Ann Thorac Surg 2003;75:1096
© 2003 The Society of Thoracic Surgeons
Invited commentary
Henning A. Gaissert, MD
Department of Surgery, Blake 1570 Fruit Street, Boston, MA 02114, USA
e-mail: hgaissert{at}partners.org
Nerve compression due to thoracic outlet syndrome (TOS) is now understood as one form of entrapment neuropathy of the upper extremity, recognizing the frequent coexistence with distal nerve compression in elbow and wrist. There is both widespread agreement that no individual neurophysiologic test can establish the diagnosis of TOS and disagreement about the indication and extent of operative decompression. The differences between skeptics and defenders of surgical therapy seem irreconcilable by current evidence. In a 1994 editorial in The Annals, Mackinnon outlined the concept of neurologic injury due to multiple crush and chronic nerve compression in TOS and proposed standards for reporting results [1]. On the occasion of another report on the surgical treatment [2], these standards deserve to be reiterated. Studies examining treatment should contain an analysis of risk factors including posture, repetitive stress, employment status, documentation of pain medication with self-report of pain before and after operation, and a complete diagnosis of cumulative trauma disorder. The purpose of detailed reporting is to replace the perceived vagueness of this syndrome with facts and data that operate within the multiple crush concept.
Balc
and colleagues performed first and cervical rib resections in 47 patients with TOS during a 15-year period. Over 90% of patients had neurologic symptoms. Complete postoperative relief of symptoms was observed during a mean follow-up of 4.6 years in 74.5%, including all cases of vascular entrapment, whereas 10.5% were improved and 15% were considered failures. Only 2 of 8 patients with TOS of traumatic origin showed improvement. An independent physician performed a follow-up examination in some patients. Outcome criteria for success or failure were not precisely defined, and ulnar nerve conduction results were given as group means only. A higher rate of failure is quoted following medical treatment alone in a separate, larger group of patients, which is not further explained. The authors are close to abandoning their tools of investigation when they state that "none of the preoperative tests used in this study seemed to be of important clinical value." There is a difference between an imprecise and an unimportant test. Balc and colleagues have demonstrated that the early results of rib resection are good in selected patients with TOS and find, as others before, deterioration after long-term observation. We continue to await prospective studies that examine first rib resection using Mackinnon’s standards over a sufficiently long period.
References
- Mackinnon S.E. Thoracic outlet syndrome. Ann Thorac Surg 1994;58:287-289.[Medline]
- Balc AE, Balc TA, Cakir Ö, Eren S, Eren MN. Surgical Treatment of thoracic outlet syndrome. Effect and Results of Surgery. Ann Thorac Surg 2003;75:1091–1096.
