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Thoracic outlet syndrome is a disease that is difficult to diagnose. It develops as a result of compression of nerves and blood vessels in the upper part of the rib cage.

What are the types of thoracic outlet syndrome?

There are three different clinical variants of TOS:

1. Neurogenic TOS. It is the most common type (about 95-98%). Nerves emerging from the neck are affected and symptoms are due to nerve compression.

2. Venous TOS. Much less common (3-4%). The subclavian vein is affected and symptoms are due to inadequate blood return from the affected arm.

3. Arterial TOS. It is the least common type (1-2%). The subclavian artery is compressed and the symptoms are due to insufficient flow to the affected arm.

What are the causes of thoracic outlet syndrome?

Women are 3-4 times more common than men.

There can be several reasons for a jam.

Extra neck rib.

Abnormal first rib.

Thick fibromuscular bands around nerves and/or blood vessels.

In some cases, overdeveloped (hypertrophic) scalene muscles can cause compression. People who use their arms and hands extensively for work and sports are particularly prone to TOS.

What are the signs of thoracic outlet syndrome?

The symptoms of thoracic outlet syndrome depend on the structures affected.

Neurogenic TOS.

Pain radiating to the shoulders, head, neck, back, armpits, chest, arms, hands and fingers. The pain may be continuous or intermittent. Sometimes chest pain can mimic a heart attack. The pain is exacerbated by physical activity and lifting the affected arm. One of the typical findings is avoiding phone calls on the affected side because of early arm fatigue and pain.

In addition to pain, patients develop numbness and loss of strength. Drowsiness can be continuous or intermittent.

Another common symptom is numbness upon waking up in the morning.

Weakness initially presents as early fatigue, but may later progress to significant muscle wasting, particularly in the affected hand.

Venous TOS.


Cyanosis (bluish discoloration).

Edema (fluid accumulation).

Symptoms may decrease as blood can easily flow back when the arm is raised.

Arterial TOS.



early fatigue

Don't get cold fast.

How is the diagnosis of thoracic outlet syndrome made?

The patient's history and physical examination are key keys to suspecting thoracic outlet syndrome. Examination with challenging tests is an important part of patient evaluation.

Cervical MRI should be performed to exclude neck hernia and nerve root compression. If there is a cervical accessory rib, X-ray and tomography examination are very useful. Doppler USG is useful for assessing blood flow in the subclavian vessels and is particularly useful when combined with provocative arm positioning.

Nerve conduction studies such as EMG and ENG can be helpful, but do not provide a definitive diagnosis in most cases. Therefore, the diagnosis is made mainly by careful clinical examination.

What is the treatment for thoracic outlet syndrome?

Mild cases are managed with medical treatment. Generally, arm rest, physical therapy, pain relievers and stretching exercises are used. In some patients, local anesthetic or Botox injections may provide temporary relief.

Severe cases are treated with surgery. During surgery, nerves, arteries and veins must be freed from being completely compressed. To achieve this goal, the surgeon must remove a significant portion of the first rib, find the nerves, arteries, and veins, and cut all the bands that stretch them to release. There is a wealth of scientific and clinical evidence showing that the first rib removal (resection) procedure is the only important factor influencing long-term success.

front approach

Generally, the first rib cannot be completely removed and the recurrence rate is high.

side approach

Vascular TOS (arterial and venous) can be effectively treated. Reaching the posterior part of the first rib with this approach is very difficult and therefore the recurrence rate is high in neurogenic TOS.

PURE procedure

It is a unique surgery that allows the complete removal of the first rib and the release of all nerves and vessels. Another important advantage of the PURE technique is its low risk for nerve and vascular damage. It has the unique feature of being the least risky when compared to other techniques. Dr. With this technique developed by Kamran AGHAYEV and known to only a few people, approximately 70 patients have been treated with this technique and no recurrence has been observed so far.

With our PURE technique, the entire first rib is removed and all nerves and vessels are freed from compression. Therefore, our patients never experience recurrence. Patients with recurrent TOS who have undergone surgery in other centers are also successfully treated with the PURE technique.

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