Thoracic Outlet Syndrome - Treatment

Among the most common types of nerve entrapment is Thoracic Outlet Syndrome (TOS) causing pain and weakness in the neck, shoulder, arm and hand.

Although all physicians understand the role of the spine problems in causing shoulder and arm pain, there is a great deal of controversy and confusion regarding the diagnosis of thoracic outlet syndrome. Nerve entrapment of the median nerve in the wrist at the carpal tunnel can affect the thumb and next two fingers - carpal tunnel syndrome. Entrapment of the ulnar nerve at the elbow is cubital tunnel syndrome. However between the spine and the elbow there are many nerves, crossing a long course when these nerves become entrapped or injured, the diagnosis may be TOS.

Thoracic outlet syndrome can affect the blood vessels, or the nerves or both. In the past, it has been easy to diagnose TOS affecting thed blood vessels - causing loss of blood flow when the arms are raised. However, diagnostic proof of TOS affecting the nerves has been considered unsatisfactory or very difficult to achieve. Now, the advent of MR Neurography and Open MR guided injections has revolutionized diagnosis and treatment in this field. With these techniques, Dr. Filler at the Institute for Nerve Medicine has shown that TOS can be divided into as many as six different types of nerve entrapment. Each of these can be reliably and confidently identified and new, minimally invasive treatments are now avaiable for each of these.

In the past, the only surgery widely offered for the treatment of TOS was resection of the first rib. This is a very invasive and difficult operation with an extended recovery period and a very significant risk of major injury to blood vessels, nerves or lung during the operation. Dr. Filler has shown that if the inidividual type of TOS affecting a patient is known in advance, then it is usually possible to plan a small, safe minimally invasive surgery to correct the problem - usually on an outpatient basis.

There are many diagnoses and treatments of thoracic outlet syndrome. Please investigate the articles in this section to learn more about individualized cases from the files of Dr. Filler.

Adhesions Causing Recurrence after 1st Rib Resection


Treatment: Mid-plexus Fibrotic Entrapment After First Rib Resection

Animation: Mid plexus fibrosis after first rib resection.

The elements of the brachial plexus both proximal and distal to the area of fibrosis demonstrate normal separation between the nerve elements.

At the area indicated by the two arrows, the elements are adherent to each other, and demonstrate some deviation from their normal course. An additional image in the plane of the plexus elements also demonstrated a posterior deviation at this point. Palpation of the plexus at this location confirmed a Tinel's sign and focal tenderness in the area suggested by this image.


Surgical Treatment for Thoracic Outlet Syndome


Treatment: Minimal access surgery with no rib resection improves outcome and reduces recovery time

Animation: Differentiation of thoracic outlet syndrome into five major categories of proximal and mid-plexus disease based on imaging characteristics.

Surgery for the treatment of thoracic outlet syndrome is offered by several different types of surgeons and with a wide variety of different surgical methods or approaches. A major difference is between methods directed at nerve release as opposed to methods involving resection of the first rib.

The first rib resection operation is a larger operation that often involves collapsing the lung. It is technically very challenging and should only be done by experts with a great deal of experience - it is typically offered by specialist vascular surgeons.

The major alternative is the "supraclavicular approach." This is less invasive and involves an incision above the collarbone. It is usually directed at cutting or partially resecting the anterior scalene muscle. There may also be resection of the middle scalene muscle. This approach gives a neurosurgeon or vascular surgeon a direct, precise access to each of the component nerves in the brachial plexus. In addition, other shoulder nerves that pass nearby such as the accessory nerve to the trapezius muscle and the long thoracic nerve (that is sometimes involved in pain affecting the shoulder blade) can be treated. It carries a much lower risk of major nerve, blood vessel, or lung injury.

At the Institute for Nerve Medicine, Dr. Filler has optimized the supraclavicular approach to use an incision that is about three centimeters in length. Some doctors use a much larger incision. In addition, Dr. Filler uses anti-scarring materials that greatly reduce the risk of recurrence from scar formation. In addition, Dr. Filler sometimes uses a second incision in the axilla (or underarm) to carry out nerve releases of nerves of the brachial plexus, shoulder and arm when they occur in this region. Sometimes, both incisions are needed.

Nerve release surgery for TOS is usually quite easy to recover from and is not particularly painful. Aside from the usual risks of all surgeries, thoracic outlet surgery includes special risks of injury to the phrenic nerve (that operates the diaphragm) and of the thoracic duct (that carries lymphatic digestive fluid to the bloodstream). Injuries to either of these can delay recovery but are usually not permanent problems. The open supraclavicular approach minimizes these risks when compared with first rib resection.



Dr. Aaron G. Filler, MD PhD

Dr. Aaron Filler is the world’s leading expert in treatment of nerve pain. He has revolutionized nerve-pain treatment by inventing several new technologies. One such technology, MR Neurography, enables doctors to use an MRI scanner to examine nerves — previously a difficult-to-impossible tissue to see through MR imaging. Dr. Filler's research in axonal transport is leading to a whole new generation of advanced pain medications. He has developed many new “minimal access” surgery methods that allow him to treat complex nerve problems with small outpatient surgeries. He has also pioneered the use of the Open MRI scanner to do surgeries and other therapies with the ultra-high precision and safety of the magnetic resonance imaging.   Click here to learn more.

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About NerveMed

NerveMed is a free online resource dedicated to helping patients worldwide with information about spine and nerve health issues. NerveMed is powered by the Institute for Nerve Medicine in Santa Monica, California, home to Dr. Aaron G. Filler, MD PhD, a leading neurosurgeon specializing in minimally invasive treatments for spine and nerve issues. Click here to learn more.

Dr. Aaron G. Filler, MD PhD

Dr. Aaron Filler is the world’s leading expert in treatment of nerve and spine pain, having revolutionized treatments by inventing several new technologies, including MR Neurography. Dr. Filler has also pioneered minimal-access surgery methods to treat complex nerve and spine problems with outpatient surgeries.   Click here to learn more.