My Treatment: Thoracic Outlet Syndrome - Treatment Options: Injections and Surgery

Thoracic Outlet Syndrome Injections and Surgery

In thoracic outlet syndrome, injections are used to diagnose the syndrome and determine which kind of TOS a patient may have. The physician may request a test called an anterior scalene muscle block, which is performed by a qualified physician (usually an anesthesiologist familiar with TOS). The anterior scalene muscle is numbed with a local anesthetic, relaxing it. If this relaxation improves symptoms for a short period of time, this tells the doctor that the anterior scalene is either pushing on the nerves or hampering their movement.

Some physicians may request that a local anesthetic and a steroid be placed around the brachial plexus between the anterior and middle scalene muscles. If this relieves symptoms using only small amounts of medicine, it tells the physician that the pain is coming from where the medicine was placed, the brachial plexus.

Other tests can be used to further refine the diagnosis, such as an epidural injection, facet injections into joint spaces in the lateral posterior cervical spine or even a discogram.

Surgery may be an option for patients whose symptoms are not improved with medication and physical therapy. Some studies say that only 10% to 20% of patients need surgery to relieve compression caused by the first rib or abnormal muscles. Surgery can be helpful, but the success rate varies. Some studies suggest that up to 80% of TOS patients who have surgery get pain relief, but other studies put that estimate at 45%.

Decompression surgery for TOS is a procedure in which the surgeon removes all or part of the extra rib if present or the first rib. The surgeon also may remove some of the small muscles attached to the rib and any tissue that may be putting pressure on the nerves or blood vessels.

If the patient's arm vein is blocked by a blood clot, the surgeon may inject a clot-dissolving medication into the arm vein before or during the decompression surgery. Sometimes the surgeon may need to repair the artery in the thoracic outlet. If the artery is severely damaged, the surgeon may replace part of the artery with a graft. The graft involves taking a blood vessel from another part of the patient's body and putting it in place of the damaged artery.

The physician may perform an angioplasty procedure to unblock an artery. During angioplasty, the surgeon inserts a catheter, a long thin tube, through the artery in the arm. When the catheter reaches the blocked artery, the surgeon opens the artery by inflating a tiny balloon. The surgeon may place a stent in the artery to help keep it open.