Clinical ResearchThe Incidence of Thoracic Outlet Syndrome
Introduction
Thoracic outlet syndrome (TOS) refers to a constellation of compressive problems that occur at the thoracic outlet. Although overlap exists, three separate types of thoracic outlet syndrome are described: compression of the nerves (brachial plexus) at the scalene triangle and/or retropectoral space produces neurogenic thoracic outlet syndrome (NTOS), compression of the vein at the anterior costoclavicular junction produces venous thoracic outlet syndrome (VTOS), and compression of the artery by the first or cervical rib leading to organic damage to it produces arterial thoracic outlet syndrome (ATOS).1 In addition, patients with ipsilateral arteriovenous access can develop a form of VTOS, likely because of the high flow created through the vulnerable vein in this situation.2
TOS has been recognized since the 19th century, and the “modern” era of treatment, especially for NTOS, dates from at least the 1970s. Despite this, however, the incidence and prevalence of these syndromes are almost completely unknown. To be fair, several factors contribute to this, including the very subjective nature of the problem and resultant lack of consensus as to diagnosis, poor physician awareness and thus recognition, and the very fuzzy line between physiologic brachial plexus compression and the true syndrome. Several authors have attempted to determine incidence and prevalence, and identify the ratio between each disorder, but such reports either rely on very old, suspect data and opinion,3 or are analyses of operative cases only based on sampling data.4,5 To attempt to answer this fundamental question, we established a prospective database of all patients who presented to our clinic with a diagnosis of potential TOS, as described below.
Section snippets
Methods
We established a database of all patients referred to our clinic from July 1, 2014, to May 18, 2018. As much information as possible, including all demographic and clinical information, scoring information, and tentative diagnosis and plan at the time of the office visit was prospectively recorded. Patients were evaluated at the University of South Florida's Vascular Surgery Clinic.
NTOS: A standardized workup sheet was used for patients with potential neurogenic TOS (Fig. 1), based on the
Results
From July 2014 to May 18, 2018, a time span of 47 months, a total of 526 patients were referred to our institution with a diagnosis of possible TOS (Table I). Of these, 432 (82%) were referred with symptoms suggestive of NTOS (proximal pain and distal neurologic compromise), 84 (16%) with symptoms suggestive of VTOS (axillosubclavian thrombosis or positional swelling), and 10 (2%) with findings and/or symptoms suggestive of ATOS (objective arterial pathology). 31 patients (6%) presented with
Discussion
It has been surprisingly difficult to determine the actual incidence (and prevalence) of thoracic outlet syndrome, especially neurogenic. First, diagnostic criteria have been difficult to determine, so much so that the existence of NTOS has been disputed in the past.9,10 Second, virtually all reports describe outcomes of those actually treated, and do not discuss this topic based on initial referrals. For example, two recent studies documented the “rates” of NTOS:VTOS:ATOS to be 97:3:14 and
Conclusions
The incidence of TOS is entirely unknown, and prior estimates have very poor face validity. After prospectively recording all patients who were referred to our clinic, we estimate the ratio of those with likely NTOS to VTOS to be approximately 80:20, although because most patients with VTOS are operated on, the rates of operation for NTOS to VTOS drops to 75:25 (ATOS being sporadic). Further, by estimating the numbers of patients referred within our catchment area, we feel the incidence of NTOS
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