Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations

Upper Vascular Thoracic Outlet Syndrome: A Case Study

Thoracic outlet syndrome (TOS) is recognised in approximately 8% of the population. Vascular presentation is rare and diagnosis is often elusive due to its rarity. As episodes of TOS in the upper extremities are rare, proven protocols for rehabilitation management are lacking. The purpose of our article is to present a clinical examination protocol and a treatment protocol for patients after an episode of venous thrombosis in the upper limb (VTOS). We report the case of a middle-aged woman with right venous TOS with pain in the right upper extremity, accompanied by oedema and mild violet discolouration. The results after 10 sessions of physiotherapy were as follows: a reduction in symptoms of approximately 40%, an improvement of approximately 15% in sports performance, and an improvement of approximately 25% in work. There was also an improvement in the results of TOS provocation tests, i.e., a 50-100% improvement in pulse rate and about 30% less discolouration in the extremity. Additionally, there was a significant improvement in posture between the two sides of the upper quadrant. The results after 10 physiotherapy sessions are surprising due to chronic disease after the thrombosis episode. It appears that even after a long period of time since diagnosis, improvement is possible.

Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) involves inconsistent symptoms, presenting a challenge for medical providers to diagnose and treat. Thoracic outlet syndrome is defined as a compression injury to the brachial plexus, subclavian artery or vein, or axillary artery or vein occurring between the cervical spine and upper extremity. Three common subcategories are now used for clinical diagnosis: neurogenic, arterial, and venous. Postural position and repetitive motions such as throwing, weightlifting, and manual labor can lead to symptoms. Generally, TOS is considered a diagnosis of exclusion for athletes due to the poor accuracy of clinical testing, including sensitivity and specificity. Thus, determining a definitive diagnosis and reporting injury is difficult. Current literature suggests there is not a gold standard diagnostic test. Rehabilitation has been shown to be a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations.

Predisposing Anatomy for Thoracic Outlet Syndrome and Functional Outcomes after Supraclavicular Thoracic Outlet Decompression in Athletes

Purpose

This study aims to examine predisposing anatomic factors and subsequent post-decompression functional outcomes among high-intensity athletes with thoracic outlet syndrome (TOS).

Materials and Methods

A single-institution retrospective review was performed on a prospective database of patients with TOS from 2018 to 2023 who had undergone operative decompression for TOS. Demographics, TOS characteristics, predisposing anatomy, operative details, and postoperative outcomes were examined. The primary outcome was postoperative return to sport. Secondary outcomes included vascular patency.

Results

A total of 13 patients who were engaged in high-demand athletic activity at the time of their diagnosis were included. Diagnoses included 8 (62%) patients with venous TOS, 4 (31%) patients with neurogenic TOS, and 1 (8%) patient with arterial TOS. Mixed vascular and neurogenic TOS was observed in 3 (23%) patients. The mean age of the cohort was 30 years. Abnormal scalene structure was observed in 12 (92%) patients, and abnormal bone structures were noted in 4 (27%) patients; 2 (15%) with cervical ribs and 3 (23%) patients with clavicular abnormalities. Prior ipsilateral upper extremity trauma was reported in 4 (27%) patients. Significant joint hypermobility was observed in 8 (62%) patients with a median Beighton score of 6. Supraclavicular cervical and/or first rib resection with scalenectomy was performed in all patients. One case of postoperative pneumothorax was treated non-operatively. Ten (77%) patients returned to sport. Duplex ultrasonography showed subclavian vein patency in all 8 patients with venous TOS and wide patency with no drop in perfusion indices in the patient with arterial TOS.

Conclusion

Athletes with TOS who required operative intervention had a high incidence of musculoskeletal aberrations and joint hypermobility. Supraclavicular decompression was associated with a high success rate, with overall good functional outcomes and good likelihood of patients returning to preoperative high-intensity athletics.

Scapular Elevation Sign - A New Sign in Evaluation of Thoracic Outlet Syndrome

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic).

Role of Lifestyle in Thoracic Outlet Syndrome: A Narrative Review

INTRODUCTION

The presence of a positional compression of the neurovascular bundle in the outlet between the thorax and the upper limb during arm movements (mainly abduction) is common but remains asymptomatic in most adults. Nevertheless, a certain number of subjects with thoracic outlet positional compression will develop incapacitating symptoms or clinical complications as a result of this condition. Symptomatic forms of positional neurovascular bundle compression are referred to as "thoracic outlet syndrome" (TOS).

MATERIALS AND METHODS

This paper aims to review the literature and discuss the interactions between aspects of patients' lifestyles in TOS. The manuscript will be organized to report (1) the historical importance of lifestyle evolution on TOS; (2) the evaluation of lifestyle in the clinical routine of TOS-suspected patients, with a description of both the methods for lifestyle evaluation in the clinical routine and the role of lifestyle in the occurrence and characteristics of TOS; and (3) the influence of lifestyle on the treatment options of TOS, with a description of both the treatment of TOS through lifestyle changes and the influence of lifestyle on the invasive treatment options of TOS.

RESULTS

We report that in patients with TOS, lifestyle (1) is closely related to anatomical changes with human evolution; (2) is poorly evaluated by questionnaires and is one of the factors that may induce symptoms; (3) influences the sex ratio in symptomatic athletes and likely explains why so many people with positional compression remain asymptomatic; and (4) can sometimes be modified to improve symptoms and potentially alter the range of interventional treatment options available.

CONCLUSIONS

Detailed descriptions of the lifestyles of patients with suspected TOS should be carefully analysed and reported.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion

It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.

Thoracic outlet syndrome: a review for the primary care provider

CONTEXT

Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS.

OBJECTIVES

This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options.

METHODS

The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS.

RESULTS

The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS.

CONCLUSIONS

The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.

[Please Don't Forget the Neurogenic Thoracic Outlet Syndrome]

Please Don't Forget the Neurogenic Thoracic Outlet Syndrome Abstract. We report the case of a 52-year-old patient who was treated for years for headaches, pain in the neck and arms, and sweating. Despite various therapeutic approaches there was no improvement in the symptoms. Further investigations showed a bilateral thoracic outlet syndrome in the status after multiple bilateral rib fractures after a fall from a window at the age of 18. After the operation of a bilateral thoracic outlet syndrome, the headache disappeared almost completely and there was no more sweating.

Thoracic Outlet Syndrome in Sport: A Systematic Review

Thoracic outlet syndrome (TOS) is a rare and heterogeneous syndrome secondary to a compression of the neurovascular bundle in the thoracic outlet area. Muscle hypertrophy is recognized to induce vascular or neurogenic compression, especially in sports involving upper-arm solicitation. Athletes represent a distinctive population because of a specific management due to an ambitious objective, which is returning to high-level competition. We evaluated the scientific literature available for the management of TOS in athletes. Article research extended to March 2021 without other restriction concerning the date of articles publication. The search was performed independently by two assessors. A first preselection based on the article titles was produced, regarding their availability in English or French and a second preselection was produced after reading the abstracts. In case of doubt, a third assessor’s advice was asked. Case reports were selected only if the sport involved was documented, as well as the level of practice. Cohorts were included if data about the number and the sport level of athletes were detailed. Seventy-eight articles were selected including 40 case reports, 10 clinical studies and 28 reviews of literature. Baseball pitchers seem to be highly at risk of developing a TOS. The surgical management appears particularly frequent in this specific population. The prognosis of TOS in athletes seems to be better than in the general population, possibly due to their better physical condition and their younger age. Some studies showed interesting and encouraging results concerning return to previous sport level. Literature shows a strong link between TOS and certain sports. Unfortunately, this syndrome still lacks rigorous diagnostic criteria and management guidelines for athletes.

Exercise rehabilitation for neurogenic thoracic outlet syndrome: a scoping review

Exercise rehabilitation has been proposed for the management of Neurogenic Thoracic Outlet Syndrome (NTOS). To date there have been no reviews of the literature regarding exercise rehabilitation for NTOS and their proposed clinical rationale. Understanding various exercise protocols and their clinical rationale may help guide rehabilitation clinicians in their exercise selection when managing NTOS. A scoping review was conducted on exercise rehabilitation for NTOS from inception to March 2021 in the PubMed database. Forty-seven articles consisting of literature reviews, non-randomized control trials, prospective and retrospective cohort studies, case series, case studies and clinical commentaries met the inclusion criteria. This scoping review provides a broad overview of the most common exercise protocols that have been published and examines the purported clinical rationale utilized in the management of NTOS.

Diagnostic and Therapeutic Management of the Thoracic Outlet Syndrome. Review of the Literature and Report of an Italian Experience

The Thoracic Outlet Syndrome is a clinical potentially disabling condition characterized by a group of upper extremity signs and symptoms due to the compression of the neurovascular bundle passing through the thoracic outlet region. Because of the non-specific nature of signs and symptoms, to the lack of a consensus for the objective diagnosis, and to the wide range of etiologies, the actual figure is still a matter of debate among experts. We aimed to summarize the current evidence about the pathophysiology, the diagnosis and the treatment of the thoracic outlet syndrome, and to report a retrospective analysis on 324 patients followed for 5 years at the Padua University Hospital and at the Naples Fatebenefratelli Hospital in Italy, to verify the effectiveness of a specific rehabilitation program for the syndrome and to evaluate if physical therapy could relieve symptoms in these patients.

A Thoracic Outlet Syndrome That Concealed a Glioblastoma. Findings from a Case Report

Background: Glioblastoma is the most frequent and aggressive malignant brain tumor among adults. Unfortunately, its symptoms can vary considerably depending on the size, location and the anatomic structures of the involved brain. Case report: A 58-year-old male amateur cyclist who suffered from sharp arm pain was examined for a thoracic outlet syndrome due to a previous clavicle fracture. Because of ambiguous results of the neck and nerve plexus imaging, he was referred to a neurosurgeon who properly suspected a brain tumor. The neuroimaging of the brain shown a 3 cm disploriferative mass with a blood enhancement within the left parietal lobe. The mass was urgently removed, and its histologic analysis stated a grade 4 glioblastoma. Conclusion: This case report highlights the differential diagnosis process and the teamwork approach needed to diagnose a rare presentation of a brain glioblastoma, which started its symptoms mimicking a thoracic outlet syndrome caused by a previous bone fracture.

Neurogenic Thoracic Outlet Syndrome in Athletes - Nonsurgical Treatment Options

ABSTRACT

Neurogenic thoracic outlet syndrome (NTOS) is an etiologically and clinically diverse disorder caused by compression of the brachial plexus traversing the thoracic outlet. Athletes who perform repetitive overhead activities are at risk of developing NTOS with sport-specific symptoms. This article reviews the controversial NTOS nomenclature, common sites of anatomic compression, and red flag symptoms that require immediate intervention. It also reviews the congenital, traumatic, and functional etiologies of NTOS, with a discussion of the differential diagnosis, diagnostic criteria, and workup for NTOS. Nonsurgical treatment is highlighted with an emphasis on thoracic outlet syndrome-specific physical therapy and updates on injection options and ultrasound guided hydrodissection. This article compares nonsurgical versus surgical functional outcome data with an emphasis on athletes with NTOS. Functional assessment tools and performance metrics for athletes are reviewed, as well as return to sport considerations.

Scalenus muscle and the C5 root of the brachial plexus: bilateral anatomical variation and its clinical significance

OBJECTIVE

To describe an anatomical variant wherein, bilaterally, the C5 ventral root passes anterior to the anterior scalene muscle.

CLINICAL IMPLICATIONS

This and other variants in the anatomy of brachial plexus may complicate diagnosis of thoracic outlet syndrome, by producing unconventional signs and symptoms. Additionally, the passage of C5 ventral root anterior to the anterior scalene muscle, as in this case, may render the nerve root more susceptible to injury, including injury during manual therapy directed to this region.

Essentials of thoracic outlet syndrome: A narrative review

Thoracic outlet syndrome (TOS) is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region. TOS results in pain, numbness, paresthesia, and motor weakness in the affected upper limb. We reviewed the pathophysiology, clinical evaluation, differential diagnoses, and treatment of TOS. TOS is usually classified into three types, neurogenic, venous, and arterial, according to the primarily affected structure. Both true neurogenic and disputed TOS are considered neurogenic TOS. Since identifying the causative lesions is complex, detailed history taking and thorough clinical investigation are needed. Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS. The existence of a disputed TOS remains controversial. Neuromuscular physicians tend to be skeptical about the existence of disputed TOS, but thoracic surgeons argue that disputed TOS is under-diagnosed. Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.

Endoscopic Release of the Brachial Plexus

Thoracic outlet syndrome is a debilitating condition, impairing the function of the upper limb, and can be considered an entrapment of neurovascular structures dedicated to the upper limb. Its open treatment uses a large approach, and to date, only the structures under the clavicle have been endoscopically approached. The purpose of this Technical Note is to describe an endoscopic brachial plexus decompression at all possible entrapment areas between the neck and the arm.

Coexistence of Brachial Plexus-Anterior Scalene and Sciatic Nerve-Piriformis Variants

The trunks of the brachial plexus typically pass through the interscalene triangle, between the anterior and middle scalene muscles and superior to the first rib. Likewise, the two components of the sciatic nerve, tibial and common fibular nerves, usually join and pass together inferior to the piriformis muscle. We present a cadaver with anatomic variations of both the right brachial plexus-interscalene triangle relationship and the sciatic nerve-piriformis relationship. The right brachial plexus C5 and C6 roots formed the superior trunk as they passed through a bifurcated anterior scalene muscle, while the C7, C8, and T1 roots passed posterior to the anterior scalene. After passing through the left greater sciatic foramen, the sciatic nerve branched into the common fibular and tibial nerves, which passed through and inferior to the piriformis muscle, respectively. The presence of these anatomic variations may predispose individuals to symptomatic nerve entrapments such as thoracic outlet syndrome and piriformis syndrome. This finding is relevant to clinicians performing invasive procedures and diagnosing neurological conditions. 

Arm Numbness at 45 Degrees Abduction: A Case Report of Thoracic Outlet Syndrome After Brachial Neuritis

Objective

To describe a case of nerve kinking correlating with surgical findings in neurogenic thoracic outlet syndrome in a patient with history of brachial neuritis. Thoracic outlet syndrome and brachial neuritis are briefly reviewed.

Case report

A 32-year-old woman with a history of bilateral brachial neuritis presented with paraesthesias in her hand when abducting her shoulder to 45° or higher. A kink in the superior trunk of the brachial plexus, as well as asymmetrically narrowed costoclavicular space, was found on magnetic resonance imaging with the shoulder abducted. Conservative measures failed, leading to partial anterior scalenectomy and neurolysis, which led to improvement in her symptoms.

Conclusion

Anatomical variations in combination with biomechanical changes after brachial neuritis can be associated with neurogenic thoracic outlet syndrome.

Acute effects of manual therapy on respiratory parameters in thoracic outlet syndrome

Background

This study aims to investigate the acute effects of manual therapy on pain perception and respiratory parameters in patients with thoracic outlet syndrome.

Methods

The study included 10 patients with thoracic outlet syndrome (1 male, 9 females; mean age 31.3±9.0 years; range, 20 to 43 years). Patients were accepted in a single session of manual therapy involving the cervical spine and thorax. Stretching of scalene, upper trapezius, sternocleidomastoid, rectus abdominis, hip flexor muscles; and mobilization of first rib, cervical and thoracic spine, sacroiliac joints and thorax were applied as manual therapy program. Pain perceptions of upper arm and neck were assessed with visual analog scale. Measurements were performed before and immediately after of a 30-minute session of manual therapy. Pulmonary function testing was performed with a spirometer. Respiratory muscle strength (inspiratory and expiratory muscle strength, maximal inspiratory pressure and maximal expiratory pressure, respectively) was measured. Respiratory muscle endurance was recorded using sustained threshold loading of 35% maximal inspiratory pressure.

Results

There were no significant changes in any pulmonary function parameters or maximal expiratory pressure following manual therapy intervention (p>0.05). However, maximal inspiratory pressure and respiratory muscle endurance improved (p<0.05). Pain perceptions of upper arm and neck reduced after treatment (p<0.05).

Conclusion

A 30-minute single manual therapy session improved inspiratory muscle strength and respiratory muscle endurance but not pulmonary function and expiratory muscle strength in patients with thoracic outlet syndrome. Manual therapy may facilitate functional breathing and support use of primary respiratory muscles more effectively together with rapid pain reduction. The long-term effects of regular manual therapy on respiratory parameters should be investigated after surgical procedures.

Evaluation of the efficacy of ropivacaine injection in the anterior and middle scalene muscles guided by ultrasonography in the treatment of Thoracic Outlet Syndrome

OBJECTIVE

A clinical, placebo-controlled, randomized, double-blind trial with two parallel groups.

OBJECTIVE

to evaluate the efficacy of ropivacaine injection in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome (TOS) compared to cutaneous pressure.

METHODS

38 patients, 19 in the control group (skin pressure in each belly of the anterior and middle scalene muscles) and 19 in the intervention group (ropivacaine). Subjects with a diagnosis of Nonspecific Thoracic Outlet Syndrome, pain in upper limbs and/or neck, with no radiculopathy or neurological involvement of the limb affected due to compressive or encephalic root causes were included. The primary endpoint was functionality, evaluated by the Disabilities of the Arm, Shoulder, and Hand - DASH scale validated for use in Brasil. The time of the evaluations were T0 = before the intervention; T1 = immediately after; T2 = 1 week; T3 = 4 weeks; T4 = 12 weeks; for T1, the DASH scale was not applied.

RESULTS

Concerning the DASH scale, it is possible to affirm with statistical significance (p> 0.05) that the intervention group presented an improvement of functionality at four weeks, which was maintained by the 12th week.

CONCLUSION

In practical terms, we concluded that a 0.375% injection of ropivacaine at doses of 2.5 ml in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome helps to improve function.