- For most patients, conservative (non surgical) treatment is recommended. Avoiding precipitating factors such as wrong exercises, and time for the condition to settle, may be all that is needed.
- Stress avoidance, work simplification and job site modification are recommended to avoid sustained muscle contraction and repetitive or overhead work that worsens symptoms.
- Physiotherapy to help strengthen the muscles around the shoulder (deltoids and rhomboids) so that they are better able to support the collar bone. Ultrasound to the scalene muscles and, sometimes strapping of the shoulders may help.
- Postural exercises to help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.
- If you are overweight, losing some weight may help.
- Anti-inflammatory medication, such as voltaren or brufen, together with rest, may help.
- If the condition settles, remember that a return to the precipitating factors may cause a recurrence. The condition does tend to flare up again, from time to time, even if the aggravating factors are avoided.
- Avoiding a recurrence: Avoid carrying heavy bags over the shoulder, and in particular, do not ever carry a heavy backpack. (TOS is often called “backpackers shoulder”, as a heavy weight pushes the collar bone down onto the first rib, narrowing the thoracic outlet).
- In certain instances Botox injection into the scalene muscles whicy surround the nerves of the brachial plexus can be done. Botox is a muscle relaxant and by lessening the rigidity of those muscles the pressure of the muscles on the nerves resulting in relief of the pain. We inject the Botox under ultrasound control to ensure accuracy. Pain relief is achieved in about 70% of patients and even if it is not permanent in some it least proves the diagnosis beyond doubt
- Surgical treatment is considered when conservative measures have failed, and the symptoms continue to be bad.
What are the exact indications for surgical treatment?
If the cause is due to bony obstruction such as a cervical rib, or fractured first rib or collarbone with malunion; then surgery will be best as the condition is unlikely to get better on its own.
If the cause is presumed to be due to compression by the scalene muscles, or inadequate space between the rib and collar bone, then surgery is recommended if there is no improvement after 3-4 months, and the symptoms are severe.
If the symptoms are longstanding and the patient can tolerate them, then conservative treatment can be continued. Surgical decompression may be performed earlier in sportsmen who want to get back to their activities earlier.
How is surgery performed?
A decompression is performed. Any cervical ribs are removed. The scalene muscles are divided off the first rib, and any scar tissue between the muscles, arteries, and nerves is removed.
It is better to also remove the first rib, to open the floor of the thoracic outlet and make sure an adequate decompression has been performed.
The incision usually just above the collar bone, about 6-8cm long. Some surgeons perform the procedure through the axilla, or armpit, for a better cosmetic result, and to stay away from the brachial plexus, thereby avoiding the risk of injuring it.
We prefer the incision above the collar bone, as we find it easier to dissect any scar tissue off the brachial plexus. We find it easier to identify the whole brachial plexus this way, and make sure there is no scar around it higher up.
Once the procedure has been done, a small drainage catheter is placed into the wound. We usually place an epidural catheter around the nerves, and give local anaesthetic through it for post operative pain relief. This is usually left in for 2 days, and initially may cause the whole arm to go numb for a few hours so we warn patients not to be worried about this before the time.
The procedure takes 1 to 11/2 hours to perform; patients generally spend two to three days in hospital and are booked off work for three to four weeks to recover. The procedure is performed by cardiothoracic surgeons, vascular surgeons, general surgeons and sometimes orthopedic surgeons.
In experienced hands the complications are virtually non-existent, but surgeons who occasionally perform the procedure tend to have more complications. It is a procedure that needs to be meticulously performed by a surgeon who knows the anatomy well.
What are the complications of the operation?
Many nerves run through the area, but luckily damage can be avoided by meticulous dissection, and identifying all the nerves before dividing the muscles.
We have not had any of these problems, but they have been seen and also described in the literature, so need to be mentioned. (The reported incidence
is < 1%):
- Phrenic nerve injury – paralysis of the diaphragm on that side.
- Long thoracic nerve injury – Paralysis of the serratus anterior muscle that pulls the scapula (shoulder blade) forwards.
- Brachial plexus injury – this is usually mild and reversible. It is worthwhile to mention that mild traction on the brachial plexus may sometimes cause a bit of numbness of the fingertips for a few days.
- Removal of the first rib may result in the pleura (membrane covering the chest cavity) being opened. This happens very rarely in our practice, and then it is recognized during the operation, and the wound drain is advanced into the chest cavity to prevent a blood collection there and to make sure the lung does not collapse.
- It is common to have an area of numbness below the wound, and this may last for months.