Thoracic Outlet Syndrome: Rise of the Conservative Viewpoint Thoracic outlet syndrome is one of the most controversial subjects in clinical medicine. In the past ten years, a growing number of authors have questioned many aspects of this syndrome, including the proposed methods of diagnosis and the value of surgery.(1,2,3,4) It is important for primary care physicians to be aware of the rising tide of skepticism surrounding diagnosis and treatment of thoracic outlet syndrome. Until recently, controversy and doubt about the management of this condition has been largely confined to the neurologic literature.
The nomenclature regarding thoracic outlet syndrome is confusing. "The disputed form," in which no objective clinical, radiologic or electrodiagnostic abnormalities are documented, is the most commonly diagnosed and surgically treated form of thoracic outlet syndrome in the United States.(5)This form of the condition is not to be confused with the rare, true neurogenic form and the uncommon vascular form in which objective abnormalities are present.
Why the rising tide of skepticism in the neurologic literature(7)First, surgical intervention for thoracic outlet syndrome carries the risk of major complications, including brachial plexopathy, laceration of the subclavian artery, pneumothorax and causalgia. Such complications are especially tragic when they occur during an elective operation for a condition that manifests few or no objective clinical abnormalities.
Second, early studies on surgery for thoracic outlet syndrome, which claimed high success rates, were reported by the same teams that performed the surgery. Accurate assessment of success is difficult when no objective preoperative or postoperative tests exist. In addition, many neurologists have seen patients with recurrence of symptoms after surgery was deemed successful.
Finally, no objective tests are available for diagnosing the disputed form of thoracic outlet syndrome. Again and again, independent investigators have convincingly challenged the use of tests that were touted as a means of confirming the diagnosis of thoracic outlet syndrome. Outlet ulnar nerve conduction studies,(6) elevated arm stress test, Adson's maneuver and plethysmography were at one time promoted as valid diagnostic procedures, but have since been called into question. With history as a guide, we should critically evaluate any investigative procedures that are promoted as a method for diagnosing a condition that does not produce objective clinical findings.
Family physicians and their patients would do well to be aware of these issues when diagnosis or, more importantly, surgical treatment of thoracic outlet syndrome is a consideration.
MICHAEL CHERINGTON, M.D.
University of Colorado School of Medicine
1. Cherington M, Happer I, Machanic B, Parry L.
Surgery for the thoracic outlet syndrome may
be hazardous to your health. Muscle Nerve
2. Cuetter AC, Bartoszek DM. The thoracic outlet
syndrome: controversies, overdiagnosis,
overtreatment, and recommendations for management.
Muscle Nerve 1989;12:410-9.
3. Hadler NM. The roles of work and of working
in disorders of the upper extremity. Baillieres
Clin Rheumatol 1989;3:121-41.
4. Nelson DA. Thoracic outlet syndrome and dys - function of the temporomandibular joint: proved
pathology or pseudosyndromes(7) Perspect Biol
5. Wilbourn Aj. Thoracic outlet syndrome surgery
causing severe brachial plexopathy. Muscle
6 Smith T, Trojaborg W. Diagnosis of thoracic
outlet syndrome. Value of sensory and motor
conduction studies and quantitative electromyography.
Arch Neurol 1987;44:1161-3.
COPYRIGHT 1991 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group