Current Pain and Headache Reports

, Volume 15, Issue 1, pp 14–21 | Cite as

Updated Perspectives on Neurogenic Thoracic Outlet Syndrome



Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Similar to other persistent pain conditions, the physical discomfort associated with NTOS can cause severe and often debilitating symptoms. In fact, those suffering from the syndrome report a quality of life impacted as significantly as those with chronic heart failure. This evidence-based literature review focuses on the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS, with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and more contemporary minimally invasive intramuscular treatments with botulinum toxin.


Thoracic outlet syndrome Botulinum toxin Scalene muscles Pain relief Neurogenic thoracic outlet syndrome Brachial plexus Computed tomography Ultrasound Fluoroscopy Electromyography Rib resection and scalenectomy Anterior scalene muscle Minimally invasive treatments 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Chang, D.C., Rotellini-Coltvet L.A., Mukherjee D, et al., Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg, 2009. 49(3): p. 630–5; discussion 635–7. This study showed that impaired quality of life in persons with NTOS can be improved with surgical intervention. CrossRefPubMedGoogle Scholar
  2. 2.
    Sheth RN, Belzberg AJ, Diagnosis and Treatment of Thoracic Outlet Syndrome. Neurosurgery Clinics of North America, 2001. 12(2): p. 295–309.PubMedGoogle Scholar
  3. 3.
    •• Povlsen, B., Belzberg A, Hansson T, et al., Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev, 2010(1): p. CD007218. This review highlights the controversial nature of TOS and reports on the lack of high-quality evidence for operative or nonoperative treatments for pain relief. Google Scholar
  4. 4.
    Brantigan, C.O. and D.B. Roos, Diagnosing thoracic outlet syndrome. Hand Clin, 2004. 20(1): p. 27–36.CrossRefPubMedGoogle Scholar
  5. 5.
    Atasoy, E., Thoracic outlet compression syndrome. Orthop Clin North Am, 1996. 27(2): p. 265–303.PubMedGoogle Scholar
  6. 6.
    Brantigan, C.O. and D.B. Roos, Etiology of neurogenic thoracic outlet syndrome. Hand Clin, 2004. 20(1): p. 17–22.CrossRefPubMedGoogle Scholar
  7. 7.
    Peet, R.M., Henriksen, J.D., Anderson T.P.,et al., Thoracic-outlet syndrome: evaluation of a therapeutic exercise program. Proc Staff Meet Mayo Clin, 1956. 31(9): p. 281–7.PubMedGoogle Scholar
  8. 8.
    • Sanders RJ, Hammond S.L., Rao NM, Thoracic Outlet Syndrome. A Review. The Neurologist, 2008. 14(6): p. 365–373. This review provides a comprehensive description of the three forms of TOS, reports on the likely scalene muscle pathology in NTOS, provides an overview of diagnostic testing, and highlights surgical results. CrossRefPubMedGoogle Scholar
  9. 9.
    Sanders RJ, Hammond SL, Rao NM, Diagnosis of thoracic outlet syndrome. Journal of Vascular Surgery, 2007. 46: p. 601–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Kai, Y., Oyama M, Kurose S, et al., Neurogenic thoracic outlet syndrome in whiplash injury. J Spinal Disord, 2001. 14(6): p. 487–93CrossRefPubMedGoogle Scholar
  11. 11.
    Atasoy, E., Thoracic outlet syndrome: anatomy. Hand Clin, 2004. 20(1): p. 7–14, v.CrossRefPubMedGoogle Scholar
  12. 12.
    Huang JH, Zager EL, Thoracic Outlet Syndrome. Neurosurgery, 2004. 55(4): p. 897–902.CrossRefPubMedGoogle Scholar
  13. 13.
    Fugate, M.W., L. Rotellini-Coltvet, and J.A. Freischlag, Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med, 2009. 11(2): p. 176–83.CrossRefPubMedGoogle Scholar
  14. 14.
    Demondion, X., Herbinet P, Van Sint Jan S, et al., Imaging assessment of thoracic outlet syndrome. Radiographics, 2006. 26(6): p. 1735–50.CrossRefPubMedGoogle Scholar
  15. 15.
    Roos, D.B., New concepts of TOS that explain etiology, symptoms, diagnosis and treatment. Vasc Surg, 1979. 13: p. 313–21.Google Scholar
  16. 16.
    Rayan, G.M. and C. Jensen, Thoracic outlet syndrome: provocative examination maneuvers in a typical population. J Shoulder Elbow Surg, 1995. 4(2): p. 113–7.CrossRefPubMedGoogle Scholar
  17. 17.
    •• Christo, P.J. Christo D.K., Carinci A.J., et al., Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med, 2010. 11(4): p. 504–11. This study describes a novel technique of CT-guided botulinum toxin injection into the anterior scalene muscle with associated pain relief over a 3-month period. CrossRefPubMedGoogle Scholar
  18. 18.
    Maruo MA, Murphy K., Thomson K, et al, Scalene blocks adn their role in thoracic outlet syndrome. Image Guided Intervention, ed. K.K. Baez JC, Murphy KPJ, Block BM. 2008, Philadelphia: Saunders. 1773–77.Google Scholar
  19. 19.
    Torriani, M., R. Gupta, and D.M. Donahue, Sonographically guided anesthetic injection of anterior scalene muscle for investigation of neurogenic thoracic outlet syndrome. Skeletal Radiol, 2009. 38(11): p. 1083–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Mashayekh A, Christo PJ., Yousem DM, Pillai JJ., CT guided Injection of the Anterior and Middle Scalene Muscles: Techniques and Complications. American Journal of Neuroradiology, 2011 (in press).Google Scholar
  21. 21.
    Jordan SE, Machleder HI., Diagnosis of thoracic outlet syndrome using electrophysiologically guided anterior scalene blocks. Ann Vasc Surg, 1998. 12: p. 260–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Braun RM, Sahadevan DC., Feinstein J., Confimatory needle placement technique for scalene muscle block in the diagnosis of thoracic outlet syndrome. Tech Hand Up Extrem Surg, 2006. 10: p. 173–176.CrossRefPubMedGoogle Scholar
  23. 23.
    Ambrad-Chalela, E., Thomas GI, and K.H. Johansen, Recurrent neurogenic thoracic outlet syndrome. Am J Surg, 2004. 187(4): p. 505–10.CrossRefPubMedGoogle Scholar
  24. 24.
    Sanders RJ, Hammond SL., Rao NM, Observations on the use of seprafilm on the brachial plexus in 249 operations for neurogenic thoracic outlet syndrome. Hand, 2007. 2: p. 179–83.CrossRefPubMedGoogle Scholar
  25. 25.
    Jordan SE, Ahn SA, Gelabert HA, Differentiation of thoracic outlet syndrome from treatment resistant cervical brachial plexus syndromes: development and utilization of a questionnaire, clinical examination and ultrasound evaluation. Pain Physician, 2007. 10: p. 441–52.PubMedGoogle Scholar
  26. 26.
    Gage, M., Scalenus anticus syndrome: a diagnostic and confirmatory test. Surgery, 1939. 5: p. 599–601.Google Scholar
  27. 27.
    Jordan SE, Ahn SS, Gelabert, HA, Combining ultrasonography and electromyography for botulinum chemodenervation treatment of thoracic outlet syndrome: Comparison with fluoroscopy and electromyography guidance. Pain Physician, 2007. 10: p. 541–6.PubMedGoogle Scholar
  28. 28.
    Crosby CA, Wehbe MA., Conservative treatment of thoracic outlet syndrome. Hand Clin, 2004. 20: p. 43–49.CrossRefPubMedGoogle Scholar
  29. 29.
    Novak CB, Conservative management of thoracic outlet syndrome. Semin Thorac Cardiovas Surg, 1996. 8: p. 201–207.Google Scholar
  30. 30.
    Voerman GE, Vollenbroek H.M., Hermans JH., Changes in pain, disability, and muscle activation patterns in chronic whiplash patients after ambulant myofeedback training. Clin J Pain, 2006. 22: p. 656–663.CrossRefPubMedGoogle Scholar
  31. 31.
    Novak CB, Collins ED., Mackinnon SE, Outcome following conservative management of thoracic outlet syndrome. J hand Surg Am, 1995. 20A: p. 542–548.CrossRefGoogle Scholar
  32. 32.
    Lindgren, K., Conservative treatment of thoracic outlet syndrome: A 2-year follow up. Arch Phys Med Rehabil, 1997. 78: p. 373–378.CrossRefPubMedGoogle Scholar
  33. 33.
    • Atasoy, E., A hand surgeon's further experience with thoracic outlet compression syndrome. J Hand Surg Am, 2010. 35(9): p. 1528–38. This paper examines surgical procedures for NTOS and notes the author's experience in treating the syndrome. CrossRefPubMedGoogle Scholar
  34. 34.
    Taskaynatan MA, Balaban B., Yaser E, et al, Cervical traction in conservative management of thoracic outlet syndrome. Journal of Muscular Pain, 2004. 15(1): p. 89–94.CrossRefGoogle Scholar
  35. 35.
    Gulbahar S, Akalin E., Baydar M, et al, Regular exercise improves outcome in droopy shoulder syndrome: a subgroup of thoracic outlet syndrome. Journal of Muscle Pain, 2005. 13(4): p. 21–6.CrossRefGoogle Scholar
  36. 36.
    Dressler, D., F.A. Saberi, and E.R. Barbosa, Botulinum toxin: mechanisms of action. Arq Neuropsiquiatr, 2005. 63(1): p. 180–5.PubMedGoogle Scholar
  37. 37.
    Gracies, J.M., Pathophysiology of spastic paresis. II: Emergence of muscle overactivity. Muscle Nerve, 2005. 31(5): p. 552–71.CrossRefPubMedGoogle Scholar
  38. 38.
    Aoki, K., Review of proposed mechanism for the antinociceptive action of botulinum toxin type A. Neurotoxicology, 2005. 26: p. 785–793.CrossRefPubMedGoogle Scholar
  39. 39.
    Sycha, T., Samal D, Chizh B, et al., A lack of antinociceptive or antiinflammatory effect of botulinum toxin A in an inflammatory human pain model. Anesth Analg, 2006. 102(2): p. 509–16.CrossRefPubMedGoogle Scholar
  40. 40.
    Sheeran, G., Botulinum toxin for the treatment of musculoskeletal pain and spasm. Curr Pain Headache Rep, 2002. 6: p. 460–469.CrossRefGoogle Scholar
  41. 41.
    Gobel, H., Heinze A, Heinze-Kuhn K, et al., [Botulinum toxin A for the treatment of headache disorders and pericranial pain syndromes]. Nervenarzt, 2001. 72(4): p. 261–74.CrossRefPubMedGoogle Scholar
  42. 42.
    Odderson IR, Botulinum Toxin Injection Guide. 2008, New York: Demos Medical Publishing.Google Scholar
  43. 43.
  44. 44.
    Graboski CL, Gray DS., Burnham RS, Botulinum toxin A versus bupivacaine trigger point injections for the treatment of myofascial pain syndrome: a randomized double blind crossover study. Pain, 2005. 118: p. 170–75.CrossRefPubMedGoogle Scholar
  45. 45.
    Foster, L., Clapp L, Erikson M, et al., Botulinum toxin A and chronic low back pain: a randomized, double-blind study. Neurology, 2001. 56(10): p. 1290–3PubMedGoogle Scholar
  46. 46.
    Childers MK, Wilson DJ., Gnatz SM, et al, Botulinum toxin type A use in piriformis syndrome. A pilot study. Am J Phys Med Rehabil, 2002. 81: p. 751–59.CrossRefPubMedGoogle Scholar
  47. 47.
    Wong SM, Hui ACM., Tong P-Y, et al, Treatment of lateral epicondylitits with botulinum toxin. A randomized, double blind, placebo-controlled trial. Ann Intern Med, 2005. 143: p. 793–98.PubMedGoogle Scholar
  48. 48.
    Jordan SE, A.S., Selective botulinum chemodenervation of the scalene muscles for treatment of neurogenic thoracic outlet syndrome. Ann Vasc Surg, 2000. 14: p. 365–9.Google Scholar
  49. 49.
    •• Torriani, M., R. Gupta, and D.M. Donahue, Botulinum toxin injection in neurogenic thoracic outlet syndrome: results and experience using an ultrasound-guided approach. Skeletal Radiol, 2010. 39(10): p. 973–80. This article describes the injection of botulinum toxin into the anterior scalene and pectoralis minor muscles under ultrasound guidance with significant pain relief over 30 days. CrossRefPubMedGoogle Scholar
  50. 50.
    Brans, J.W., Lindeboom R, Aramideh M, et al., Long-term effect of botulinum toxin on impairment and functional health in cervical dystonia. Neurology, 1998. 50(5): p. 1461–3.PubMedGoogle Scholar
  51. 51.
    Annese, V., Bassotti G, Coccia G, et al., Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia. The Gismad Achalasia Study Group. Aliment Pharmacol Ther, 1999. 13(10): p. 1347–50CrossRefPubMedGoogle Scholar
  52. 52.
    Freund, B. and M. Schwartz, The use of botulinum toxin for the treatment of temporomandibular disorder. Oral Health, 1998. 88(2): p. 32–7.PubMedGoogle Scholar
  53. 53.
    • Colhado, O.C., M. Boeing, and L.B. Ortega, Botulinum toxin in pain treatment. Rev Bras Anestesiol, 2009. 59(3): p. 366–81. This review describes the pharmacology of botulinum toxin, its role in reducing pain, and clinical applications for specific hypertonic and painful conditions. CrossRefPubMedGoogle Scholar
  54. 54.
    Monsivais JJ, Monsivais DB, Botulinum toxin in painful syndromes. Hand Clin, 1996. 12: p. 787–9.PubMedGoogle Scholar
  55. 55.
    Roos, D.B., Throacic outlet syndrome is underdiagnosed. Muscle Nerve, 1999. 22: p. 126–9 [discussion 136–7].CrossRefPubMedGoogle Scholar
  56. 56.
    Chang, D.C., Lidor AO, Matsen SL, et al., Reported in-hospital complications following rib resections for neurogenic thoracic outlet syndrome. Ann Vasc Surg, 2007. 21(5): p. 564–70.CrossRefPubMedGoogle Scholar
  57. 57.
    Franklin GM, Fulton-Kehoe D, Bradley C, et al, Outcome of surgery for thoracic outlet syndrome in Washington state worker's compensation. Neurology, 2000. 54: p. 1252–7.PubMedGoogle Scholar
  58. 58.
    Sanders RJ, Hammond SL., Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg, 2002. 36: p. 51–56.CrossRefPubMedGoogle Scholar
  59. 59.
    Sanders RJ, Haug CE, Thoracic outlet syndrome: a common sequela of neck injuries. 1991, Philadelphia: Lippincott. p. 77.Google Scholar
  60. 60.
    Roos, D., Congenital Anomalies Associated with Thoracic Outlet Syndrome. The American Journal of Surgery, 1976. 132: p. 771–778.CrossRefGoogle Scholar
  61. 61.
    Roos, D.B., Sympathectomy for upper extremities: anatomy, indications, and techniques, new concepts in etiology, diagnosis and surgical treatment for thoracic outlet syndrome. Pain syndromes in the shoulder and arm: an integrated view, ed. R.L. Greep DM, Smith AR, Roos DB. 1979, The Hague: Martinus Nijhoff.Google Scholar
  62. 62.
    Buonocore M, Manstretta C., Mazzucchi G, et al:, The clinical evaluation of conservative treatment in patients with the thoracic outlet syndrome. G Ital Med Lav Ergon, 1998. 20: p. 249–254.PubMedGoogle Scholar
  63. 63.
    Wilbourn, A.J., Thoracic outlet syndrome is overdiagnosed. Muscle Nerve, 1999. 22(1): p. 130–136.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical Care Medicine, Division of Pain MedicineJohns Hopkins University School of MedicineBaltimoreUSA

Personalised recommendations