Purpose: Historically the classification of Thoracic Outlet Syndrome
(TOS) has been based on symptoms rather than the underlying pathology. Therefore,
TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter
Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion
among medical practitioners, difficulty in making the diagnosis, and the poor results
with surgical intervention. Methods: The published papers from PubMed on
the newer understanding of the pathogenesis and the surgical treatment of TOS were
reviewed. Results: More recently TOS has been classified based on the underlying
pathologic entity. Based on this classification, patients who are suspected of having
TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the
result of “Subclavian Vein Compression Syndrome”. This classification has resulted
in more accurate diagnosis, better patient selection for surgery, and excellent
surgical results. This paper outlines the algorithm for making the appropriate diagnosis
in patients who present with neurovascular symptoms of the upper extremity and the
selection of the appropriate patients for surgery. Conclusion: Based on the
algorithm for surgical decision making, patients with Cervical Rib Disease should
undergo cervical exploration and resection of the pathologic entity which results
in compression of the brachial plexus or the subclavian artery in the neck. Patients
with Thoracic outlet Syndrome who are found to have extrinsic compression of the
subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic
MRA should undergo robotic first rib resection.
References
[1]
Peet, R.M. (1956) Thoracic-Outlet Syndrome: Evaluation of a Therapeutic Exercise Program. Proceedings of the Staff Meetings of the Mayo Clinic, 31, 281-287. https://doi.org/10.1155/2014/248163
[2]
Freischlag, J. and Orion, K. (2014) Understanding Thoracic Outlet Syndrome. Scientifca (Cairo), 2014, 248163.
Peek, J., Vos, C., Ünlü, Ç., et al. (2016) Outcome of Surgical Treatment for Thoracic Outlet Syndrome: Systematic Review and Meta-Analysis. Annals of Vascular Surgery, 40, 303-326. https://doi.org/10.1016/j.avsg.2016.07.065
[5]
Falconer, M.A. and Li, F.W. (1962) Resection of the First Rib in Costoclavicular Compression of the Brachial Plexus. Lancet, 1, 59-63. https://doi.org/10.1016/S0140-6736(62)91716-6
[6]
Gharagozloo, F., Meyer, M., Tempesta, B., et al. (2012) Proposed Pathogenesis of Paget-Schroetter Disease: Impingement of the Subclavian Vein by a Congenitally Malformed Bony Tubercle on the First Rib. Journal of Clinical Pathology, 65, 262-266. https://doi.org/10.1136/jclinpath-2011-200479
[7]
Gkikas, A., Lampridis, S., Patrini, D., et al. (2022) Thoracic Outlet Syndrome:Single Center Experience on Robotic Assisted First Rib Resection and Literature Review. Frontiers in Surgery, 9, Article ID: 848972. https://doi.org/10.3389/fsurg.2022.848972
[8]
Gharagozloo, F., Meyer, M., et al. (2012) Robotic Enbloc First-Rib Resection for Paget-Schroetter Disease, a Form of Thoracic Outlet Syndrome: Tech-nique and Initial Results. Innovations, 1, 39-44. https://doi.org/10.1097/imi.0b013e3182542ab3
[9]
Gharagozloo, F., Meyer, M., Tempesta, B., et al. (2019) Robotic Transthoracic First Rib Resection for Paget-Schroetter Syndrome. European Journal of Cardio-Thoracic Surgery, 55, 434-439. https://doi.org/10.1093/ejcts/ezy275
[10]
Gharagozloo, F. and Meyer, M. (2022) Proposed Pathogenesis for a Subgroup of Patients with Neurogenic Thoracic Outlet Syndrome. Journal of Clinical Surgery and Research, 3, No. 4. https://doi.org/10.31579/2768-2757/045
[11]
Gharagozloo, F., Werden, S., Meyer, M., et al. (2022) Historic Basis for the New Developments in the Diagnosis and Treatment of Thoracic Outlet Syndrome (TOS). Clinical Surgery Journal, 1, 1-16.
[12]
Gharagozloo, F. and Meyer, M. (2022) Robotic Transthoracic First Rib Resection for Neurogenic Thoracic Outlet Syndrome. World Journal of Cardiovascular Surgery, 12, 1-11. https://doi.org/10.4236/wjcs.2022.121001
[13]
Kobayashi, S., Takeno, K., Miyazaki, T., et al. (2008) Effects of Arterial Ischemia and Venous Congestion on the Lumbar Nerve Root in Dogs. Journal of Orthopaedic Research, 11, 1533-1540. https://doi.org/10.1002/jor.20696
[14]
Ferrante, M.A. and Wilbourn, A.J. (1995) The Utility of Various Sensory Nerve Conduction Responses in Assessing Brachial Plexopathies. Muscle & Nerve, 18, 879-889. https://doi.org/10.1002/mus.880180813
[15]
Gharagozloo, F. (2022) Reevaluating the Pathogenesis and Classification of Thoracic Outlet Syndrome. Academia Letters, Article 5408. https://doi.org/10.20935/AL5408