Kerri Smart describes her family's journey with Thoracic Outlet Syndrome (TOS) and their treatment experience with Dr. Dean Donahue, director of the TOS Program in the Division of Thoracic Surgery at Massachusetts General Hospital.
Explore This Treatment
About the Program
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 thoracic outlet syndrome:
- Arterial (ATOS)
- Neurogenic (NTOS)
- Venous (VTOS)
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 initial treatment 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.
At Mass General, we see many patients who suffer from sports-related injuries. These patients can range from the youth level to professional athletes.
Multidisciplinary Approach to Care
Our doctors are highly skilled in properly diagnosing and treating thoracic outlet syndrome. 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:
- Pain Management Center
- Department of Neurology
- Department of Orthopaedic Surgery
- Department of Physical and Occupational Therapy
- Fireman Vascular Center
- Interventional Radiology - Musculoskeletal (MSK)
- Physical Medicine and Rehabilitation Service
- Vascular Interventional Radiology
For many patients, our initial treatment includes a combination of physical therapy and medications, as 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.
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.
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:
- Poor diaphragmatic breathing
- 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
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.
Surgery for 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:
- If present, removal of an additional rib in the neck or an abnormality in the spine at the base of the neck
- Partial removal of the scalene muscles in the neck
- Removal and reconstruction of the subclavian artery (an artery leading to each arm that delivers blood to the heart)
- Removal of other tissues or scarring, which may be causing compression of the thoracic outlet area
- Removal of the first thoracic rib
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, involving 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.
Our experts customize a diagnostic and treatment program for each patient. A diagnostic treatment process begins by evaluating other disorders and then testing to see if the condition involves the nerves (NTOS), the blood vessels (VTOS or ATOS) or some combination.
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 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
- A specialized 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
- Invasive vascular studies:
- Arteriogram (an X-ray that uses contrast dye to visualize the arteries)
- Venogram (an X-ray that uses contrast dye to visualize the veins)
- Magnetic resonance angiography (MRA), a noninvasive exam of the blood vessels
- MRI of the cervical spine or shoulder
- Nerve-conduction studies to evaluate the function of the motor and sensory nerves
- Noninvasive, ultrasound-guided vascular exams
Testing & Procedures
As part of our evaluation and treatment, some patients may need additional testing and procedures. Some of the testing may include a cardiothoracic (CT) scan and Ultrasound-Guided Botox® injections.
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
Botox® changed my quality of life. I am able to be in less pain and have more of my regular life functionality brought back. I felt less pain at work, could sleep better at home and feel better overall. It is a miracle treatment and I’m grateful to live in a place that offers it. It has really been so life changing for me.
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 TOS 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.
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.
Information for New Patients
Mass General 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
- 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.
- Schedule an appointment: To schedule an appointment or to refer a patient, please call 617-643-8727 or request an appointment online
- Complete questionnaire: Once the forms have been submitted, you will be contacted to schedule an appointment. In the meantime, please download and fill out the New Patient Questionnaire
- 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
Our mailing address is:
Dr. Dean Donahue
Massachusetts General Hospital
Thoracic Outlet Syndrome Program, Founders 7
55 Fruit Street
Boston, MA 02114
New Patient Process for a Worker's Compensation Case
If you have worker's compensation insurance, please inform our staff immediately.
- Contact your adjuster and request a prior authorization for a new patient consultation. Dr. Donahue’s National Provider Identifier (NPI) is 1548236052.
- After you have obtained an authorization, you must provide our staff with the following information (included in the request an appointment form):
- 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.
Patient Gateway provides secure online access to your health information whenever you need it. You can check upcoming appointments, communicate with your doctor's office, review medications and pay medical bills.
If you are an international patient, please complete the Mass General International Patient Center online registration form.
Billing and Insurance
Mass General accepts most health insurance plans, including Medicare and Medicaid.
Before scheduling your hospital visit, check with your health insurance provider to see if you are covered and learn the specifics of your coverage. Insurance plans are agreements made between you and your insurer, and Massachusetts General Hospital cannot ensure that an insurance provider will pay for your care. It is your responsibility to understand what types of coverage your health insurance provides and to be sure that you meet all requirements stipulated by your specific plan.
Your health insurance provider will be able to inform you of your level of coverage and what, if any, copayments, coinsurances and deductibles will be your responsibility. If you do not contact your provider, you can be ultimately be responsible for all or a large portion of your bill.
Research Focused on Diagnostic Techniques
Making the correct diagnosis is the key to successfully treating thoracic outlet syndrome. 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.
- Patient Story
- Apr | 22 | 2019
In 2017, Karen English began experiencing pain related to Thoracic Outlet Syndrome (TOS). After nearly a year of medical consultations, she was referred to the Division of Thoracic Surgery to meet with Dean Donahue, MD, the director of the TOS Program.
- Patient Story
- Jun | 1 | 2018
In 2015, Julia came to Massachusetts General Hospital to see Dr. Dean Donahue and receive treatment for thoracic outlet syndrome (TOS).
- Patient Story
- Aug | 15 | 2015
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.