The Art of Caring in the Treatment of Thoracic Outlet Syndrome

Those who diagnose and treat patients with thoracic outlet syndrome, especially those patientswith neurogenic thoracic outlet syndrome, have a practice, which needs to include many modalities todiagnose, treat, and intervene to improve their quality of life for the present and for the future.[...].

Choosing the correct treatment, the correct timing of the treatment, and the succession to a different treatment for the patient with neurogenic thoracic outlet syndrome is the key for long-term success in alleviating symptoms for these patients [8]. These authors emphasize the need for a complete history and physical exam which will lead to the right intervention. They also outline the mainstay of the appropriate physical therapy protocol and the use of anterior scalene blocks.
The use of ultrasound in identifying anatomic variants in patients with thoracic outlet are described in detail by Leonhard and colleagues [9]. Utilizing both cadaver necks (82) and student subjects (22), brachial plexus variation was seen in 62.1% and 21%, respectively. Of the students, 50% had neurogenic thoracic outlet symptoms, which was higher than those with classic anatomy (14%). Ultrasonography can be helpful in diagnosis of neurogenic thoracic outlet syndrome, especially if provocative testing is negative.
The diagnosis and treatment of pectoralis minor syndrome is discussed in detail by Sanders and Annest [10]. This anatomical variant of thoracic outlet syndrome is rare but can be differentiated from neurogenic thoracic outlet syndrome by symptoms and physical exam, especially tenderness found in the axillary area. A pectoralis minor block can be used similarly to an anterior scalene block to make the diagnosis.
Utilizing a patient-centered care appraisal regarding symptoms before and after first rib resection, Ryan and colleagues tailor their diagnostic tests and intervention in patients with venous compression (McCleary's syndrome) or venous thrombosis [11]. Their findings in 59 patients, who underwent first rib resection and anterior scalenectomy, demonstrated no difference in outcome if the patient had received thrombolysis, or when the rib resection had been performed which matched similar findings by Guzzo and colleagues [12]. Their conclusion is that paying attention to patient symptoms and not just vein patency can lead to appropriate intervention in patients with venous thoracic outlet syndrome.
Peek and colleagues report on a retrospective multicenter study on patients who underwent operations for thoracic outlet syndrome from 2005 to 2016 [13]. Patients were assessed by the 11 item version of the QuickDASH questionnaire. Sixty-two patients were evaluated-36 neurogenic, 13 arterial, 7 venous, and 6 combined-and 73% returned the survey. Fifty-four percent (27) had complete relief and 90% had improvement. These findings were similar to previous findings by Chang [14] and Rochlin [15], when patients are chosen appropriately.
A unique report on high performance musicians who played bowed string instruments is presented by Adam and colleagues [16]. Sixty-four high performance musicians were evaluated and compared to 52 healthy volunteers with duplex scanning and provocative maneuvers. Duplex scans were abnormal in 69% of musicians showing compression, as compared to 15% of controls (p = 0.03), and provocative maneuvers were positive in 44% of musicians as compared to 3% of controls (p = 0.03). This alerts us to the high incidence of potential thoracic outlet syndrome in these musicians as many of us has seen and treated them.
An excellent summary of the present state of the art of diagnosis, treatment, and outcomes is presented by Povlsen and Polvsen [17]. They hypothesize that the ability to stratify patients according to their exact compressive mechanism could lead to better outcomes.
In summary, these 10 informative manuscripts provide a roadmap for the future excellent treatment of those patients with thoracic outlet syndrome.

Conflicts of Interest:
The author declare no conflict of interest.