A NEW CLASSIFICATION OF THORACIC OUTLET SYNDROME
Carlos A. Selmonosky,MD FACS Raul Poblete Silva,MD FACS
The lack of a uniform classification of the symptoms and signs of thoracic outlet syndrome has resulted in general confusion about the meaning of the terms used to define thoracic outlet syndrome and the numerous approaches to its diagnosis.
Dr. Wehbe, editor of the Hand Clinic, dedicated to thoracic outlet syndrome in 2004, stated, “there are as many ways to diagnose thoracic outlet syndrome as surgeons treating them.”(1)
The diagnosis of TOS as reported in the medical literature lacks a standardized set of signs and symptoms; it is the most common overlooked and misdiagnosed peripheral entrapment neuropathy; an a diagnostic gold standard accepted by the majority of physicians is not available. (2-26)
The description of TOS as Types in the medical literature are: Neurogenic TOS, Arterial TOS, Venous TOS, True Neurogenic TOS, Disputed TOS, Nonspecific TOS, Common TOS.
The description of TOS as types, Neurogenic, Arterial, and Venous in the medical literature is that they are well defined and distinct. (24, 27-30, 33). This is in contradiction with the above statements about the difficulty of diagnosing TOS.
The problem is that the classification in types is not a classification of symptoms and signs of TOS but of their neurogenic, arterial and venous complications. In addition, the types are not so well outlined and specific, the symptoms and signs are mixed among these three types.(5,11,29,22,31-42)They should be called Predominant Neurogenic, Arterial, or Venous.(37)
Before the complications of TOS occurs, as shown in the description of symptoms and signs in the old classification, there is a period where uncomplicated TOS is misdiagnosed. Delay from symptoms to diagnosis are reported in the medical literature to be from three months to 15 years (7, 33, 43-59).
The reason for this classification of TOS is to allow the Primary Care Physicians to diagnose the Uncomplicated Form by using a diagnostic triad (60-62) and a pertinent physical examination. The early diagnosis of TOS will likely reduce the incidence of complications and improve the quality of life for many
According to these considerations a new classification of TOS is proposed, there are two forms of TOS, one is the Uncomplicated Form and the other is the Complicated Form
The Uncomplicated Form it is the most common and previously called: Disputed TOS, Nonspecific TOS, Common TOS, it the most undiagnosed, or misdiagnosed.
The Uncomplicated Form should also be divided in Predominant Neurogenic, Predominant Arterial, and Predominant Venous types. Again, when one of the types is diagnosed , the other two should be ruled out.
The Uncomplicated Form can present with a broad spectrum of symptoms, for mild-to-severe pain, with the mildest form having positional paresthesias as the only symptom. The symptoms are frequently intermittent and oscillating.
The Complicated Form is easy to diagnose, but too late, the symptoms and signs of the Complicated Form TOS are easily noted.Atrophy of the muscles of the hands; marked weakness of the hands in the Neurogenic type. Non-positional ischemia of the fingers and hands, thrombosis And or embolism of the arteries of the upper extremities, subclavian aneurysm, and cerebral embolism ,are symptoms of Arterial TOS. Venous thrombosis of the subclavian/axillary veins, Paget-von Schrötter syndrome, these are the signs and symptoms of the Venous type.
Pain and paresthesias of the upper extremities are common in the three types. Shoulder, neck, and chest pains, facial pain, and occipital headaches are usually ignored symptoms in the Predominant Neurogenic type, both in the Uncomplicated or Complicated Forms.
1)Wehbe MA. Preface. Thoracic outlet syndrome. Hand Clin 2004; 20, x1.
2)Sanders RJ, Haug CE, Eds. Thoracic outlet syndrome: a common sequela of neck injuries. Philadelphia: Lippincott; 1991; 71-84.
3)Novak CB, Mackinnon SE, Patterson GA. Evaluation of patients with thoracic outlet syndrome. J Hand Surg [Am] 1993; 18:292-299.
4)Nakatsuchi T, Smitoh S, Hosaka M, Matsuda S. Conservative treatment of thoracic outlet syndrome using an orthosis. J Hand Surg 1995; 20B:34-39.
5)Sanders RJ. Results of the surgical treatment for thoracic outlet syndrome. Semin Thorac Cardiovasc Surg 1996; 8:221-228.
6)Atasoy E. Thoracic outlet compression syndrome. Orthop Clin North Am 1996 Apr; 27(2):265-303.
7)Gockel M. Operative treatment of thoracic outlet syndrome in Finland. Ann Chir Gynaecol 1996; 85(1):59-61.
8)Beer S, Schlegel C. Hasegawa A. Conservative therapy in thoracic outlet syndrome. Literature review and pathogenetic considerations. Schweiz Med Wochenschr 1997; 127:617-622.
9)Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using electrophysiologically guided anterior scalene blocks. Ann Vasc Surg 1998;12:260-264.
10)Binham DH. TOS is a misunderstood and potentially devastating problem. Neb Med J 1998 May; 79(5):145-50.
11)Edwards DP, Mulkem E, Raja AN, Barker P. Transaxillary first rib excision for thoracic outlet syndrome. J R Coll Surg Edim 1999 Dec; 44:362-5.
12)Donaghy M, Matkovic Z, Morris P. Surgery for suspected neurogenic thoracic outlet syndromes: a follow up study. J Neurol Neurosurg Psychiatry 1999 Nov; 67(5):602-6.
13)Remy-Jardin et al. Helical CT angiography of thoracic outlet syndrome: functional anatomy. AJR 2000 Jan; 174:1667-1674.
14)Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001; 12:295-309.
15)Cooke RA. Thoracic outlet syndrome – aspects of diagnosis in the differential diagnosis of hand-arm vibration syndrome. Occup Med (Lond) 2003 Aug; 53(5):331-6.
16)Novak CB. Thoracic outlet syndrome. Clin Plast Surg 2003 Apr; 30(2):175-88.
17)Leffert RD. Complications of surgery for thoracic outlet syndrome. Hand Clin 2004; 20:91-98.
18)Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome. Hand Clin 2004; 20:27-36.
19)Atasoy E. History of thoracic outlet syndrome. Hand Clin 2004; 20:15-6; v.
20)Haung JH, Zager EL. Thoracic outlet syndrome. Neurosurgery 2004 Oct; 55(4):897-903.
21)Tolson TD. “EMG” for thoracic outlet syndrome. Hand Clin 2004; 20:37-42, vi.
22)Molina JE, D’Cumha J. The vascular component in neurogenic arterial thoracic outlet syndrome. J Angiol 2008; 17(2):83-87.
23)Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. Neurologist 2008 Nov; 14(6):365-73.
24)Atasoy E. A hand surgeon’s further experience with thoracic outlet compression syndrome. J Hand Surg Am 2010 Sep; 35(9):1528-38.
25)Boezaart AP, Haller A, Laduzenski S, Koyyalamudi, VB, Ihnatsenda B, Wright T. Neurogenic thoracic outlet syndrome: A case report and review of the literature. Int J Shoulder Surg 2010 Apr; 4(2):27-35.
26)Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev 2010 Jan 20; (1):CD007218.
27)Pollak EW, ed. Thoracic outlet syndrome: diagnosis and treatment. Mount Kisco, NY: Futura Publication Company; 1986.
28)Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg 2007 Sep; 46(3):601-4.
29)Brooke BS, Freischlag JA. Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol 2010 Nov; 25(6):535-40.
30)Frugate MW, Freischlag JA. Thoracic outlet syndrome. ACS Surgery. Principles and practice. Thoracic 2010; Chapter 9:10-11.
31)Brown H, Smith RA. First rib resection for neurovascular syndromes of the thoracic outlet. Surg Clin. NA 1974 Dec; 54(6):1277-1289.
32)Wilhelm A, Wilhelm F. Thoracic outlet syndrome and its significance for surgery of the hand (on the etiology and pathogenesis of epicondylitis, tendovaginitis, median nerve compression and trophic disorders of the hand). Handchir Mikrochir Plast Chir 1985; 17:173-187.
33)Sellke FW, Kelly TR. Thoracic outlet syndrome. Am J Surg 1988; 156:54-57.
34)Mailis A, Papagapiou M, Vanderlinden RG, Campbell V, Taylor A. Thoracic outlet syndrome after motor vehicle accidents in a Canadian pain clinic population. Clin J Pain 1995; 11:316-324.
35)Pang D, Wessel HB. Thoracic outlet syndrome. Neurosurgery 1998; 22:105-121.
36)Axelrod DA, Proctor MC, Geisser ME, Roth RS, Greenfield LJ. Outcomes after surgery for thoracic outlet syndrome. J Vasc Surg 2001; 33:1220-1225.
37)Poblete Silva R. Results of surgery of the thoracic outlet syndrome. Critical point on reoperation. Chilean J Surg 2002 Dec; 54(6):566-572.
38)Urschel HC, Patel A. Thoracic outlet syndrome. Curr Treat Options Cardiovasc Med April 2003; 5(2):163-168.
39)Degeorges R, Reynaud C, Becquemin JP. Thoracic outlet syndrome surgery: Long-term functional results. Ann Vasc Surg 2004; 18:558-565.
40)Sanders RJ, Hammond SL. Subclavian vein obstruction without thrombosis. J Vasc Surg 2005; 41:285-290.
41)Lan MY, Chang YY, Liu JS. Postural compression of subclavian vein in droopy shoulder syndrome. Angiology 2006; 57:387-389.
42)Criado E, Berguer R, Greenfield L. The spectrum of arterial compression at the thoracic outlet. J Vas Surg 2010 Aug; 52(2)406-11.
43)Lawrence MS, Rossi NP, Tidrik RT. Thoracic outlet compression syndrome. J. Iowa Med Soc 1967 Jun; 62(6):561-66.
44)Jamieson WG, Merskey H. Representation of the thoracic outlet syndrome as a problem in chronic pain and psychiatric management. Pain 1985 Jun; 22(2):195-200.
45)Hendler NH, Kozikowski JG. Overlooked physical diagnoses in chronic pain patients involved in litigation. Psychosomatics 1993 Nov-Dec; 34(6):494-501.
46)Poole GV, Thomae KR. Thoracic outlet syndrome reconsidered. Am Surg 1996 Apr; 62(4):287-91.
47)Schelo C, Kroger K, Hinrichs A, Rensing N, Rudofsky G. Ischemia of the arm with finger necroses: differential carpal tunnel syndrome and thoracic outlet syndrome diagnosis. Vasa 1997 Nov; 26(4):311-3. Review. German.
48)Nehler MR, Taylor LM Jr, Moneta GL, Porter JM. Upper extremity ischemia from subclavian artery aneurysm, caused by bone abnormalities of the thoracic outlet. Arch Surg 1997 May; 132(5):527-32.
49)Roos DB. Thoracic outlet syndrome is underdiagnosed. Muscle Nerve 1999 Jan; 22(1):126-9; discussion 137-8.
50)Tekaya R, Neji O, Mahfoudhi M, Ben Hadj Yahia C, Abdelmoula L, Chaabouni L, Zouari R. Thoracic outlet syndrome. Tunis Med 2001 Nov; 89(11):809-13.
51)Athanassiadi K, Kalvarouziotis G, Karydakis K, Bellenis I. Treatment of thoracic outlet syndrome: long-term results. World J Surg 2001 May; 25(5):553-7.
52)Landry GJ, Moneta GL, Taylor LM Jr, Edwards JM, Porter JM. Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. J Vasc Surg 2001 Feb; 33(2):312-7; discussion 317-9.
53)Pascarelli EF, Hsti YP. Understanding work related upper extremity disorders: clinical findings in 486 computer users, musicians and others. J Occup Rehabil 2001 Mar; 11(1):1-21.
54)Greenberg SA. Neurological thoracic outlet syndrome. Neurology 2002 Jul 23; 59(2):E3.
55)Rochkind S, Shemesh M, Patish H, Graif M, Segev Y, Salame K, Shifrin E, Alon M. Thoracic outlet syndrome: a multidisciplinary problem without rib resection. Acta Neurochir Suppl 2007; 100:145-7.
56)Dragu A, Lang W, Unglaub F. Horch RE. Thoracic outlet syndrome: differential diagnosis and surgical therapeutic options. Chirurg 2009 Jan; 80(1):65-76.
57)Rigatelli G, Dellavvocata F, Ronco F. Patient foramen ovale-mania: an unusual case of misdiagnosis. Minerva Cardioangiol 2011 Dec; 59(6):613-6.
58)Figiel S, Dubuisson A. Two post-traumatic “Gilliatt-Sumner hands” from decompensation of thoracic outlet syndrome. Rev Med Liege 2011 Feb; 66(2):86-91.
59)Ioannou CV, Kafetzakis A, Kounnos C, Koukoumtzis D, Tavlas E, Kostas T. A delayed diagnosis that altered the professional orientation of an athlete with upper limb chronic arterial embolization. Med Sci Monit 2011 Dec 22; 18(1):CS1-3.
60)Selmonosky CA, Byrd R, Blood C, Blanc JS. Useful triad for diagnosing the cause of chest pain. South Med J 1981; 74:974-949.
61)Selmonosky CA. The white hand sign. A new single maneuver useful in the diagnosis of thoracic outlet syndrome. Southern Med Journal 2002; 85:557. Abstract.
62)Selmonosky CA, Poblete Silva R. The diagnosis of thoracic outlet syndrome. Myths and Facts. Chilean J of Surg 2008 June; 60(3):255-261.