Thoracic Outlet (Brachial Plexus) Syndrome

Thoracic outlet syndrome (TOS), also called brachial plexopathy or brachial plexus dysfunction, is the constellation of pain, decreased movement or decreased sensation in the arm and shoulder due to a nerve problem. It is usually due to neuropathy of the brachial plexus, an area where a nerve bundle from your spinal cord splits into the individual nerves on their way to your shoulder and arm. Usually, the damage is due to direct injury to the nerve(s), indirect traction-stretching injuries, pressure from tumors or abnormal anatomical spacing among nerve trunks, adjacent muscles, the clavicle or the first rib. Thoracic outlet syndrome is a difficult condition to diagnose and treat. Many patients tell us they went to nearly a dozen doctors before presenting to Dr. Ducic and finding out what was truly wrong with them. Considering the complexity of surrounding anatomical structures, this surgery requires specialized training, which Dr. Ducic has, both from a busy clinical practice and from an additional fellowship year of training in peripheral nerve surgery.

Common symptoms of Thoracic Outlet Syndrome (Brachial plexopathy) include:

  • Numbness or tingling in the upper extremity, especially if raised above head
  • Pain in the shoulder or arm
  • Symptoms may start as intermittent, progressing to constant
  • In more advanced cases, muscle weakness can follow
  • With the arm raised above the head, numbness, loss of pulse or arm weakness can be observed

Peripheral Nerve Surgery for Thoracic Outlet Surgery

Patients should first have their neck evaluated by a neurologist to ensure their symptoms do not originate from the cervical spine. An MRI to evaluate the cervical spine can exclude the presence of any compressing mass or possible shoulder joint pathology and can define the presence or absence of a cervical rib.

If no masses, cervical spine or shoulder pathology are identified; then conservative methods, such as medications, lifestyle changes, and physical therapy should be initially considered. If symptoms persist despite these measures, evaluation with Dr. Ducic for peripheral nerve surgery for thoracic outlet syndrome is warranted. The success of the surgery depends on how long the nerves were compressed, the severity of the compression, extent of nerve damage due to injury and possible presence of underlying medical or cervical spine problems. It is Dr. Ducic’s belief and practice that addressing the cause of the problem, rather than focusing just on the symptoms, is the only positive way to address any neuropathy, and particularly brachial plexus neuropathy.

During Thoracic Outlet / Brachial plexus Surgery:

  1. You will receive anesthesia so you won’t feel any pain during the surgery.
  2. Applying minimally invasive peripheral nerve surgery principles, a small incision is made above your collar bone. The anterior scalene muscle which is pressing on the nerves is released, while smaller vasculature compressing the nerves, as well as fibrous bands (if present) are all released. In this way we preserve your fist rib, which makes post-operative recovery much better and faster. In addition, in this way we nearly exclude the possibility of nerve injury during surgery, which has been reported with first rib removal by thoracic or vascular surgeons. Moreover, by preserving your first rib, we also minimize, if not completely exclude, the possibility of pneumothorax (punctured lung), which would mandate insertion of a chest tube and prolonged hospitalization if it were to occur during rib resection. Only if a cervical rib (which is different from the normal 1st rib) is radiologically identified, will its removal be planned.
  3. The skin is then closed in anatomical layers.
  4. Considering the anatomical structures in the area, surgery will require an overnight stay in the hospital. The surgical dressing will stay on for about 3-4 days, while the sutures are removed about two weeks later.

If you are not sure about your eligibility for surgery, and if you are not in the Washington, D.C. area, you can send Dr. Ducic your records so he can determine if you are a good candidate for treatment. Visit Dr. Ducic patient forms page for a downloadable form.