THORACIC OUTLET SYNDROME AFTER MOTOR-VEHICLE ACCIDENTS IN A CANADIAN PAIN CLINIC POPULATION

Objective: To record symptoms and signs, operative findings, and long- term outcome in operated and nonoperated patients with the diagnosis o f thoracic outlet syndrome after a motor vehicle accident. Design: Des criptive prospective study. Setting: Pain clinic population in the Tor onto Hospital (Western Division), Toronto, Ontario, Canada. Patients: Thirty-two patients diagnosed as having thoracic outlet syndrome after injuries sustained in a car accident (based on specific symptoms and signs as web as exclusion of other disorders generating brachialgia). Interventions: Conservative management versus transaxillary or supracl avicular exploration of the thoracic outlet. Outcome measures: Pain/sy mptom relief. Results: Most patients presented with pain and paresthes iae, but conspicuous discoloration of the symptomatic extremity was se en in 41%. Osseous anomalies were seen in 22% of the patients in simpl e neck x-rays. Vascular studies were abnormal in 24% of tested patient s. During transaxillary first rib resection in 15 patients, 87% were f ound to have musculotendinous and less often osseous anomalies comprom ising primarily the lower trunk of the brachial plexus. Long-term foll ow up demonstrated very good pain relief (based on patients' estimates ) only in 47% of the operated patients and 20% of the conservatively t reated patients. Reoperation was necessary in six cases through a supr aclavicular decompression with only one patient experiencing substanti al improvement with long-term follow-up. The difficulties in diagnosis as well as reasons for failures of conservative and surgical manageme nt are discussed, and the authors' current protocol for diagnosis and management is presented.