NEUROGENIC THORACIC OUTLET SYNDROME
Once diagnosis is confirmed, treatment initially consists of physiotherapy with the aim of correcting any posture, alignment and movement abnormalities of the neck, shoulder and upper limb. If there are not significant abnormalities found during physical therapy, then surgical options are considered, specifically, excision of the scalene muscle (scalenectomy) along with any other muscular variants compressing the brachial plexus. The need to excise the first rib is a highly debated topic, with good response achieved in those who have had as well as those who haven’t had first rib resection along with scalenectomy. In those patients where the symptoms are long-standing or there is a lack of response to scalene muscle block, the outcomes of surgery are poorer.
VENOUS THORACIC OUTLET SYNDROME
When the diagnosis of venous thoracic outlet syndrome is confirmed, treatment consists of surgery to decompress of the costo-clavicular space and removal of the front part of the 1st rib. If the vein is still seen to be narrow due to chronic scarring, additional techniques, such as a vein patch or venous angioplasty may be needed to help open up the vein. In cases where the vein is blocked due to fresh clot, techniques to unblock the vein (thrombolysis) are used to first try to re-open the vein. If successful, the patient is prescribed blood thinning medications for a short period of time before undergoing first rib resection and decompression of the costo-clavicular space.
ARTERIAL THORACIC OUTLET SYNDROME
Surgery is recommended for all patients who present with signs of an aneurysm or evidence of a small clot lodging in the arm/hand. Similar to other forms of thoracic outlet syndrome, the surgery involves excising the cervical rib, fibrous bands, part of the scalene muscle and usually the first rib as well. Surgery is successful in vast majority of cases with the chance of recurrence being very small.