Predictors of Surgical Outcome in Thoracic Outlet Syndrome: Analysis of One Thousand Operated Cases Over 18 Years

BACKGROUND: Thoracic outlet syndrome (TOS) comprises a heterogeneous group of neurovascular compression disorders with variable clinical presentation and complex diagnostic pathways. Despite widespread use of surgical decompression, robust long-term outcome data from large standardized cohorts remain limited. METHODS: This retrospective cohort study included 1000 consecutive patients who underwent surgical decompression for neurogenic, venous, arterial, or mixed TOS between January 2007 and December 2024 at a tertiary cardiothoracic and vascular surgery center. All procedures were performed by a single surgeon using a standardized supraclavicular approach with first rib resection and scalenectomy. Diagnosis was based on clinical evaluation supported by imaging and neurophysiological studies. Outcomes were analyzed according to TOS subtype. Primary outcomes included functional improvement measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) score, symptom resolution, recurrence, and venous patency. Secondary outcomes included operative characteristics and perioperative complications. RESULTS: The mean participant age was 37.9 years, with the majority being female (70%). Neurogenic TOS accounted for 55% of cases. Significant differences were observed between TOS subtypes in terms of clinical presentation, symptom duration, and outcomes (p < 0.05). Mean DASH score improved from 52.8 preoperatively to 11.98 postoperatively (mean ΔDASH: 40.8). At 48 months, 81.7% of patients achieved full functional recovery. Recurrence and chronic pain occurred in 18.3% of patients, with higher rates in neurogenic and post-traumatic cases. Primary Venous patency was maintained in all patients with vascular TOS. Minor postoperative complications were infrequent and managed conservatively, with no major intraoperative neurovascular injuries. CONCLUSIONS: Supraclavicular thoracic outlet decompression provides safe, reproducible, and durable functional improvement across all TOS subtypes. Subtype-specific differences highlight the importance of early diagnosis and tailored surgical management. These findings support the role of specialized high-volume centers in optimizing outcomes for this complex condition.