THORACIC OUTLET SYNDROME - FACT OR FANCY - A REVIEW OF 409 CONSECUTIVE PATIENTS WHO UNDERWENT OPERATION

OBJECTIVES: From an analysis of patients operated on by a single surge on between 1973 and 1994 for thoracic outlet syndrome (TOS), to determ ine what findings are helpful in substantiating this diagnosis and wha t are the results of decompressive thoracic outlet surgery in the mana gement of TOS. DESIGN: A chart review with emphasis on signs, symptoms and results. A preoperative questionnaire was presented to all patien ts operated on since 1989. Postoperative follow-up was by interview or telephone. SETTING: A 560-bed university-affiliated tertiary-care tea ching hospital. PATIENTS: There were 409 adults; 83% were women and th e average age was 36 years. In 95% of patients physiotherapy had been unsuccessful. Patients presented with neurologic type (368 [(90%]), ar terial impingement (29 [7%]) and venous obstructive symptoms (12 [3%]) . The series included 44 patients with bilateral symptoms and 26 patie nts with cervical ribs. Some form of litigation or compensation was as sociated with 177 patients. INTERVENTIONS: Transaxillary first rib res ection in 380 (93%) patients and supraclavicular thoracic outlet decom pression in 29 (7%). In 244 patients there was a follow-up of at least 2 years. These patients constituted the follow-up group. RESULTS: Pre operatively, in the 368 patients who had neurologic TOS, 99% displayed supraclavicular brachial plexus tenderness and 98% exacerbation of sy mptoms with arms in the abduction external rotated position. There wer e eight complications of surgical intervention (1.9%). In the follow-u p group, there were no deaths, no subclavian/axillary artery or vein d amage and no brachial plexus injury. Seventy-eight percent of the pati ents with neurologic TOS in this group improved postoperatively; 21% h ad complete relief, 32% had good relief and 25% had fair relief. Twent y-two percent showed no improvement. CONCLUSIONS: Signs and symptoms h elpful in making the diagnosis of neurologic TOS are supraclavicular t enderness on palpation and exacerbation of symptoms with the arms in t he abducted external rotated position. The surgical procedures are saf e. Patients with TOS refractory to medical management can benefit from thoracic outlet decompression.