Thoracic outlet syndrome reconsidered.

During a four year period, 50 patients were evaluated for possible thoracic outlet syndrome (TOS). These 11 men and 39 women ranged in age from 27 to 60 years, with a mean age of 38.6 years. Their symptoms had been present from 3 months to 10 years (mean = 2.1 years). Twenty-seven had previously undergone 33 operations, including carpal tunnel release, shoulder arthroscopy, rotator cuff repair, cervical discectomy, and first rib resection, all without benefit. Patients were evaluated by history, physical examination, and radiographs of the cervical spine and chest. Additional studies such as electromyography/nerve conduction studies, computed tomography, magnetic resonance imaging, angiography, and myelography were obtained selectively. Only 12 patients were thought to have TOS, seven of whom underwent operation. Four had complete resolution of symptoms; three were improved but had residual symptoms for associated problems. Three patients who were not thought to have TOS underwent first rib resection in other hospitals; none was improved after surgery. The only study of positive value was evidence of unilateral subclavian artery compression with shoulder positioning on physical examination. All other studies were of value only if they demonstrated some other cause of the patient's symptoms. Of the 35 patients without TOS in whom long-term follow-up was obtained, four underwent appropriate operations with benefit, and 20 had good results from physical therapy and nonoperative management. Patients whose symptoms were work-related, and those who had engaged the services of a lawyer, were less likely to demonstrate improvement, regardless of the treatment employed. TOS is a relatively unusual cause of upper extremity pain and dysfunction. History and physical examination are the most important diagnostic studies, and radiographs of the chest and cervical spine and electromyography/nerve conduction studies are useful to identify other causes of pain and disability. Careful selection of patients for surgery can yield satisfactory results. A coordinated team of surgeons, neurologists, and physical therapists is important in the management of these patients.