Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a diagnosis steeped in controversy. The term is used to describe symptoms which arise from compression of either the subclavian artery (arterial TOS), the subclavian vein (venous TOS), or brachial plexus (neurogenic TOS). The first two are well-recognized entities, however they account for less than 5% of patients with TOS. By far, the majority of patients with this diagnosis have neurogenic TOS. The diagnosis itself is controversial. Many believe that neurogenic TOS does not exist because there are no universally-accepted objective tests available to diagnose it. Those who do believe the diagnosis exists argue that there is a large collective experience from many countries with patients who exhibit symptoms characteristic of neurogenic TOS and who improve after surgery directed at decompression of the lower brachial plexus.

We believe that neurogenic TOS does exist, and that some patients with TOS require surgery for relief of their symptoms. All patients with neurogenic TOS should first undergo physical therapy. Only those whose severe symptoms persist should be offered surgery. We favor a video-assisted, minimally-invasive transaxillary approach. This technique affords complete visualization of the thoracic outlet through a three-inch axillary incision. Video assistance allows us to reduce the size of the incision, and also to lessen the amount of traction on the shoulder to gain adequate exposure. The muscular and tendonous attachments to the first rib are divided, then the first rib is removed back to the transverse process. Our long term success rate with this approach is greater than 90%. The most common postoperative complaint is numbness on the inner part of the arm, which tends to subside over time.