Management of Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) refers to a group of com-plex symptoms in the upper extremity caused by compres-sion of the brachial plexus, the subclavian artery, and the subclavian vein between the interscalene triangle and the inferior border of the axilla. Patients complain of diffuse numbness, chronic pain of the head and neck, and pain and weakness of the upper extremities. Predisposing factors for TOS include exaggerated and repetitive motion, preexisting bone, muscle or tendinous anomaly. A traumatic event is described as a precipitating factor in 21% of TOS patients. The median age of patients is 29 years, more common in women. Neurogenic TOS comprises over 90% of cases in adults. The dominant symptoms are pain and paresthesias (88% and 83%, respectively) of the hand and forearm (especially ulnar nerve distribution). Vascular TOS is characterized by subclavian artery and vein complications, accounting for 1% to 10%. Disputed TOS is a category that embraces a multiplic-ity of vague organic and functional disorders of the upper limb, for which no other diagnosis has been reached. At the time of surgical intervention, median duration of symptoms is 24 months. Clinical outcomes following surgery show resolu-tion of pain and/or paresthesias in 50% to 60% of patients and partial response in 20% to 30%. Recurrence of symptoms were reported in 20% of the operated patients. The care-ful selection of patients for surgery by a coordinated team comprised of a neurosurgeon, vascular surgeon, radiologist, neurophysiologist, physical therapist and rehabilitation and pain management specialist can yield satisfactory results.