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Am Fam Physician. 2021;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

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.

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Email letter submissions to afplet@aafp.org. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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