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Requisites to be met before elective surgery for thoracic outlet syndrome

Carlos A Selmonosky, M.D. FACS, FACCP, FACC, AAFP.

Surgery for persistent disabling symptoms of TOS should be performed when other forms of therapy have failed. Depression, preexistent or secondary to chronic pain, should be ruled out in all patients and treated, and also small vessels disease of the hands and fingers.

The diagnosis has to be certain, symptoms of TOS are many, but not all need to be present. Symptoms of anginal chest pain or non-cyclical breast pain, shoulder and neck pain, dizziness, and headaches are seldom attributed to TOS by the examining physician.

The physical examination should be pertinent, including the Selmonosky Diagnostic Triad (SDT) it has to be reported as being present or not. The validity of this triad rest in the fact that is not present in any other diseases or syndromes, and will allow the health provider to assess if the patient symptoms are due to TOS. The SDT consist of 1) Weakness of the pulp pinch strength between the thumb and the fifth finger as compared with the pulp pinch strength between the thumb and the index finger. 2) tiredness and or tingling and or numbness associated or not with paleness of the hand on elevation of the upper extremities( as shown in the Selmonosky position maneuver), associated or not with paleness of the hand or hands, marked paleness of the hand or hands, cadaveric in appearance is called the White Hand Sign. 3) Tenderness on thumb pressure on the  supraclavicular area.

A plain cervical spine  chest X rays should be examined in all patients, the lengthening, enlargement or deformity of the transverse apophysis of the 7th cervical vertebra should be reported. These anomalies are  frequently present in TOS patients, together with an evident verticality and enlargement of the anterior arch of the first rib; to rule out also cervical ribs or other pathologies of the chest and cervical spine.

If the SDT is not clearly present, diagnostic imaging confirmation of the neurovascular compression should be obtained by means of MRI angio or MRI neurography.

Arterial compression always should be clearly documented with standardized positional pneumatic or photo plethysmographic studies of the upper extremities. This is important because postoperatively the same tracings should be repeated to objectively asses if the positional arterial compression has been eliminated with the surgery, The positional venous compression can be verified by means of the simple observations of the upper extremities vein enlargement or, when necessary, documented together with the arterial positional compression by means of a ultrasound study of the subclavian vessels. Arteriography or phlebography are exceptionally required for this purpose, electrical neurological tests do not contribute to the usual TOS diagnosis, and they are of value only in cases with obvious  neurological complications.

The surgeon has to be experienced in the diagnosis, management and surgery of TOS. The patient should and must ask the surgeon “How many operations for TOS have you done” and “What are your results”. Established surgeons will not have any problems answering these patient’s essential questions. The results of the surgery are very good in competent hands, but serious complications can occur in the best of hands and the surgeon should discuss them with the patient.

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