Types of Thoracic Outlet Syndrome

TOS is divided into three types, based on the predominant structures affected.

• Neurogenic TOS is the most common type, affecting the brachial plexus nerves. Patients may experience neck, shoulder, or arm discomfort or headaches. Patients often report that symptoms began after experiencing a traumatic injury. Experts believe this occurs most commonly due to the shortening and thickening of the anterior scalene muscle, which connects the spine to the first rib.
• Venous TOS is the next most common type, with complete or high-grade blockage of the subclavian-axillary vein (located between the first rib and the collarbone). Patients often report previous repetitive overhead shoulder movements, such as pitching or swimming. Patients may present with swelling of the whole arm, discoloration, and pain.
• Arterial TOS is the least common type, although it is the most dangerous. Chronic compression of the subclavian artery may lead to a blockage or the creation of an aneurysm—a weakening and ballooning of the artery. Patients may present with a cold, painful arm and difficulty moving or feeling their fingers.

We recognize that TOS is a complex condition and that treatment is highly specific to each patient. On a patient’s first visit, we perform a detailed history and physical exam. If TOS is suspected, a variety of specialized diagnostic tests may be performed to support the diagnosis.

For patients presenting with neurogenic TOS, physical therapy may be the first-line therapy. This may treat the scalene muscles, muscles surrounding the spine, and the muscles that support the thoracic outlet and shoulder. Botox® therapy of the anterior scalene muscle is another treatment option for patients with persistent symptoms. While conservative treatment is often successful in alleviating symptoms of neurogenic TOS, surgical decompression may be recommended if patients do not find long-term relief.

For patients presenting with venous or arterial TOS, our vascular surgeons will first perform revascularization to relieve symptoms. This is often performed from an endovascular, or minimally invasive, approach. Surgical decompression and reconstruction of the vessel may then be performed to address the underlying cause.

Our vascular and thoracic surgeons offer several approaches to decompression surgery to meet each patient’s specific anatomy, symptoms, and goals for recovery.