How is thoracic outlet syndrome treated?

Early identification of TOS can help improve the success of treatment. Thoracic outlet syndrome treatments vary, depending on the type of TOS you have and your symptoms. The goals of treatment are to reduce symptoms and pain. Your health care provider will recommend the treatment option that is right for you.

Before choosing any treatment, it is important to talk to your health care provider about the potential benefits, risks and side effects of your treatment options.

Treatment of neurogenic thoracic outlet syndrome

  • Physical therapy: The most common initial treatment for neurogenic thoracic outlet syndrome is physical therapy. Physical therapy increases the range of motion of the neck and shoulders, strengthens muscles and promotes better posture. Most patients experience an improvement in symptoms after undergoing physical therapy.
  • Medications: For pain relief, over-the-counter pain medications, such as aspirin, acetaminophen (Tylenol), or ibuprofen (Motrin), may be recommended. Your doctor may prescribe a muscle relaxant for additional pain relief.
  • Surgery: In some cases, surgery may be needed to treat neurogenic thoracic outlet syndrome if symptoms continue, despite an optimal course of physical therapy.

Treatment of venous thoracic outlet syndrome

To reduce the risk of blood clots and pulmonary embolism, treatment for venous thoracic outlet syndrome may include thrombolytic (clot-busting) or anticoagulant (blood thinning) medications and surgery. In many cases, the patient will be treated with thrombolytic medications and start anticoagulation therapy before surgery.

  • Thrombolytic medications are given to dissolve blood clots. This type of medication is always given to the patient in the hospital so he/she can be closely monitored. The medication(s) may be injected directly into the vein or delivered via a catheter, a long slender tube, which is guided through the vein to the area where the blood clot is located. The clot-dissolving drug is sent through the catheter into the clot. The clot usually dissolves in a matter of hours to a few days. In some cases, the narrowed area of the vein will need to be treated with angioplasty (opening the vein using a balloon) to keep more clots from forming. Surgery is often recommended after the clot in the vein has been effectively treated/dissolved.
  • Anticoagulant medications decrease the blood’s ability to clot and keep more clots from forming. Anticoagulant medications include warfarin (Coumadin), heparin, low-molecular weight heparin and fondaparinux (Arixtra). You will receive information about how to take the anticoagulant medication that is prescribed for you.
  • Surgery may be necessary along with medications to manage your symptoms. Surgery corrects the narrowing that is causing problems with the vein and may be recommended after the clot in the vein has been effectively treated/dissolved with medications.

Treatment of arterial thoracic outlet syndrome

  • Surgery: Patients with arterial thoracic outlet syndrome often require surgical treatment. Surgery may be performed to remove the first rib and make more room for the vessels and nerves. Surgery may also be performed to repair any structural problems of the artery.
  • Thrombolytic medications may be given before surgery, if necessary, to dissolve blood clots. This type of medication is always given to the patient in the hospital so he/she can be closely monitored. The medication(s) may be injected directly into the artery or delivered via a catheter, a long slender tube, which is guided through the artery to the area where the blood clot is located. The clot-dissolving drug is sent through the catheter into the clot. The clot usually dissolves in a matter of hours to a few days. In some cases, the narrowed area of the artery will need to be treated with angioplasty (opening the artery using a balloon) to prevent more clots from forming.

When is surgery necessary?

Although only 10 to 20 percent of patients with TOS need surgical treatment, most patients with venous or arterial TOS will need surgical treatment.

Surgery for venous and arterial TOS is very effective. Among patients with venous TOS, elective surgery corrects symptoms in 90 to 95 percent of cases; elective surgery resolves symptoms in more than 95 percent of patients with arterial TOS.

Some patients with neurogenic TOS will need surgery. The primary goal of surgery in these patients is to remove the source of compression on the spinal nerves that supply stimulation to the arm, forearm and hand (the brachial plexus). This is typically accomplished by removing the first rib, abnormal muscles or fibrous bands. If there is an extra rib causing compression, it may also be removed.

Known as “decompression surgery,” the procedure is typically completed by making an incision in the underarm area on the affected side. It can also be performed through an incision made above the clavicle (collar bone). An alternative surgical approach known as video-assisted thoracoscopic surgery (VATS), which is performed through several small incisions, may be used in some cases.

Surgical risks

Like all extensive surgical procedures, there are risks associated with decompression surgery. One significant risk is failure to respond to surgery. In experienced centers, approximately 50 to 70 percent of patients will have improvement in their symptoms after decompression surgery. For this reason, surgery to treat neurogenic TOS is reserved for those patients that remain debilitated despite appropriate noninvasive therapy, including supervised physical therapy and pain relief. Other complications are rare, occurring in only 2 to 3 percent of cases, but include:

Length of hospital stay

Following surgery, you will stay in the hospital for one night, and in some cases an additional day. During your recovery, you will begin physical therapy to you gain function and minimize pain and the recurrence of symptoms.

Last reviewed by a Cleveland Clinic medical professional on 07/19/2019.

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