• The brachial plexus (responsible for arm and hand strength and sensation).
• The subclavian artery.
• The subclavian vein. When compression happens, symptoms vary depending on the affected structure.

Types of Thoracic Outlet Syndrome

• Neurogenic (>90%): caused by nerve compression.
  
  • Pain in neck, shoulder, arm, or hand.
  • Tingling and numbness in fingers.
  • Quick fatigue and weakness in the arm, worse when elevated.
• Venous (≈5%): occurs when the vein is compressed.
  
  • Swelling in arm and hand.
  • Pain and dilated veins, potentially leading to venous thrombosis.
• Arterial (≈1%): very rare but serious.
  
  • Cold and pale hand.
  • Intense pain when raising the arm.
  • Risk of aneurysm or arterial obstruction.

Why does this happen? Causes can be:

• Congenital: cervical rib or alterations in clavicle/1st rib.
• Muscular: shortening and hypertrophy of pectoralis minor, subclavius, and scalenes, and anatomical variations.
• Postural/acquired: poor posture (prolonged use of cell phones and computers), repetitive microtraumas, post-trauma or post-surgery fibrosis. Narrowing of the costoclavicular space is the main origin of compression in most cases.

How is the diagnosis made?

• Clinical exam with specific tests (like Adson, Wright, Scratch Collapse Test, Tinel on the plexus, and digitopression on plexus trigger points).
• Imaging exams, such as dynamic contrast-enhanced magnetic resonance for nerves and vascular ultrasound, to identify the site and intensity of compression.

Treatment

1. Conservative

• Physiotherapy: stretching of pectoralis minor and subclavius, strengthening of trapezius and rhomboids.
• Postural reeducation.
• Medication for pain and neural protection.

2. Surgical Indicated when there is no improvement or significant impairment. Endoscopic Surgery – Main indication in Neurogenic cases Dr. José Carlos Garcia is a world pioneer in endoscopic decompression of the brachial plexus.

• His results published in 2025 in JSES International show:
  
  • 95% clinical improvement in patients.
  • Pain reduction (VAS: 5.6 → 1.3).
  • Significant functional improvement (QDASH: 41.9 → 5.4).
  • Low rate of complications or reoperations. Advantages of the endoscopic technique: ✔ Less bleeding. ✔ Fewer scars and adhesions. ✔ Faster recovery. ✔ Excellent results in neurogenic and mixed cases without major vascular impairment. First Rib Removal – Vascular cases When there is severe vessel compression (subclavian artery or vein), especially in thrombosis, aneurysm, or significant obstruction, isolated endoscopic or open soft tissue surgery may not be sufficient. In these cases, the best option is first rib removal (rib resection) and complete vessel decompression.
• The approach can be supraclavicular, transthoracic, or transaxillary.
• This technique remains the gold standard for arterial and severe venous TOS.

Post-operative

• Sling for 1 to 2 weeks.
• Suture removal and gradual return to movements shortly after.
• In endoscopic surgeries, in most cases, gradual strength progression restores patient functions.
• In open surgeries with first rib removal, recovery may be slower, requiring physiotherapy and progressive rehabilitation.

Conclusion Thoracic Outlet Syndrome is a complex condition that can significantly impact quality of life.

• In neurogenic cases (the vast majority), the minimally invasive endoscopic surgery developed by Dr. Garcia is one of the most modern and effective techniques today.
• In severe vascular cases, open first rib removal remains the gold standard, ensuring complete vessel decompression and preventing major complications.

Why choose Dr. José Carlos Garcia? Dr. José Carlos Garcia has a nationally and internationally recognized career: He has been working in the field since 2003 and has established himself as one of the world’s leading experts in Neurogenic Thoracic Outlet Syndrome. His career combines over 20 years of clinical practice with scientific pioneering in the development of endoscopic and minimally invasive techniques.

1. Clinical experience and pioneering since 2003

• More than two decades of experience in shoulder and brachial plexus surgery.
• Active participation as a speaker in national and international congresses.
• Recognition as a reference in complex surgeries and nerve compressions.

2. Development and innovation line by Dr. José Carlos in Thoracic Outlet Syndrome First steps and nerve endoscopy

• 2009 – Scientific Publication: Arthroscopic Decompression of the Suprascapular Nerve: Surgical Technique (Tech Shoulder & Elbow Surg). Pioneering description of arthroscopic decompression of the suprascapular nerve, showing that arthroscopy could be applied beyond joints.
• 2010 – Presentation at the Brazilian Congress of Shoulder and Elbow Surgery (SBCOC, Campos do Jordão): first clinical series of neurogenic TOS cases treated surgically by open release, initial milestone in the research area.

Plexus exploration and robotics

• 2011 – Scientific Publication: Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial (J Neurosurg). Experimental study combining endoscopy and robotics in brachial plexus management.
• 2012 – Scientific Publication: Brachial plexus endoscopy: feasibility study on cadavers (Chirurgie de la Main). First published anatomical study confirming the feasibility of brachial plexus endoscopy in the lab.
• 2012 – Scientific Publication: Telerobotic manipulation of the brachial plexus (J Reconstr Microsurg). Consolidation of robotics applied to the plexus, expanding technical possibilities.
• 2013 – Book Chapter: Nerve Entrapment (Telemicrosurgery, Springer, Paris). International review on peripheral nerve compressive syndromes, integrating microsurgery concepts and minimally invasive techniques.

Clinical expansion and applied endoscopy

• 2013 – Scientific Publication: Suprascapular Nerve, Arthroscopic Release Outcomes (Arthroscopy). Study on outcomes of arthroscopic release of the suprascapular nerve, confirming clinical efficacy.
• 2015 – Scientific Publication: Arthroscopic release of the suprascapular nerve: surgical technique and clinical cases (Rev Bras Ortop). National clinical series validating the efficacy of arthroscopic release of the suprascapular nerve.

Consolidation of plexus endoscopic technique

• 2019 – World Congress of Shoulder and Elbow Surgery (Buenos Aires, Argentina): presentation of clinical series with endoscopic release of the brachial plexus in neurogenic TOS.
• 2020 – Scientific Publication: Endoscopic Release of the Brachial Plexus (Arthroscopy Techniques). First detailed clinical description of endoscopic release of the brachial plexus for neurogenic Thoracic Outlet Syndrome.
• 2022 – Book Chapter: Thoracic Outlet Syndrome (Shoulder Diseases, Di Livros). Didactic review addressing differential diagnosis and conservative and surgical treatment options.
• 2022 – Brazilian Congress of Shoulder and Elbow Surgery (Gramado, RS): presentation of clinical series of patients treated endoscopically, showing significant improvement in pain and function.

International expansion of the technique

• 2023 – Book Chapter: Endoscopic Release of the Brachial Plexus for Thoracic Outlet Syndrome (Arthroscopy and Endoscopy of the Shoulder, Springer, Singapore). Standardization of the endoscopic technique with systematized description of portals and surgical sequence.
• 2023 – International Shoulder Surgery Course – Annecy, France: brachial plexus endoscopy surgery for neurogenic thoracic outlet syndrome treatment transmitted live from the operating room to over 800 specialists in the Imperial Palace convention center auditorium in Annecy.

Comprehensive reviews and approach expansion

• 2024 – Book Chapter: Thoracic Outlet Syndrome (Orthopedics and Traumatology, 6th ed., Di Livros). Reference text in Brazil, aimed at medical education.
• 2024 – Scientific Publication: Comprehensive Endoscopic Brachial Plexus Release for Neurogenic Thoracic Outlet Syndrome (Arthroscopy Techniques). Technical advancement including scalenotomy and suprascapular nerve release, making the technique more complete and comprehensive.
• 2024 – National courses and symposia with live surgical demonstrations of the endoscopic technique applied to TOS.

International recognition and leadership

• 2025 – Book Chapter: Thoracic Outlet Syndrome (Neurological Shoulder, Griffin, Italy). In-depth review on classification, multimodal diagnosis, and innovative therapies, highlighting the endoscopic approach.
• 2025 – Scientific Publication: Endoscopy for Neurogenic Thoracic Outlet Syndrome: Effectiveness and safety assessments (JSES International). Robust clinical study with patients followed for at least 2 years, demonstrating:
  
  • Expressive pain reduction (VAS 5.6 → 1.3).
  • Significant functional improvement (QDASH 41.9 → 5.4).
  • Over 95% good clinical results without serious complications or reoperations.
• 2025 – European Congress of Shoulder and Elbow Surgery (SECEC, Rotterdam-Netherlands): Lecture on endoscopic treatment of neurogenic TOS.
• 2025 – Live surgeries event on thoracic outlet endoscopy post-SECEC Congress at VieCuri Medisch Centrum Hospital (Rotterdam-Netherlands).
• 2026 – Third World Thoracic Outlet Syndrome Summit: lecture on the endoscopic technique, reinforcing Dr. Garcia’s position as a world reference.

Conclusion Throughout his career, Dr. José Carlos Garcia has transformed the management of Neurogenic Thoracic Outlet Syndrome with the scientific validation of brachial plexus endoscopy, uniting practice, science, and innovation. Today, his technique is considered one of the most modern, safe, and effective options in the world for patients with neurogenic TOS.

See below the bibliography of Prof. Dr. José Carlos’s publications on Neurogenic Thoracic Outlet Syndrome:

Book Chapters

1. Garcia, J.C. Correa MFP, Bizetto EL, Lafosse T, Muzy PC. Thoracic outlet Syndrome. In: Peretti G, Peretti M (eds). Neurological Shoulder. 1ª ed. Figino Serenza – Italia: Griffin, 2025, p. 126-163.
   Link
2. Garcia, J.C. Correa MFP, Muzy PC. Síndrome do Desfiladeiro Torácico. In: Sizinio H, Lech O. (eds) Ortopedia e Traumatologia. 6ª ed. Rio de Janeiro: Di Livros, 2024, p. 783-799.
   Link
3. Garcia, JC, Lafosse T, Bader D. Endoscopic Release of the Brachial Plexus for Thoracic Outlet Syndrome. In: Lui, T.H. (eds). Arthroscopy and Endoscopy of the Shoulder. 1ª ed. Singapura: Springer, 2023, p. 419-424.
   Link
4. Garcia, J.C.. Síndrome do desfiladeiro Torácico. In: Doenças do Ombro. 1ª ed. Rio de Janeiro: Di livros, 2022, p. 469-482.
   Link
5. Garcia, Jose Carlos. Nerve Entrapment. In: Telemicrosurgery. 1ª ed. Paris: Springer Paris, 2013, p. 109-117.
   Link

Publications in Scientific Periodicals

1. Garcia JC, Correa MFP, Fadel GW, Mendes RB, Garcia JM, Muzy PC, et al. Endoscopy for Neurogenic Thoracic Outlet Syndrome: Effectiveness and safety assessments. JSES Int; 2025. 9(3):852-858.
   https://jsesinternational.org/article/S2666-6383(24)00499-7/fulltext
2. Lafosse T, Garcia JC, Lafosse L, Kimmeyer M. Comprehensive Endoscopic Brachial Plexus Release for Neurogenic Thoracic Outlet Syndrome Including Suprascapular Nerve Release and Scalenotomy.Arthroscopy Techniques. 2024; 14(2):103237.
   https://www.arthroscopytechniques.org/article/S2212-6287(24)00377-3/fulltext
3. Bader D, Lafosse T, Garcia JC. Endoscopic Release of the Brachial Plexus.Arthroscopy Techniques.2020;9:e1565-e1569.
   https://www.sciencedirect.com/science/article/pii/S2212628720301663
4. Gonçalves MHL, Garcia JC,  Steffen AM, Cordeiro EF, Fink LFS. Suprascapular Nerve, Arthroscopic Release Outcomes. Arthroscopy. 2013; 29(10):e89-e90. https://www.arthroscopyjournal.org/article/S0749-8063(13)00643-9/fulltext
5. Garcia JC Jr, Mantovani G, Liverneaux PA. Brachial plexus endoscopy: feasibility study on cadavers. Chir Main. 2012;31(1):7-12.
   Link https://www.sciencedirect.com/science/article/abs/pii/S1297320312000029?via%3Dihub
6. Garcia JC Jr, Lebailly F, Mantovani G, Mendonca LA, Garcia J, Liverneaux P. Telerobotic manipulation of the brachial plexus. J Reconstr Microsurg. 2012 Sep;28(7):491-4. doi: 10.1055/s-0032-1313761. Epub 2012 May 24. PMID: 22628115. https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0032-1313761 
7. Mantovani G, Liverneaux P, Garcia JC Jr, Berner SH, Bednar MS, Mohr CJ. Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial. J Neurosurg. 2011 Sep;115(3):659-64. doi: 10.3171/2011.3.JNS10931. Epub 2011 Apr 8. PMID: 21476812. https://thejns.org/view/journals/j-neurosurg/115/3/article-p659.xml
8. Garcia Júnior JC, Paccola AM, Tonoli C, Zabeu JL, Garcia JP. ARTHROSCOPIC RELEASE OF THE SUPRASCAPULAR NERVE: SURGICAL TECHNIQUE AND EVALUATION OF CLINICAL CASES. Rev Bras Ortop. 2015 Nov 17;46(4):403-7. doi: 10.1016/S2255-4971(15)30252-4. PMID: 27027028; PMCID: PMC4799278. https://www.scielo.br/j/rbort/a/zw8bfXJsvHVfc5jpnscsrWG/?lang=en
9. Garcia JC. Arthroscopic Decompression of the Suprascapular Nerve: Surgical Technique. Techniques in Shoulder & Elbow Surgery. 2009; 10(4):157-159. DOI: 10.1097/BTE.0b013e3181bbd49a https://journals.lww.com/shoulderelbowsurgery/abstract/2009/12000/arthroscopic_decompression_of_the_suprascapular.6.aspx

Prof. Dr. José Carlos Garcia Jr.

• Medical Degree: Graduated in Medicine from the Federal University of São Paulo-Brazil (Unifesp).
• Orthopedic Surgery Residency: Completed at the Federal University of São Paulo-Brazil (Unifesp).
• Fellowship: Completed at IFOR São Paulo -Brazil
• Visiting Clinician in Shoulder and Elbow Surgery: Mayo Clinic and Princeton Orthopaedics PA, USA.
• Research Fellowship in Robotic Microsurgery: University of Strasbourg, France.
• Certification in Robotic Surgery: European School of Surgery, Paris, France.
• Master’s Degree: University of Liverpool, England.
• Doctorate in Health Sciences: University of São Paulo (USP).
• Authored 14 book chapters and 46 articles in scientific journals, with over 150 presentations at specialty conferences.
• Currently working on 2 additional book chapters and 4 more scientific articles in progress. 

Office: Av. Pres. Juscelino Kubitschek, 180, 13th floor – Itaim Bibi, São Paulo – SP – Brazil, 04543-000 

Phone/WhatsApp: +5511987778579