Randomised clinical trial| Volume 64, ISSUE 1, P119-127, July 2022

Surgery Versus Continued Conservative Treatment for Neurogenic Thoracic Outlet Syndrome: the First Randomised Clinical Trial (STOPNTOS Trial)


      Neurogenic thoracic outlet syndrome (NTOS) is one of the most controversial clinical entities in medicine. Several major case series have shown promising results of surgery; however, solid scientific evidence is lacking. The aim of this trial was to objectify the effect of thoracic outlet decompression (TOD).


      A single centre (high volume, tertiary TOS centre), non-blinded, randomised controlled trial was conducted with parallel group design. Patients with a diagnosis of NTOS refractory to conservative therapy were randomised to one of two intervention arms, receiving either a transaxillary thoracic outlet decompression (TA-TOD) or continued conservative treatment. After three months, the conservative treated group was also offered a TA-TOD. The primary outcome was change in Disability of the Arm, Shoulder and Hand (DASH) questionnaire score. Secondary outcomes were changes in Cervical Brachial Symptoms Questionnaire (CBSQ), TOS disability scale, and quality of life scores. Outcomes were assessed at baseline, three, six, and 12 months after inclusion.


      Fifty patients were enrolled in this trial: 25 in the TA-TOD group and 25 in the continued conservative treatment group. Follow up was completed in 24 and 22 patients, respectively. At three months, there was a statistically significant difference in DASH scores (TA-TOD: mean 45.15, 95% confidence interval [CI] 38.08 – 52.21; conservative treatment: mean 64.92, 95% CI 57.54 – 72.30; p < .001). All patients in the conservative treatment group applied for surgery three months after randomisation. After surgery of the conservative treatment group, there was no statistically significant difference between the groups for all primary and secondary outcome measures.


      TA-TOD for NTOS is effective in patients who do not respond to conservative treatment. Trial register number: NL63986.100.17.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Vascular and Endovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Povlsen B.
        • Hansson T.
        • Povlsen S.D.
        Treatment for thoracic outlet syndrome.
        Cochrane Database Syst Rev. 2014; 11: CD007218
        • Illig K.A.
        • Donahue D.
        • Duncan A.
        • Freischlag J.
        • Gelabert H.
        • Johansen K.
        • et al.
        Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome.
        J Vasc Surg. 2016; 64: e23-35
        • Huang J.H.
        • Zager E.L.
        Thoracic outlet syndrome.
        Neurosurgery. 2004; 55: 897-902
        • Illig K.A.
        Neurogenic thoracic outlet syndrome: bringing order to chaos.
        J Vasc Surg. 2018; 68: 939-940
        • Balderman J.
        • Holzem K.
        • Field B.J.
        • Bottros M.M.
        • Abuirqeba A.A.
        • Vemuri C.
        • et al.
        Associations between clinical diagnostic criteria and pretreatment patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.
        J Vasc Surg. 2017; 66: 533-544
        • Balderman J.
        • Abuirqeba A.A.
        • Eichaker L.
        • Pate C.
        • Earley J.A.
        • Bottros M.M.
        • et al.
        Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.
        J Vasc Surg. 2019; 70: 832-841
        • Hasanadka R.
        • Towne J.B.
        • Seabrook G.R.
        • Brown K.R.
        • Lewis B.D.
        • Foley W.D.
        Computed tomography angiography to evaluate thoracic outlet neurovascular compression.
        Vasc Endovascular Surg. 2007; 41: 316-321
        • Hooper T.L.
        • Denton J.
        • McGalliard M.K.
        • Brismee J.M.
        • Sizer Jr., P.S.
        Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis.
        J Man Manip Ther. 2010; 18: 74-83
        • Povlsen S.
        • Povlsen B.
        Diagnosing thoracic outlet syndrome: current approaches and future directions.
        Diagnostics (Basel). 2018; 8: 21
        • Weaver M.L.
        • Lum Y.W.
        New diagnostic and treatment modalities for neurogenic thoracic outlet syndrome.
        Diagnostics (Basel). 2017; 7: 28
        • Cuetter A.C.
        • Bartoszek D.M.
        The thoracic outlet syndrome: controversies, overdiagnosis, overtreatment, and recommendations for management.
        Muscle Nerve. 1989; 12: 410-419
        • Campbell W.W.
        • Landau M.E.
        Controversial entrapment neuropathies.
        Neurosurg Clin N Am. 2008; 19: 597-608
        • Sanders R.J.
        • Hammond S.L.
        • Rao N.M.
        Diagnosis of thoracic outlet syndrome.
        J Vasc Surg. 2007; 46: 601-604
        • Lindgren K.A.
        • Oksala I.
        Long-term outcome of surgery for thoracic outlet syndrome.
        Am J Surg. 1995; 169: 358-360
        • Cherington M.
        Thoracic outlet syndrome: rise of the conservative viewpoint.
        Am Fam Physician. 1991; 43: 1998
        • Wilbourn A.J.
        The thoracic outlet syndrome is overdiagnosed.
        Arch Neurol. 1990; 47: 328-330
        • Urschel Jr., H.C.
        • Razzuk M.A.
        The failed operation for thoracic outlet syndrome: the difficulty of diagnosis and management.
        Ann Thorac Surg. 1986; 42: 523-528
        • Freischlag J.A.
        A decade of excellent outcomes after surgical intervention: 538 patients with thoracic outlet syndrome.
        Trans Am Clin Climatol Assoc. 2018; 129: 88-94
        • Caputo F.J.
        • Wittenberg A.M.
        • Vemuri C.
        • Driskill M.R.
        • Earley J.A.
        • Rastogi R.
        • et al.
        Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations.
        J Vasc Surg. 2013; 57: 149-157
        • Chang D.C.
        • Rotellini-Coltvet L.A.
        • Mukherjee D.
        • De Leon R.
        • Freischlag J.A.
        Surgical intervention for thoracic outlet syndrome improves patient's quality of life.
        J Vasc Surg. 2009; 49: 630-635
        • Rochlin D.H.
        • Gilson M.M.
        • Likes K.C.
        • Graf E.
        • Ford N.
        • Christo P.J.
        • et al.
        Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy.
        J Vasc Surg. 2013; 57: 436-443
        • Cordobes-Gual J.
        • Lozano-Vilardell P.
        • Torreguitart-Mirada N.
        • Lara-Hernandez R.
        • Riera-Vazquez R.
        • Julia-Montoya J.
        Prospective study of the functional recovery after surgery for thoracic outlet syndrome.
        Eur J Vasc Endovasc Surg. 2008; 35: 79-83
        • Peek J.
        • Vos C.G.
        • Unlu C.
        • Schreve M.A.
        • van de Mortel R.H.W.
        • de Vries J.P.M.
        Long-Term functional outcome of surgical treatment for thoracic outlet syndrome.
        Diagnostics (Basel). 2018; 8: 7
        • Peek J.
        • Vos C.G.
        • Unlu C.
        • van de Pavoordt H.
        • van den Akker P.J.
        • de Vries J.P.M.
        Outcome of surgical treatment for thoracic outlet syndrome: systematic review and meta-analysis.
        Ann Vasc Surg. 2017; 40: 303-326
        • Dale W.A.
        Thoracic outlet compression syndrome. Critique in.
        Arch Surg. 1982; 117: 1437-1445
        • Wilbourn A.J.
        Thoracic outlet syndrome surgery causing severe brachial plexopathy.
        Muscle Nerve. 1988; 11: 66-74
        • Hooper T.L.
        • Denton J.
        • McGalliard M.K.
        • Brismee J.M.
        • Sizer Jr., P.S.
        Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management.
        J Man Manip Ther. 2010; 18: 132-138
        • Pesser N.
        • Bode A.
        • Goeteyn J.
        • Hendriks J.
        • van Nuenen B.F.L.
        • van Sambeek M.
        • et al.
        Same admission hybrid treatment of primary upper extremity deep venous thrombosis with thrombolysis, transaxillary thoracic outlet decompression, and immediate endovascular evaluation.
        Ann Vasc Surg. 2021; 71: 249-256
        • Sanders R.J.
        Recurrent neurogenic thoracic outlet syndrome stressing the importance of pectoralis minor syndrome.
        Vasc Endovascular Surg. 2011; 45: 33-38
        • Burt B.M.
        • Palivela N.
        • Cekmecelioglu D.
        • Paily P.
        • Najafi B.
        • Lee H.S.
        • et al.
        Safety of robotic first rib resection for thoracic outlet syndrome.
        J Thorac Cardiovasc Surg. 2021; 162: 1297-1305
        • Gharagozloo F.
        • Meyer M.
        • Tempesta B.
        • Werden S.
        Robotic first rib resection for thoracic outlet syndrome.
        Surg Technol Int. 2020; 36: 239-244
        • Horowitz S.H.
        Brachial plexus injuries with causalgia resulting from transaxillary rib resection.
        Arch Surg. 1985; 120: 1189-1191
        • Pesser N.
        • Goeteyn J.
        • van der Sanden L.
        • Houterman S.
        • van Alfen N.
        • van Sambeek M.
        • et al.
        Feasibility and outcomes of a multidisciplinary care pathway for neurogenic thoracic outlet syndrome: a prospective observational cohort study.
        Eur J Vasc Endovasc Surg. 2021; 61: 1017-1024
        • Beaton D.E.
        • Katz J.N.
        • Fossel A.H.
        • Wright J.G.
        • Tarasuk V.
        • Bombardier C.
        Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity.
        J Hand Ther. 2001; 14: 128-146
        • Watson L.A.
        • Pizzari T.
        • Balster S.
        Thoracic outlet syndrome part 2: conservative management of thoracic outlet.
        Man Ther. 2010; 15: 305-314
        • Hisamoto J.
        Physical therapy as primary treatment for neurogenic TOS.
        in: Donahue D.M. Jordan S.E. Lum Y.W. Gelabert H.A. Thoracic Outlet Syndrome (Illig KA, Thompson RW, Freischlag JA. 2nd edn. Springer, London2021
        • Al-Hashel J.Y.
        • El Shorbgy A.A.
        • Ahmed S.F.
        • Elshereef R.R.
        Early versus late surgical treatment for neurogenic thoracic outlet syndrome.
        ISRN Neurol. 2013; 2013673020
        • Wilbourn A.J.
        The thoracic outlet syndrome is overdiagnosed.
        Arch Neurol. 1990; 47: 328-330
        • Wilbourn A.J.
        • Lederman R.J.
        Evidence for conduction delay in thoracic-outlet syndrome is challenged.
        N Engl J Med. 1984; 310: 1052-1053
        • Yoshizumi T.
        • Murata H.
        • Kanno H.
        • Shinonaga M.
        Efficacy of supraclavicular scalenotomy followed by external neurolysis without rib resection for post-traumatic neurogenic thoracic outlet syndrome.
        Spine (Phila Pa 1976). 2021; 46: E632-E638
        • Abdel Ghany W.
        • Nada M.A.
        • Toubar A.F.
        • Desoky A.E.
        • Ibrahim H.
        • Nassef M.A.
        • et al.
        Modified interscalene approach for resection of symptomatic cervical rib: anatomic review and clinical study.
        World Neurosurg. 2017; 98: 124-131
        • Desai S.S.
        • Toliyat M.
        • Dua A.
        • Charlton-Ouw K.M.
        • Hossain M.
        • Estrera A.L.
        • et al.
        Outcomes of surgical paraclavicular thoracic outlet decompression.
        Ann Vasc Surg. 2014; 28: 457-464
        • George R.S.
        • Milton R.
        • Chaudhuri N.
        • Kefaloyannis E.
        • Papagiannopoulos K.
        Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome.
        Ann Thorac Surg. 2017; 103: 241-245
        • Glynn R.W.
        • Tawfick W.
        • Elsafty Z.
        • Hynes N.
        • Sultan S.
        Supraclavicular scalenectomy for thoracic outlet syndrome--functional outcomes assessed using the DASH scoring system.
        Vasc Endovascular Surg. 2012; 46: 157-162
        • Lafosse T.
        • Le Hanneur M.
        • Lafosse L.
        All-endoscopic brachial plexus complete neurolysis for idiopathic neurogenic thoracic outlet syndrome: a prospective case series.
        Arthroscopy. 2017; 33: 1449-1457
        • Rinehardt E.K.
        • Scarborough J.E.
        • Bennett K.M.
        Current practice of thoracic outlet decompression surgery in the United States.
        J Vasc Surg. 2017; 66: 858-865
        • Stallworth J.M.
        • Quinn G.J.
        • Aiken A.F.
        Is rib resection necessary for relief of thoracic outlet syndrome?.
        Ann Surg. 1977; 185: 581-592
        • Sanders R.J.
        • Hammond S.L.
        Supraclavicular first rib resection and total scalenectomy: technique and results.
        Hand Clin. 2004; 20: 61-70
        • Altobelli G.G.
        • Kudo T.
        • Haas B.T.
        • Chandra F.A.
        • Moy J.L.
        • Ahn S.S.
        Thoracic outlet syndrome: pattern of clinical success after operative decompression.
        J Vasc Surg. 2005; 42: 122-128