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Thoracic Outlet Syndrome

Thoracic outlet syndrome: neurogenic vs vascular, first rib resection (corpus-synthesised).

Overview

Thoracic outlet syndrome (TOS) is a specific disease entity characterized by distinct symptoms and is treatable [2]. Despite its treatability, consensus on diagnostic criteria has not yet been established [1]. Arterial TOS is rare but can be devastating when the diagnosis is overlooked or delayed [3]. A major concern in treatment is the failure to make the correct diagnosis or to appreciate the presence of a significant shoulder problem or additional peripheral nerve problems [5].

General first-line therapy for TOS is conservative treatment [1]. Most patients are successful with conservative management unless there is significant neural loss or vascular compression [6]. Surgery is considered for patients who fail conservative therapy [1]. Surgical decompression is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections [7].

Anatomic anomalies associated with TOS may be better understood through the use of multidetector CT and three-dimensional reconstructions [12]. Nonunion of a first rib fracture may lead to TOS that is unresponsive to conservative treatment, necessitating resection of the first rib [14].

Anatomy & Pathophysiology

Thoracic outlet syndrome is a specific disease with specific symptoms [2]. Arterial thoracic outlet syndrome is rare but can be devastating when the diagnosis is overlooked or delayed [3].

Osseous

Multidetector CT and three-dimensional reconstructions hold promise for refining the understanding of anatomic anomalies associated with thoracic outlet syndrome [12]. Misalignment of the clavicle after intramedullary fixation of a midshaft fracture with a titanium elastic nail can result in acute neurovascular thoracic outlet syndrome [10]. Possible transformation or straightening of the natural curvature of the clavicle may cause neurovascular thoracic outlet syndrome [10].

Ligamentous & Muscular

Compression of the brachial plexus in a reported case was probably caused in part by the abnormal attachment of the subclavius muscle [28]. Compression of the brachial plexus in a reported case was probably caused in part by an anomalous coracoclavicular joint [28].

Classification

Clinical Entity: Thoracic Outlet Syndrome (TOS) is a specific disease characterized by specific symptoms [2]. It is a controversial condition involving compression of neurovascular structures by fibromuscular and fibro-osseous tissues [9]. The entity comprises distinct vascular and neurogenic subtypes [11].

Neurogenic TOS: Disputed neurogenic TOS, now termed electrically negative neurogenic TOS, accounts for the vast majority of cases [11]. This subtype lacks definitive diagnostic studies [11].

Arterial TOS: Arterial thoracic outlet syndrome is rare [3]. However, it can be devastating when the diagnosis is overlooked or delayed [3].

Venous TOS: Treatment for venous thoracic outlet syndrome addresses three problems: the clot, the extrinsic compression, and the intrinsic damage to the vein [13].

Other Considerations: Possible transformation or straightening of the natural curvature of the clavicle may cause neurovascular thoracic outlet syndrome [10]. Anatomical variations such as muscle fusion or nerve piercing the muscle are common in the Japanese population [17]. These variations may have implications for thoracic outlet syndrome diagnosis and management [17]. The scalene triangle base width in the Japanese population (8.2 mm) is narrower than in Western populations [17]. Multidetector CT and three-dimensional reconstructions hold promise for refining the understanding of anatomic anomalies associated with thoracic outlet syndrome [12].

Clinical Presentation

Thoracic Outlet Syndrome (TOS) is a specific disease characterized by distinct symptoms [2]. It involves compression of neurovascular structures by fibromuscular and fibro-osseous tissues [9]. The condition is controversial [9] and often subject to misdiagnosis [9]. TOS is a clinical entity with distinct vascular and neurogenic subtypes [11]. Disputed neurogenic TOS, now termed electrically negative neurogenic TOS, accounts for the vast majority of cases [11]. This subtype lacks definitive diagnostic studies [11].

Vascular Subtypes: Arterial TOS is rare [3] but can be devastating when the diagnosis is overlooked or delayed [3]. Venous TOS treatment addresses three problems: the clot, the extrinsic compression, and the intrinsic damage to the vein [13].

Etiological Factors: Possible transformation or straightening of the natural curvature of the clavicle may cause neurovascular TOS [10]. Nonunion of a first rib fracture may lead to TOS that is unresponsive to conservative treatment [14]. Traumatic events in previously asymptomatic individuals with congenital synostoses of the first and second ribs can lead to combined arterial and neurogenic TOS [16].

Anatomical Considerations: The scalene triangle base width in the Japanese population is 8.2 mm, which is narrower than in Western populations [17]. Anatomical variations such as muscle fusion or nerve piercing the muscle are common in the Japanese population [17].

Investigations

Thoracic outlet syndrome is a controversial condition involving compression of neurovascular structures by fibromuscular and fibro-osseous tissues [9]. Consensus in diagnostic criteria for thoracic outlet syndrome has not yet been established [1]. Compression of neurovascular structures in thoracic outlet syndrome often leads to misdiagnosis [9]. Failure to make the correct diagnosis is a major concern in the treatment of patients with thoracic outlet syndrome [5]. Failure to appreciate the presence of a significant shoulder problem is a major concern in the treatment of patients with thoracic outlet syndrome [5]. Failure to appreciate the presence of additional peripheral nerve problems is a major concern in the treatment of patients with thoracic outlet syndrome [5].

Plain radiography: Possible transformation or straightening of the natural curvature of the clavicle may cause neurovascular thoracic outlet syndrome [10].

CT: Multidetector CT and three-dimensional reconstructions hold promise for refining the understanding of anatomic anomalies associated with thoracic outlet syndrome [12].

Other Considerations: Disputed neurogenic thoracic outlet syndrome, now termed electrically negative neurogenic TOS, accounts for the vast majority of cases [11]. Electrically negative neurogenic TOS lacks definitive diagnostic studies [11]. Exercise-enhanced, ultrasound-guided anterior scalene muscle/pectoralis minor muscle blocks can facilitate the diagnosis of neurogenic thoracic outlet syndrome in the high-performance overhead athlete [15]. Arterial thoracic outlet syndrome is rare [3]. Arterial thoracic outlet syndrome can be devastating when the diagnosis is overlooked or delayed [3].

Treatment

Non-Operative

General first-line therapy for thoracic outlet syndrome is conservative treatment [1]. Most patients with thoracic outlet syndrome are successful with conservative treatment unless there is significant neural loss or vascular compression [6].

Operative

Indications: Surgery is considered for patients with thoracic outlet syndrome who fail conservative therapy [1]. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections [7]. Nonunion of a first rib fracture may lead to thoracic outlet syndrome that is unresponsive to conservative treatment, and resection of the first rib may be necessary [14]. Corrective clavicular osteotomy and plate fixation can effectively alleviate persistent symptoms of thoracic outlet syndrome caused by clavicular malunion [21].

Surgical Approach / Technique: For patients with neurogenic thoracic outlet syndrome that fail nonoperative management, surgical release of the pectoralis minor may be performed safely with effective resolution of neurogenic symptoms [20]. The treatment of venous thoracic outlet syndrome addresses three problems: the clot, the extrinsic compression, and the intrinsic damage to the vein [13].

Postoperative Care: Postoperative care protocols exist for patients who had thoracic outlet release with scalenectomy and neurolysis [8]. Successful outcomes in treated cases of neurogenic thoracic outlet syndrome in high-performance overhead athletes were mirrored by resolution of symptoms and return to athletic performance [15].

Complications

Diagnostic Oversight: Failure to establish the correct diagnosis is a major concern in the treatment of patients with thoracic outlet syndrome [5]. This diagnostic challenge is compounded by the failure to appreciate the presence of a significant shoulder problem [5] or additional peripheral nerve problems [5] [5].

Vascular Catastrophe: Arterial thoracic outlet syndrome can be devastating when the diagnosis is overlooked or delayed [3].

Iatrogenic and Traumatic Etiologies: Misalignment of the clavicle after intramedullary fixation of a midshaft fracture with a titanium elastic nail results in acute neurovascular thoracic outlet syndrome [10]. Possible transformation or straightening of the natural curvature of the clavicle may cause neurovascular thoracic outlet syndrome [10]. Furthermore, traumatic events in previously asymptomatic individuals with congenital synostoses of the first and second ribs can lead to combined arterial and neurogenic thoracic outlet syndrome [16].

Recovery

Conservative treatment is the general first-line therapy for thoracic outlet syndrome [1]. Most patients with thoracic outlet syndrome are successful with conservative treatment unless there is significant neural loss or vascular compression [6]. Surgery is considered for patients with thoracic outlet syndrome who fail conservative therapy [1]. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections [7].

Rehabilitation protocol: A postoperative care protocol for patients who had thoracic outlet release with scalenectomy and neurolysis is presented [8].

Other Considerations: Failure to make the correct diagnosis or to appreciate the presence of a significant shoulder problem or additional peripheral nerve problems is a major concern in the treatment of patients with thoracic outlet syndrome [5]. Nonunion of a first rib fracture may lead to thoracic outlet syndrome that is unresponsive to conservative treatment [14]. Resection of the first rib may be necessary for thoracic outlet syndrome caused by nonunion of a first rib fracture [14]. First rib resection yielded satisfactory results in the follow-up for acute arterial and neurogenic thoracic outlet syndrome following clavicle nonunion surgery [18]. First rib resection avoids the added risk of nonunion associated with plate removal and refixation in the treatment of acute arterial and neurogenic thoracic outlet syndrome following clavicle nonunion surgery [18].

Key Evidence

  • [L5] This article aims to review the epidemiology, etiology, relevant anatomy, clinical presentations, diagnosis, and management of thoracic outlet syndrome, noting that while consensus in diagnostic criteria has not yet been established, general first-line therapy is conservative treatment and surgery is considered for patients who fail conservative therapy. (10.3390/jcm10050962)
  • [L5] Thoracic outlet syndrome (TOS) is a specific disease with specific symptoms that is treatable. (10.1016/s0749-0712(03)00087-8)
  • [L5] Arterial thoracic outlet syndrome is rare but can be devastating when the diagnosis is overlooked or delayed. (10.1016/s0749-0712(03)00086-6)
  • [L5] The author emphasizes that failure to make the correct diagnosis or to appreciate the presence of a significant shoulder problem or additional peripheral nerve problems is a major concern in treatment of patients with thoracic outlet syndrome. (10.1016/s0749-0712(03)00084-2)
  • [L5] Most patients with thoracic outlet syndrome are successful with conservative treatment unless there is significant neural loss or vascular compression. (10.1016/s0749-0712(03)00081-7)
  • [L5] Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. (10.1016/j.jhsg.2022.07.004)
  • [L5] This article presents the authors' postoperative care protocol for patients who had thoracic outlet release with scalenectomy and neurolysis. (10.1016/s0749-0712(03)00091-x)
  • [L5] Thoracic outlet syndrome is a controversial condition involving compression of neurovascular structures by fibromuscular and fibro-osseous tissues, often leading to misdiagnosis. (10.1016/s0749-0712(03)00114-8)
  • [L4] Possible transformation or straightening of the natural curvature of the clavicle may cause neurovascular thoracic outlet syndrome. (10.1016/j.jse.2015.12.014)
  • [L4] The technique holds promise for refining the understanding of anatomic anomalies associated with thoracic outlet syndrome. (10.1016/s0749-0712(03)00115-x)
  • [L5] The treatment of venous thoracic outlet syndrome addresses three problems: the clot, the extrinsic compression, and the intrinsic damage to the vein. (10.1016/s0749-0712(03)00094-5)
  • [Case_report] Nonunion of a first rib fracture may lead to thoracic outlet syndrome that is unresponsive to conservative treatment, and resection of the first rib may be necessary. (10.1016/j.jse.2010.03.011)
  • [L4] Successful outcomes in these cases were mirrored by resolution of symptoms and return to athletic performance after treatment. (10.1177/0363546516665801)
  • [L4] Traumatic events in previously asymptomatic individuals with congenital synostoses of the first and second ribs can lead to combined arterial and neurogenic thoracic outlet syndrome. (10.1016/j.jhsa.2014.08.034)
  • [L4] The scalene triangle base width in the Japanese population (8.2 mm) is narrower than in Western populations, and anatomical variations such as muscle fusion or nerve piercing the muscle are common, which may have implications for thoracic outlet syndrome diagnosis and management. (10.1186/s12891-025-09048-2)
  • [Case_report] First rib resection yielded satisfactory results in the follow-up for acute arterial and neurogenic thoracic outlet syndrome following clavicle nonunion surgery, without the added risk of nonunion associated with plate removal and refixation. (10.1016/j.xrrt.2025.07.016)
  • [L5] For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed safely with effective resolution of neurogenic symptoms. (10.1016/j.xrrt.2022.05.008)
  • [L4] Corrective clavicular osteotomy and plate fixation can effectively alleviate persistent symptoms of thoracic outlet syndrome caused by clavicular malunion. (10.2106/00004623-200203000-00016)
  • [Case_report] Compression of the brachial plexus in this patient was probably caused in part by the abnormal attachment of the subclavius muscle, as well as by the anomalous coracoclavicular joint. (10.2106/00004623-199309000-00012)

References

[1] Thoracic Outlet Syndrome: A Narrative Review. Journal of Clinical Medicine. 2021. DOI: 10.3390/jcm10050962

[2] Thoracic outlet syndrome. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00087-8

[3] Arterial thoracic outlet syndrome. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00086-6

[5] Complications of surgery for thoracic outlet syndrome. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00084-2

[6] Conservative treatment for thoracic outlet syndrome. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00081-7

[7] Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2022.07.004

[8] Therapy after thoracic outlet release. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00091-x

[9] History of thoracic outlet syndrome. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00114-8

[10] Misalignment of the clavicle after intramedullary fixation of a midshaft fracture with a titanium elastic nail results in acute neurovascular thoracic outlet syndrome. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.014

[11] Thoracic Outlet Syndrome. 2021.

[12] Appendix: use of multidetector CT and three-dimensional reconstructions in thoracic outlet syndrome: a preliminary report. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00115-x

[13] Venous thoracic outlet syndrome. Hand Clinics. 2004. DOI: 10.1016/s0749-0712(03)00094-5

[14] Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: A case report. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.03.011

[15] Exercise-Enhanced, Ultrasound-Guided Anterior Scalene Muscle/Pectoralis Minor Muscle Blocks Can Facilitate the Diagnosis of Neurogenic Thoracic Outlet Syndrome in the High-Performance Overhead Athlete. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516665801

[16] Thoracic Outlet Syndrome Caused by Synostosis of the First and Second Thoracic Ribs: 2 Case Reports and Review of the Literature. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.08.034

[17] Anatomical and histological analysis of the scalene triangle in a Japanese population: implications for thoracic outlet syndrome diagnosis and management. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09048-2

[18] Operative Treatment of Clavicle Nonunion Complicated With Acute Thoracic Outlet Syndrome: A Case Report and Review of Literature. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.016

[20] Pectoralis minor syndrome – review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome. JSES Reviews, Reports, and Techniques. 2022. DOI: 10.1016/j.xrrt.2022.05.008

[21] THORACIC OUTLET SYNDROME TREATED BY DOUBLE OSTEOTOMY OF A CLAVICULAR MALUNION. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200203000-00016

[28] Thoracic outlet syndrome associated with an anomalous coracoclavicular joint. A case report.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199309000-00012

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