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Chapter 30, When it is Not Cervical Radiculopathy: Thoracic Outlet Syndrome—A Prospective Study on Diagnosis and Treatment

J. Paul Muizelaar, M.D., Ph.D., and Marike Zwienenberg-Lee, M.D.

Many neurosurgeons see a large number of patients with some type of discomfort in the head, neck, shoulder, arm, or hand, most of which are (presumably) cervical disc problems. When there is good agreement between the history, physical findings, and imaging (MRI in particular), the diagnosis of cervical disc disease is easily made. When this agreement is less than ideal, we usually get an electromyography (EMG), which in many cases is sufficient to confirm cervical radiculopathy or establish another diagnosis. However, when an EMG does not provide too many clues as to the cause of the discomfort, serious consideration must be given to other painful syndromes such as thoracic outlet syndrome (TOS) and some of its variants, occipital or C2 neuralgia, tumors of or affecting the brachial plexus, and orthopedic problems of the shoulder (Table 30.1). Of these, TOS is the most controversial and difficult to diagnose.

Although the neurosurgeons Adson (1–3) and Naffziger (10,11) are well represented as pioneers in the literature on TOS, this condition has received only limited attention in neurosurgical circles. In fact, no original publication in NEUROSURGERY or the Journal of Neurosurgery has addressed the issue of TOS, except for an overview article in NEUROSURGERY (12). At the time of writing of this paper, two additional articles have appeared in Neurosurgery: one general review article and another strictly surgical series comprising 33 patients with a Gilliatt-Sumner hand (7). In one of the neurosurgical handbooks, the heading of TOS in the index only refers to the chapter on EMG where the condition is mentioned as occurring in conjunction with carpal tunnel syndrome (CTS), whereas four pages are devoted to cervical rib syndrome, hyperabduction syndrome, and costoclavicular syndrome, which are all part of TOS (9). In two newer neurosurgical textbooks, together containing over 4,200 pages, one and one half and four pages, respectively, are devoted to TOS (8, 9). Nevertheless, patients with pain in the neck and discomfort in the upper extremity are seen frequently by neurosurgeons. The surgical treatment of herniated cervical discs, CTS, and tardy ulnar neuropathy—all to be considered in the differential diagnosis of TOS—is practically "daily bread" for most neurosurgeons.

The aim of the present paper is to share the personal clinical experience of a single neurosurgeon with a referral practice for TOS with other neurosurgeons. Over a 3-year period, data for this paper were prospectively gathered on all patients referred with a suspected diagnosis of TOS or in whom the author seriously considered TOS in the differential diagnosis.

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