THORACIC OUTLET SYNDROME RECONSIDERED

During a four year period, 50 patients were evaluated for possible tho racic outlet syndrome (TOS), These 11 men and 39 women ranged in age f rom 27 to 60 years, with a mean age of 38.6 years. Their symptoms had been present from 3 months to 10 years (mean = 2.1 years). Twenty-seve n had previously undergone 33 operations, including carpal funnel rele ase, shoulder arthroscopy, rotator cuff repair, cervical discectomy, a nd first rib resection, all without benefit. Patients were evaluated b y history, physical examination, and radiographs of the cervical spine and chest. Additional studies such as electromyography/nerve conducti on studies, computed tomography, magnetic resonance imaging, angiograp hy, and myelography were obtained selectively. Only 12 patients were t hought to have TOS, seven of whom underwent operation. Four had comple te resolution of symptoms; three were improved but had residual sympto ms for associated problems. Three patients who were not thought to hav e TOS underwent first rib resection in other hospitals; none was impro ved after surgery. The only study of positive value was evidence of un ilateral subclavian artery compression with shoulder positioning on ph ysical examination. All other studies were of value only if they demon strated some other cause of the patient's symptoms. Of the 35 patients without TOS in whom long-term follow-up was obtained, four underwent appropriate operations with benefit, and 20 had good results from phys ical therapy and nonoperative management. Patients whose symptoms were work-related, and those who had engaged the services of a lawyer, wer e less likely to demonstrate improvement, regardless of the treatment employed. TOS is a relatively unusual cause of upper extremity pain an d dysfunction. History and physical examination are the most important diagnostic studies, and radiographs of the chest and cervical spine a nd electromyography/nerve conduction studies are useful to identify ot her causes of pain and disability. Careful selection of patients for s urgery can yield satisfactory results. A coordinated team of surgeons, neurologists, and physical therapists is important in the management of these patients.