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Thoracic Outlet Syndrome

Thoracic outlet syndrome is difficult to diagnose and not well understood by physicians who have not seen many cases. The Center for Thoracic Outlet Syndrome (TOS) at the Washington University and Barnes-Jewish Heart & Vascular Center offers internationally recognized expertise on all aspects of TOS. 

Center of Excellence for Thoracic Outlet Syndrome

Thoracic outlet syndrome is a complex condition that requires precise, individualized treatment. At the Heart & Vascular Center, you will find:

  • Exceptional knowledge: Patients come to us for our extensive familiarity with TOS. Our surgeons operate on about 300 patients per year, the largest volume of any TOS program in the world. We treat people from across the U.S. and more than 20 countries, including Major League Baseball players and other athletes. Find out more about us.
  • Accurate diagnosis: You will receive an accurate diagnosis, based on many years of experience. We can provide answers, even if you have sought multiple opinions or had procedures that did not resolve your symptoms.
  • Personalized care: Our team provides individualized treatment to resolve symptoms and help you return to your activities as soon as possible. Customized physical therapy plans support you as you launch your recovery, either instead of or after surgery. Learn more about the Center for Thoracic Outlet Syndrome.
  • Pain management: We aim to limit your pre- and postoperative discomfort while also minimizing the use of narcotic medications. We devised new ways to use regional anesthesia blocks to reduce pain while you await surgery. Learn more about pain management and rehabilitation.

What Is Thoracic Outlet Syndrome?

Thoracic outlet syndrome (TOS) is a group of rare conditions involving compression of the brachial plexus, a group of nerves and blood vessels that serves the arm and hand. Problems can also affect the subclavian blood vessels that pass through the base of the neck and behind the collarbone. 

Learn more about the anatomy of the thoracic outlet.

Types and Causes of Thoracic Outlet Syndrome

There are three types of thoracic outlet syndrome

  • Neurogenic TOS: Tears in the scalene muscles (on the sides of the neck) cause stiffening and muscle spasms, which can irritate brachial plexus nerves. About 4 in 5 TOS diagnoses involve neurogenic TOS.
  • Venous TOS: Vein injury, scarring and narrowing can lead to clots and blockage in the subclavian vein, between the collarbone and first rib. Venous TOS often affects athletes who use their arms heavily in overhead positions or lifting. But it can develop in any active, healthy individual. It is also known as “effort thrombosis” or Paget-Schroetter syndrome.
  • Arterial TOS: An extra rib or change in the first (highest) rib compresses or blocks the subclavian artery in the neck. You may develop an aneurysm (bulge or weakness) in the artery. Small blood clots can form, break off and travel to the hand, causing pain and numbness. 

Risk Factors and Symptoms of TOS

Thoracic outlet syndrome generally occurs in young people who are otherwise healthy and active. More than half of people with neurogenic TOS are women. Venous TOS and arterial TOS affect people of any gender.

When TOS causes compression, you may experience:

  • pain in the neck and shoulder
  • pain, numbness, tingling and weakness in the hand and fingers
  • arm swelling and discoloration (due to a clot in the vein to the arm)
  • cold, painful fingers
  • arm fatigue (due to an aneurysm of the artery to the arm)

Symptoms may worsen when you have: 

  • arm elevated overhead
  • poor posture
  • repetitive use of the arm and hand

Diagnosing Thoracic Outlet Syndrome

Many patients with TOS come to us for a second opinion after a referral from a spine surgeon, hand surgeon or rehabilitation physician who has ruled out other problems. 

Our surgeons perform a complete physical exam to diagnose TOS. We talk with you about your symptoms, activities and treatments you have received. We may order imaging studies and diagnostic tests to pinpoint the cause of symptoms. Our expertise enables us to assess your case and accurately diagnose or rule out TOS. Read more about what to expect from your visit.

Thoracic Outlet Syndrome Treatment

We customize your TOS treatment based on your symptoms, the type of TOS and how far it has progressed. 

To begin, you see a physical therapist and our pain management team to receive regional pain blocks, all under the direction of the surgical team. In most cases, you receive all of this care within the same morning or afternoon.

Surgery for neurogenic TOS

Caught early, mild symptoms of neurogenic TOS usually respond to appropriate physical therapy. For disabling neurogenic TOS that does not improve with conservative care, we may recommend surgery. Most people have substantial improvement after surgery.

During surgery for neurogenic TOS, your surgeon: 

  1. makes an incision above the collarbone
  2. removes the anterior scalene muscle and clears fibrous scar tissue away from each nerve to restore mobility
  3. removes the middle scalene muscle
  4. protects the nerves while exposing and removing the first rib
  5. makes a second incision near the shoulder to divide the pectoralis minor muscle tendon, if necessary

After surgery, you work with a physical therapist as early as the next morning to begin range-of-motion exercises to support your recovery. Most people stay in the hospital three to five days after surgery. 

Surgery for venous TOS

Venous thoracic outlet syndrome usually involves two hospitalizations. Often, we diagnose venous TOS because of a blood clot that requires urgent treatment. We use percutaneous (catheter-based) treatment to clear the clot. You return home with anticoagulation (blood-thinning) treatments. Four to six weeks later, you come back for surgery.

Venous TOS surgery begins the same way as surgery for neurogenic TOS. The surgeon then: 

  1. makes a second incision just below the collarbone
  2. removes the entire first rib and any scar tissue from around the subclavian vein
  3. opens and repairs the vein with a patch or bypass graft if the subclavian vein is still narrowed

After surgery for venous TOS, most people spend four to seven days in the hospital.

Surgery for arterial TOS

Arterial TOS often presents as an urgent, limb-threatening situation. When a clot blocks blood flow to your arm and hand, we first resolve the clot. Then you have TOS surgery during the same hospitalization.

After the initial surgery (the same as for neurogenic TOS), your surgeon: 

  1. removes an extra “cervical” rib
  2. repairs the subclavian artery by removing the aneurysm and using a graft to replace the damaged artery
  3. uses small balloon catheters (tiny tubes inserted into an artery) and thrombolytic (clot-busting) drugs to clear small clots from blood vessels in the lower arm and hand

If you undergo emergency surgery for arterial TOS, you will stay in the hospital seven to 10 days. The stay is shorter — three to five days — if you have an evaluation and referral to surgery before the condition becomes urgent.

Research and Clinical Trials for Thoracic Outlet Syndrome

We continually explore new ways to manage pain and discomfort related to thoracic outlet syndrome. You may have access to investigational therapeutic options that are not ordinarily available. Other research opportunities seek to develop new knowledge to help future patients. Learn more about our innovation.

Contact Us

To make an appointment with a Washington University vascular specialist at Barnes-Jewish Hospital, call 314-273-7373.