Letters to the Editor

Thoracic Outlet Syndrome Is Typically Not an Urgent Condition

 

Am Fam Physician. 2021 Mar 1;103(5):261.

Original Article: Neck Pain: Initial Evaluation and Management

Issue Date: August 1, 2020

See additional reader comments at: https://www.aafp.org/afp/2020/0801/p150.html

To the Editor: In Table 1 of their article, Drs. Childress and Stuek list findings that warrant urgent evaluation in patients with neck pain, including thoracic outlet syndrome. No physical examination findings have high sensitivity or specificity for thoracic outlet syndrome. The Roos test has poor predictive value and a high false-positive rate; consequently, some researchers have indicated that it should be abandoned.1

The table also implies that all thoracic outlet syndrome presentations warrant “urgent evaluation.” This is not the case. Thoracic outlet syndrome can be neurologic, arterial, or venous. The overwhelming majority of thoracic outlet syndrome is neurogenic, with only 1% of all thoracic outlet syndrome presentations consisting of potential limb-threatening etiologies, which are mostly embolic or thrombotic.2 Most of these presentations are seen in individuals with cancer and in persons who have recently had invasive vascular procedures.3

In most cases, thoracic outlet syndrome is diagnosed after more common diagnoses have been ruled out (e.g., cervical radiculopathy, shoulder impingement, upper extremity nerve entrapment).4 When diagnostic testing is warranted for embolic or thrombotic thoracic outlet syndrome, the test of choice is duplex ultrasonography. Magnetic resonance imaging, which is listed in the table as an option, is a poor screening test but has more utility for surgical planning.5

Author disclosure: No relevant financial affiliations.

References

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1. Hixson KM, Horris HB, McLeod TCV, et al. The diagnostic accuracy of clinical diagnostic tests for thoracic outlet syndrome. J Sport Rehabil. 2017;26(5):459–465....

2. Hussain MA, Aljabri B, Al-Omran M. Vascular thoracic outlet syndrome. Semin Thorac Cardiovasc Surg. 2016;28(1):151–157.

3. Ohman JW, Annest SJ, Azizzadeh A, et al. Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19. J Vasc Surg. 2020;72(3):790–798.

4. Kuhn JE, Lebus GF V, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015;23(4):222–232.

5. Hardy A, Pougès C, Wavreille G, et al. Thoracic outlet syndrome: diagnostic accuracy of MRI. Orthop Traumatol Surg Res. 2019;105(8):1563–1569.

In Reply: The response from Dr. Martin is fair and is an appropriate discussion about the true risks for thoracic outlet syndrome. Thoracic outlet syndrome includes a variety of potential etiologies that could manifest in similar symptoms. Our goal in mentioning the condition in our article was to maintain some vigilance in the differential diagnosis of neck pain, as some, albeit rare, patterns of neck pain and associated symptoms (that might prompt the question of thoracic outlet syndrome) could reflect these potentially limb-threatening conditions. We would agree that the far more common causes of this syndrome would not be classified as urgent. In the differential provided in Table 1 of our article, we did not subdivide this condition adequately to allow for the breadth of these salient points.

Author disclosure: No relevant financial affiliations.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.

 

 

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