Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome

Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.