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Clinical Judgment Remains the Most Important Tool in the Diagnosis of Neurogrenic Thoracic Outlet Syndrome
Colin P. Ryan, B.S.1, Nicolas J. Mouawad, M.D., M.P.H., M.B.A.2, Patrick S. Vaccaro, M.D., M.B.A.2, Michael R. Go, M.D.2.
1The Ohio State University College of Medicine, Columbus, OH, USA, 2The Ohio State University, Columbus, OH, USA.

OBJECTIVES: Diagnosis of neurogenic thoracic outlet syndrome (nTOS) can be difficult, yet appropriate patient selection is paramount to achieving good surgical outcomes. The utility of predictors of success including arterial Doppler studies (AD), nerve conduction velocities (NCV), electromyography (EMG), and physical therapy (PT) is unclear. We investigated whether preoperative AD, NCV, EMG, or PT predicted successful surgery.
METHODS: All patients undergoing surgery for nTOS at our institution from June 5, 2001 through December 31, 2013 were reviewed. Demographics, diagnostic workup details, and surgical outcomes were collected. Relief of symptoms was defined as complete (no residual symptoms), partial (improvement with some residual symptoms), temporary (initial improvement with relapse any time during follow-up), or none.
RESULTS: 121 first and/or cervical rib resections with scalenotomy/scalenectomy were performed on 93 patients for nTOS. 78.4% were female, mean age was 35.3, and mean follow-up was 54 weeks. 3.2% of patients had a family history of nTOS. 14% were athletes, 23.6% were unemployed or disabled, 29.0% were sedentary workers, and 30.1% performed frequent or repetitive overhead activity at work. Shoulder pain, numbness, and/or tingling were present in over 90% of cases while scalene tenderness was present in only 16.5%. In 40.5% of cases, patients were taking opioid medications preoperatively. Overall, complete or partial symptom relief occurred in 65.3% of cases. Preoperative AD was done in 44%, NCV and EMG in 53%, and PT in 95%. Test results as related to surgical outcomes are shown in Table I. EMG was associated with surgical outcome with statistical significance, but sample size was low; AD, NCV, and PT were not associated with surgical outcome.
CONCLUSIONS: In properly selected patients, surgery for nTOS offers acceptable success rates, but preoperative diagnosis remains difficult. In this retrospective contemporary series, outcomes of preoperative AD, NCV, and PT were not associated with symptom relief after surgery. Clinical judgment remains the most important tool in the diagnosis of nTOS.
Test (Total Number of Cases in which Test was Done)Test ResultComplete or Partial Relief of Symptoms After Surgery (% of Complete or Partial Relief)Temporary or No Relief of Symptoms After Surgery (% of Temporary or No Relief)P
arterial Doppler (53)+29 (72.5)10 (76.9)1
-11 (27.5)3 (23.1)
NCV (64)+13 (32.5)6 (25.0).5249
-27 (67.5)18 (75.0)
EMG (64)+8 (20.0)0 (0.0).0207
-32 (80.0)24 (100.0)
physical therapy (115)+30 (40.0)23 (57.5).0730
-45 (60.0)17 (42.5)

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