[Jomar]

Thoracic outlet syndrome: rise of the conservative viewpoint - editorial
American Family Physician, June, 1991 by Michael Cherington

Thoracic Outlet Syndrome: Rise of the Conservative Viewpoint Thoracic outlet syndrome is one of the most controversial subjects in clinical medicine. In the past ten years, a growing number of authors have questioned many aspects of this syndrome, including the proposed methods of diagnosis and the value of surgery.
more here-
http://www.findarticles.com/p/articl...43/ai_10996849

[sawxray]

Dr. Cherington is a colleague of Asa Wilbourn at the Cleveland Clinic, both well-known for their out of proportion negative responses to TOS. I could quote you extensive articles regarding the ongoing battles between Wilbourn and Roos, but these two have a viewpoint definitely in the tiny minority of medical opinion.

And while there is controversy about aspects of TOS, dismissing a large number of patients by saying, "There is no such thing", and NOT having any alternative diagnosis, does not help patients in any way.

A few key points that Wilbourn and Cherington make:

1. There are no EMG abnormalities in patients with TOS
2. Surgery is done way too often (in their opinion), and therefore must be done only for profit
3. Very few patients with low-paying insurance receive this diagnosis (again, presumable in their opinion as a sign of sinister profit-taking by surgeons)
4. Surgery is only done in one major city (Denver), and is therefore invalid
5. Surgical outcome studies are biased

The counter to these arguments:

1. ALL compressive and entrapment neuropathies have normal EMG's early in the course of the disease. If you wait until the EMG is abnormal, there is a strong chance of permanent nerve damage. Additionally, EMG can not be done in the normal manner when examining a TOS patient, as one probe can not be placed on the proximal part of the nerve being tested (the brachial plexus). EMG abnormalities in other conditions, like carpal tunnel syndrome, can be placed on the nerve on both sides of the compression. Kline at LSU did measure some nerve conductions of the brachial plexus DURING SURGERY, and DID find the appropriate abnormalities.

2. Circular reasoning. Who determines how often surgery is appropriate? If one believes that TOS almost never occurs (a la Wilbourn and Cherington), then ANY surgery is too much. So they make one assumption, then the second merely because the surgery is too often for their first assumption. Weak logic, IMHO.

3. This happens in all of medicine. Patients with low-paying insurance don't get the same care as those with better insurance. The study needs to compare the difference in TOS (between good and bad insurance) with the differences seen in other procedures. Many other procedures are performed more often on patients with paying insurance. If these other procedures see the same differences as those in TOS surgery, than TOS is no different, and this point has no merit.

4. Actually, surgery is done in many, many cities. TOS patients are seen frequently at Harvard Medical School, University of California Los Angeles, University of California San Francisco, Washington University in St. Louis, University of Washington in Seattle, Johns Hopkins in Baltimore.....

Many highly-esteemed medical authorities evaluate these patients on a regular basis. And have published lots and lots of papers from these universities, and around the world. In fact, since the 1960's, over 1700 research papers have been published in peer-reviewed journals (that means that other medical experts say OK or NO to publishing the article), with over 450 articles in the last 10 years alone. Julie Freischlag, MD, who saw 800 patients a year at UCLA for evaluation of TOS, was selected to be the first woman Chair of Surgery at Johns Hopkins (which has won the Best Hospital in the US from US News and World Report for like 12 years in a row). No way Hopkins is going to take anyone but the best, someone with a peerless reputation.

5. Wilbourn and Cherington say that the surgeons who publish all these papers are biased, and recommend an independent panel to review the surgeons' findings before they publish. First, that sounds a lot like an accusation of academic dishonesty. Second, as above, peer-reviewed articles are scrutinized by other experts, so the chances of hundreds and hundreds of papers being faked is pretty remote. Third, nobody who publishes goes through anything like this, INCLUDING Wilbourn and Cherington. So they are trying to dismiss TOS by establishing a completely different standard of research than anyone else uses, INCLUDING Wilbourn and Cherington.


My opinion: They have an agenda, and don't mind leaving out the facts to forward that agenda. Critical reading lends a lot more credence to the existence of TOS, and much more commonly than some would have you believe.

My two cents.

[Donna7]

I noticed the article is 15 years old. I wonder if things have changed much in the last 15 years, and if the authors would have anything different to say now. Is the "conservative viewpoint" still on the rise? It seems to me most of what I've read has been written more recently, and that TOS is becoming a much less disputed diagnosis...treatment methods are still controversial, of course, but it seems from my research that TOS itself is more readily accepted as a valid diagnosis.

Any thoughts?

[johannakat]

FWIW I will add my two cents-
1. I agree with Donna, the artical is older.
2. Every TOS doctor I have seen thus far, ( 2 neurologists and 1 orthopedic, all pretty familiar with TOS) have told met hat PT is generally useless. Personally, think that partially because of a lot of PT's who are not familiar with TOS, but I think it is telling that every one of the dotors has told me the same about the PT.

Of course, I am still trying the PT, because if it works I think it is a better option than surgery
Johanna

[gibbrn]

article is now too old to be valid in my opinion the hand clinics disputes all of these arguments

Victoria

[Jomar]

Good comments-
and while it is an old article -
I'm afraid many general doctors still believe and practice this thinking on TOS - that's why I posted it. They are not up to date either.

[dabbo]

I'm with you Johanna - I'm trying PT, hoping that it will be the solution!
Jo - you're right that ALOT of Dr's are out of date on this. My Thoracic surgeon was lamenting the fact that we've known about "phantom" nerve injuries since around the Civil War, when there were alot of amputations, and guys would have horrible pains in the feet they didn't have. Since then, medical science has had HUGE knowledge gains (ie. penicillin, chemo, etc, etc,) but our knowledge of TOS, RSD/CPRS, etc is still minimal. He even went so far to say that too many Dr.'s don't "believe" in them. Not to ramble on, but i have a friend in PT school, and when I mentioned RSD, he kinda half-rolled his eyes. I guess some teacher had basically said he thought it was a BS Dx, or just a Dx of last resort. I assured him that it was, in fact, NOT BS, and that his teacher was wrong.

[johannakat]

wow, rolled his eyes at RSD?


Maybe you should send him to the RSD board to read some of those posts.

[gibbrn]

Hi guys,

This just goes to show you how antiquated information is used in today's practice. I find it disgusting that doctors snubb their noses at information that is well documented in articles that are very recent. Is well documented about RSD and thoracic outlet syndrome now and for someone to say that this is an incorrect diagnosis will that is frankly BS!!!

One of my physicians clearly explained to me that there is a problem with doctors who practice on their own. They do not have to interaction with other physicians to discuss new articles and updated information as it comes along. They also do not necessarily attend teaching sessions and learn about new diagnosis and new treatments..... not that either of these diagnosis are new....!!!!

I find it disturbing that we have to take the articles to educate the physicians who are supposed to be taking care of us. I have done this since the beginning of my TOS journey.... and will continue to do this, as well as making sure anyone who needs articles can take them to their physicians if they need to!!!

That's where I come in! I will be happy to lookup any article and have access to them through my Master University affiliation. I can usually get full articles, so anyone who needs them, please do not hesitate to ask

Love and hugs, Victoria

[gbsb]

Well said gibbrn (anybody seen a "thumbs up" emoticom here? )
While I feel I'm in pretty good hands, todays visit to the ortho surgeon further convinced me that surgeons/docs need more/new info regarding TOS.
I'm not one of those warm and fuzzy types falls for the "if it helps just one person/child it's all worth it" types. But......I really wish we could take folks from this forum and sit down with our docs to educate them with our experiences and the latest findings.
I'd be more than happy to put the effort into it if it'd help one person be relieved of the pain, stress, and uncertainty of this.