Thoracic Outlet Syndrome Program

The Massachusetts General Hospital Division of Thoracic Surgery provides comprehensive evaluation and treatment for patients with all forms of thoracic outlet syndrome (TOS), including neurogenic, venous and arterial.
Learn more about thoracic outlet syndrome

Call to request an appointment or refer a patient: 617-643-8727

Overview

The Thoracic Outlet Syndrome Program in the Division of Thoracic Surgery at Massachusetts General Hospital provides expert diagnosis, treatment and support to patients with thoracic outlet syndrome (TOS) and related conditions.

TOS is an uncommon disorder caused by pressure on the nerves in an area called the brachial plexus, or on the blood vessels just behind the collarbone. There are three types of TOS: neurogenic (NTOS), venous (VTOS) and arterial (ATOS).

The symptoms for each patient usually vary, but may include pain and tingling in the arm, neck, shoulder, upper chest and back.

TOS can be extremely difficult to diagnose and treat. Doctors who treat TOS often have differing opinions and approaches to patient care. At Mass General, our approach is to recommend a combination of physical and drug therapy as a first line of defense before surgery. Patients who do not respond to this approach may be evaluated for surgical treatment. Qualified patients will meet with their surgeon to discuss their options.

Multidisciplinary Approach to Care

Our doctors are highly skilled in properly diagnosing and treating TOS. Our program attracts patients from New England and all over the country who may suffer from TOS. Mass General is a major referral center for this disorder, and our physicians have a history of offering solutions for patients whose prior treatments were unsuccessful. We work collaboratively with specialists across various disciplines at Mass General to provide expert care to our patients with the goal of achieving the best possible outcomes. These areas include:

  • Center for Pain Medicine
  • Department of Neurology
  • Department of Orthopaedic Surgery
  • Department of Physical and Occupational Therapy
  • Physical Medicine and Rehabilitation Service

Patient Experience

Dr. Dean Donahue examines a patient as part of a comprehensive clinical assessment.
Dean Donahue, MD, examines a patient as part of a comprehensive clinical assessment.

Our experts customize a diagnostic and treatment program for each patient. A diagnosis is established by ruling out other disorders and then testing to see if the condition involves the nerves (NTOS), the blood vessels (VTOS or ATOS) or some combination of these.

Our thorough clinical assessment begins with a detailed history and physical examination during the initial office visit. Additional examinations are tailored to each patient’s needs and may include:

  • A computed tomography (CT) angiogram that takes images using contrast dye to better visualize the blood vessels and blood flow within them. This unique scan was developed at Mass General
  • A high-resolution magnetic resonance imaging (MRI) scan, developed at Mass General, of the thoracic outlet that takes images from various angles to get a more complete picture of your condition
  • Magnetic resonance angiography (MRA), a noninvasive exam of the blood vessels
  • MRI of the cervical spine or shoulder
  • Noninvasive, ultrasound-guided vascular exams
  • Invasive vascular studies:
    • Venogram (an X-ray that uses contrast dye to visualize the veins)
    • Arteriogram (an X-ray that uses contrast dye to visualize the arteries)
  • Nerve-conduction studies to evaluate the function of the motor and sensory nerves

Treatment for TOS

For many patients, our initial treatment includes a combination of physical therapy and medications. Many of our patients do not require surgery to improve their symptoms. Each treatment decision, including the decision to perform surgery, is specific to each patient.

Neurogenic TOS (NTOS)

Physical therapy is the first line of treatment for the majority of NTOS patients. In some cases, several months of dedicated physical therapy may be required before a patient begins to notice their symptoms improve. Physical therapy may address:

  • Shortening and tightness of the scalene muscles (a group of muscles in the neck, located in the front on either side of the throat)
  • Weakness of the cervical flexor muscles (attached to the front of the spine), upper thoracic extensor muscles (attached to the back of the spine) and the muscles that provide support across joints
  • Poor diaphragmatic breathing

Ultrasound-guided injections into the neck and chest muscles with Botox® may be used to ease nerve pain in some patients. Many patients whose symptoms have improved following Botox injections may be able to participate more actively in a physical therapy program, which can improve the overall results.

For NTOS, a successful surgical outcome depends upon a combination of an accurate diagnosis and technical precision during surgery. Determining whether or not surgery is a good option to treat NTOS can be difficult. The patient’s care team will make a recommendation based on his/her evaluation.

Venous TOS (VTOS)

The treatment of VTOS begins during the initial diagnostic contrast venogram. When a clot is identified, medication to dissolve this clot can be administered immediately. In most patients, the underlying problem is narrowing of the vein from thoracic outlet compression. This is why treating the clot alone is not sufficient in many patients. If there is vein compression, surgery may be recommended depending upon the severity. Patients may need to remain on medications to prevent clotting (blood thinners) for up to three months following surgery, but can then return to normal activity.

Arterial TOS (ATOS)

ATOS represents thrombosis of the subclavian artery (an artery leading to each arm that delivers blood to the heart) or aneurysm formation within the thoracic outlet, and it is a rare occurrence. ATOS is almost exclusively seen in patients with bone abnormalities such as a cervical rib or an abnormality in the spine at the base of the neck. Injury to the axillary artery can also occur in athletes due to compression of the artery near the shoulder from repetitive use. Patients with ATOS and these arterial complications are candidates for surgery.

Surgery for TOS

Dean Donahue, MD (left), and Eric Feins, MD (right), perform a complex surgery on a patient with thoracic outlet syndrome.
Dean Donahue, MD (left), and Eric Feins, MD (right), perform a complex surgery on a patient with thoracic outlet syndrome.

Patients who require surgery can be confident that they will receive specialized care from an experienced team. Surgery for TOS may involve:

  • Removal of the first thoracic rib
  • Partial removal of the scalene muscles in the neck
  • Removal of an additional rib in the neck or an abnormality in the spine at the base of the neck
  • Removal of other tissues or scarring, which may be causing compression of the thoracic outlet area
  • Removal and reconstruction of the subclavian artery

The preferred surgical approach is a 2.5-3 inch incision, or cut, above the collarbone at the base of the neck. Patients with VTOS or ATOS may require repair of veins and arteries, which may involve a second smaller incision below the collarbone. The average stay at Mass General following surgery is one to two days.

The thoracic outlet may also become compressed in an area below the pectoralis minor muscle (a thin, triangular muscle located in the upper chest) and just under the shoulder. This is known as pectoralis minor syndrome. In our experience, this occurs in less than half of our patients. When this is present, it may require an additional surgical procedure performed through a 2-inch incision in the armpit. This is a less extensive procedure than rib removal, and it is typically done on an outpatient basis.

Schedule an Appointment

To schedule an appointment or to refer a patient, please call 617-643-8727. Our new patient process can assist you with more information on becoming a new patient of the thoracic surgery department. Our nurse coordinator will answer any questions that you may have and help schedule an appointment. Our coordinator will also assist with scheduling any necessary tests or procedures.

Research Focused on Diagnostic Techniques

Making the correct diagnosis is the key to successfully treating TOS. Our research efforts have focused on improving diagnostic techniques. In collaboration with the Mass General Department of Radiology, our researchers have developed unique protocols for MRI and CT scans in diagnosing TOS. Our team has developed two new evaluation strategies that build upon the standard MRI and CT technologies. We recalibrated each technology to develop images that are more detailed than previously available, providing a more accurate diagnosis.

Why Mass General?

Mass General is consistently ranked among the best hospitals in the country by U.S. News & World Report. Our ranking is based on our quality of care, patient safety and reputation in 16 different specialties. Our commitment to excellence means that we work to ensure that you receive the best care at all points during your visit. Patients of the Thoracic Outlet Syndrome Program at Mass General can benefit from shared expertise, leading research, and our commitment to quality and excellence.

For New Patients

Massachusetts General Hospital is dedicated to ensuring that people understand their health care choices and have the necessary information to make decisions affecting their health and well-being. Use this new patient information to help ensure a smooth registration process. This process will be used if you are a new patient to Mass General and Thoracic Surgery.

Below you will find information about the new patient process, worker’s compensation and international patient process.

New Patient Process

  1. Obtain medical record number: Call Mass General Registration at 866-211-6588 and have your insurance information ready. You will be given a medical record number (MRN) when you have successfully registered. If you are already a patient at Mass General, please update your registration information by calling Mass General Registration at 866-211-6588. Before scheduling an appointment, please check to see if Mass General accepts your insurance plan.
  2. Call the nurse coordinator. Once you have successfully registered, contact the program’s nurse coordinator, Julie Donahue, by phone at 617-643-8727 and leave a message on her voicemail or by email at jadonahue@partners.org. Please include your name, MRN, telephone number and a brief message about why you are contacting her (i.e. new patient appointment). You can expect to receive a call back from her within approximately five business days, when she will do an initial screening of your history and symptoms. 
  3. Schedule your appointment. Call the office at 617-724-0969 and inform our staff that you have been instructed to book a new patient appointment. If you have been referred to us, please have your referral faxed to our office at 617-726-7667. Once our staff has received your referral information, we can then move forward with scheduling your appointment. If you are filing a workers’ compensation case, scroll down for more information.
  4. Complete new patient forms. After you are scheduled in the system, you will receive new patient forms via mail. The forms include a diagram that you can use to indicate where you are experiencing symptoms in the body, as well as a questionnaire about your medical history. Please complete these forms and send them back to our office prior to your appointment.

    Our mailing address is:

    Dr. Dean Donahue
    Massachusetts General Hospital
    Thoracic Outlet Syndrome Program, Founders 7
    55 Fruit Street
    Boston, MA 02114

  5. Submit imaging discs and reports. Prior to your new patient appointment, please send us any imaging discs and reports that are pertinent to your condition and an up-to-date list of medications. Some examples of images and reports that are helpful for our team to see include:

    • Magnetic resonance imaging (MRIs) of the neck, chest or shoulders
    • CAT or CT scans of the neck or chest
    • Plain x-rays of the neck or chest
    • Electromyogram (EMG) and nerve conduction studies
    • Vascular studies, such as Doppler ultrasounds
    • Venogram reports
    • Operative notes from prior Thoracic Outlet Syndrome surgeries
    • Operative notes from prior neck or shoulder surgeries

Learn how to request a copy of your medical records at Mass General.

New Patient Process for a Worker's Compensation Case

If you have worker's compensation insurance, please inform our staff immediately.

  1. Contact your adjuster and request a prior authorization for a new patient consultation. Dr. Donahue’s National Provider Identifier (NPI) is 1548236052.
  2. After you have obtained an authorization, you must provide our staff with the following information:
    • Your claim number
    • The name of your company’s worker’s compensation insurance
    • Your employer’s name and telephone number
    • Your adjuster’s name and telephone number

    The Mass General billing department will then contact your adjuster to agree on payment for this visit. Please inform our staff if the adjuster requires a request from our office. Once this information is processed, you will be scheduled for a new patient appointment.

International Patients

If you are an international patient, please complete the Mass General International Patient Center online registration form.

For more information, or if you have any questions, please call the Mass General Thoracic Surgery office at 617-724-0969.

 

 

Testing and Procedures

As part of our evaluation and treatment, some patients may need additional testing and procedures. Some of the testing may include a CT Scan and Ultrasound-Guided Botox® Injections.

CT Scan

Many of our patients will need a specialized CT Angiogram of the neck and the chest. This is a unique scan developed at Mass General that shows a detailed view of the thoracic outlet region from the top of the neck to the mid-chest area. The three-dimensional images in this scan take approximately 10 days for the radiologists to reconstruct and read, so your results will not be immediately available. The results are an important piece of information that our team will use to determine how to treat your symptoms. For the interpretation of these results, please call the office approximately 10 days after the study and request to be put on our call-back list.

Ultrasound-Guided Botox Injections

In some cases, the muscles in the neck and shoulder area can be contributing to compression or irritation of the nerves and blood vessels in the thoracic outlet. One way our team evaluates patients is by injecting Botox® into certain muscles in the thoracic outlet. These injections are performed by physicians in the Department of Radiology using ultrasound to precisely target specific muscles. The injections may help relieve some of the compression in the thoracic outlet.

After your appointment is scheduled, the Thoracic Outlet Syndrome administrator will send you Botox® forms via email. The forms are designed to help keep record of your symptoms before and after the injections. Depending on your body’s reaction to Botox®, it can take up to one month for you to feel any effects.

After the Botox® injections, you should describe how you are feeling using the forms provided. When you have completely answered all questions in the form, please send it back to our office via fax or mail.

Insurance Process

The specialized CT scan and Botox® injections require prior authorizations from your insurance company, which may take up to three weeks to process. We ask that you please be patient during this time.

Once the authorizations are approved by your insurance company, the Thoracic Outlet Syndrome administrator will call you to schedule the CT scan and Botox® injections. If you have not heard from our office within one month of your initial consult, please call us to check in.

For more information, or if you have any questions, please call the Mass General Thoracic Surgery office at 617-724-0969.

Conditions & Diseases

  • Thoracic Outlet Syndrome

    Thoracic outlet syndrome (TOS) is an uncommon disorder that results from compression or irritation of the nerves and/or blood vessels in the base of the neck underneath the collarbone.

News

  • Life-changing care for thoracic outlet syndrome - 8/15/2015, Mass General

    Rachael Vaters-Carr shares her experience as a patient in the Thoracic Outlet Syndrome (TOS) Program at Massachusetts General Hospital, including the comprehensive and compassionate care she received from her team of specialists.

Video

  • Brian A. McGovern Award for Clinical Excellence 2016 Nominee: Dean Donahue, MD

    Brian A. McGovern Award for Clinical Excellence 2016 Nominee: Dean Donahue, MD

    Dean Donahue, MD, head of the Thoracic Outlet Syndrome (TOS) Program at Massachusetts General Hospital, is a 2016 nominee for the Brian A. McGovern Award for Clinical Excellence. The Massachusetts General Physicians Organization (MGPO) created this award to honor the memory of Brian McGovern, MD, and recognize a physician within the MGPO who shares his dedication, compassion and kindness to all patients and staff.

Contact

Contact Us

Thoracic Outlet Syndrome Program

Thoracic Surgery Department, Founders 7

55 Fruit Street Boston, MA 02114
  • Phone: 617-643-8727
  • Fax: 617-726-7667
Learn more about thoracic outlet syndrome

Call to request an appointment or refer a patient: 617-643-8727

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