PubMed · 8007310
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S Namikawa, M Kimura, M Kusagawa. 1994. [Chest wall deformity].. https://pubmed.ncbi.nlm.nih.gov/8007310/
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There are 5 syndromes involving the thoracic outlet. The first four, although not well known, especially the first two, are authentic; they are: 1) arterial, due to a well formed cervical rib or to an incompletely formed first rib; 2) neurological, related to the fibrous band associated with a rudimentary cervical rib or a giant transverse process of C7; 3) venous, namely "effort thrombosis"; 4) late post-traumatic, secondary to a fracture of the clavicle. The study of these four syndromes prepares the reader to that of the controversial fifth syndrome, which is entirely subjective, made only of symptoms. The fifth syndrome, by very far the most frequent in the literature, called "scalenus anticus syndrome" in the past, now called "thoracic outlet syndrome" or "TOS" by North-American authors, has two varieties, one where hypotonic shoulder muscles, mostly in women, respond well to specific and simple exercises, and one where there is an accident in the background, a whiplash type of injury in most cases. Despite the fact that TOS is made only of symptoms, "diagnosing" it has led to scores of operations, scalenotomy in the past, now mostly resection of the first rib, sometimes scalenectomy. Huge surgical statistics, that deal mostly with resection of the first rib, have not proven the authenticity of this second variety of the 5th syndrome. Surgeons report only early surgical results, and the results claimed are invariably impressive. Never is there a statistic about return to work after surgery. First rib resection can be dangerous and it can be complicated by tardy permanent brachial plexopathy. One very recent European study proves the discrepancy between the early appreciation of the results by the surgeon and the late appreciation by independent observers.
We have attempted throughout this review to identify the issues surrounding thoracic outlet syndrome as well as to highlight their origins. It should be clear that many aspects of TOS remain controversial from the definition of the entity through pathogenesis, diagnosis, and treatment. The conflicts surrounding TOS are underlined most poignantly in the many letters to the editor of the New England Journal of Medicine in response to Urschel's 1972 publication. It is incumbent upon those of us who treat patients with TOS to dispel the ignorance surrounding this syndrome with astute, accurate, and reproducible observations. We must clearly define TOS as a clinical entity such that we may analyze the characteristics of the patients we treat. We must continue to search for innovative and specific diagnostic criteria. We must quantitatively and reproducibly measure subjective end points of pain severity and quality of life. The use of these methods will provide yardsticks for therapeutic success and act as determinants for the natural history of TOS. The objectives of treatment will remain the alleviation of symptoms and the restoration of function. We have applied these principles to the formulation of a protocol in which we record, in a prospective manner, both routine and innovative clinical parameters. With quantification of subjective end points, we may be able to correlate clinical presentation with outcome. We also may be able to define with some accuracy this entity we call thoracic outlet syndrome.