition mostly in baseball pitchers who perform overhead throwing. Some patients with milder and more recent neurogenic symptoms do well with skilled physical therapy. Vascular TOS should be treated promptly by a vascular surgeon.

On Oct. 23 – 24, Thompson and Washington University School of Medicine hosted the first national symposium entirely focused on TOS. This symposium, “Thoracic Outlet Syndrome: Challenges, Controversies, and Consensus,” included a professional conference for physicians and therapists to identify priorities for improving the diagnosis and treatment of TOS and a patient support and advocacy conference sponsored by the American TOS Association (ATOSA) to address issues important to the care of patients with TOS.
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