New Classification TOS
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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.

                                        

 

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