NTOS for the Primary Care Team: When to Consider the Diagnosis?
Thoracic outlet syndrome (TOS) is a real but uncommon syndrome, and, as a result diagnosis is often delayed and referral to a specialist frequently comes later than the patient and physician would like. It is actually a spectrum of diseases, potentially i
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NTOS for the Primary Care Team: When to Consider the Diagnosis? Karl A. Illig and Dean M. Donahue
Abstract
Thoracic outlet syndrome (TOS) is a real but uncommon syndrome, and, as a result diagnosis is often delayed and referral to a specialist frequently comes later than the patient and physician would like. It is actually a spectrum of diseases, potentially involving the arteries, veins, or nerves (and these usually occur separately). By far the most common is neurogenic TOS (NTOS). This can be thought of as a chronic compressive brachial plexus problem – essentially a chronic compartment syndrome of the brachial plexus. Considerable controversy and confusion exists regarding this problem. The entity is also associated with a high incidence of insurance claims, workman’s compensation issues, and litigation. For these reasons and more, the current role of the primary care physician is probably identification that this problem potentially exists and referral to an interested and competent specialist. In general, a putative diagnosis depends on three things: proper history, suggestive physical examination, and absence of obvious alternative diagnoses. An example of the first is a patient who complains of shoulder, neck, head, chest and arm problems with activity, elevation, or dangling, the second one with supraclavicular or infraclavicular tenderness, and the third absence of obvious cervical disk, rotator cuff, or carpal tunnel pathology. If these general findings are present, referral to a specialist is indicated.
K.A. Illig, MD (*) Department of Surgery, Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, STC 7016, Tampa, FL 33606, USA e-mail: [email protected] D.M. Donahue, MD Department of Thoracic Surgery, Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114, USA e-mail: [email protected]
Introduction Thoracic outlet syndrome (TOS) is a real but uncommon syndrome, and, as a result, diagnosis is often delayed and referral to a specialist frequently comes later than the patient and physician would like. It is actually a spectrum of diseases, potentially involving the arteries, veins,
K.A. Illig et al. (eds.), Thoracic Outlet Syndrome, DOI 10.1007/978-1-4471-4366-6_5, © Springer-Verlag London 2013
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K.A. Illig and D.M. Donahue
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or nerves (and these usually occur separately). By far the most common is neurogenic TOS (NTOS). This can be thought of as a chronic compressive brachial plexus problem – essentially a chronic compartment syndrome of the brachial plexus. Such compression can occur at the scalene triangle, pectoralis minor insertion site, or both. Considerable controversy and confusion exists regarding this problem – for example, there has not been a multi-author textbook on this topic until now. The entity is also associated with a high incidence of insurance claims, workman’s compensation issues, and litigation. For these reasons and more, the current role of the primary care physician is probably identification that this
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