What is the treatment for thoracic outlet syndrome? 

Light cases are managed conservatively. Armrest, physical therapy, pain killers, breathing and stretching exercises are usually helpful. In some patients, local anesthetic and/or Botox injections can provide temporary relief. 

Severe cases are treated with surgery. It requires complete decompression of the nerves comprising brachial plexus, subclavian artery and subclavian vein.  In order to achieve this goal, a surgeon must remove significant portion of the first rib, find  all nerves, artery and the vein and free them up by cutting all fibrotic bands stretching/compressing them. There is abundant scientific and clinical evidence indicating that the extent of 1st and accessory (if present) rib removal is the single most important factor affecting long-term success. Failure to accomplish total removal results in recurrence of symptoms post-operatively. 

Anterior or supraclavicular approach

Surgeon approaches brachial plexus and subclavian vessels from the front. An incision is made above the clavicle (collar bone) and surgeon proceeds with exposure and manipulation of the brachial plexus. The major handicap of this approach is limited access to brachial plexus nerves located at depth of the wound. The subclavian artery and the vein are in front of the nerves further impending the access. 1st and accessory cervical rib removal is technically very difficult because they are located even deeper — under the brachial plexus. Therefore, in some cases the brachial plexus cannot be fully visualized and decompressed and the 1st rib is either left untouched or partially removed. These patients usually either do not benefit from surgery or develop relapse of symptoms after brief improvement period. Not infrequently some patients become significantly worse than before surgery due to significant nerve manipulation during surgery. 

Lateral or transaxillary approach

Surgeon approaches the first rib from the armpit. This approach is preferred by thoracic surgeons. The wound is usually narrow and deep and only midsection of the first rib with subclavian artery and vein can be adequately accessed. Therefore, vascular TOS (arterial and venous) can be effectively treated. Posterior section of the first rib is very hard to expose and remove with this approach. Even if the entire 1st rib resection is performed only very limited lower portion of the brachial plexus can be visualized and decompressed. Therefore like with anterior approach, nTOS treated with this type of surgery may recur.