Perspectives in Biology and Medicine

THORACIC OUTLET SYNDROME AND DYSFUNCTION OF THE TEMPOROMANDIBULARJOINT: PROVED PATHOLOGY OR PSEUDOSYNDROMES? DEWEY A. NELSON* Over the past 10 years, two disparate but strangely similar scientific struggles have been raging in medicine and dentistry. The various scientific disagreements spun off from these conflicts are the subject of this review, disputes that at first appear different because of the anatomical diversity of the syndromes involved. But they are indeed related by their historicity and by failed concepts of physiology. In addition, they are quite similar in the stridency and bitterness found in recent scientific publications concerning them, which will be described. Diseases to be discussed are the thoracic outlet syndrome (TOS), first described by Murphy in 1910 [1], and dysfunction of the temporomandibular joint (TMJ), first described by Costen in 1934 [2]. The signs and symptoms of TOS are said to emanate from the superior thoracic aperture and are produced by congenital anomalies, injuries , and poor posture; they are also brought on by various arm motions or circulatory deficiencies where the neurovascular bundle arches over the first rib. By comparison, TMJ refers to any number of painful signs and symptoms localized in or near the temporomandibular joint, its capsule and menisci, muscles of chewing, scalp and cervical muscles, and cranial as well as cervical nerves. The clinical descriptions of both syndromes changed significantly over 50 years, as variegated types were appended to the original clinical pictures. Although the importance of these two diseases pales when compared with cancer and vascular disease, about 25 percent of patients who attend pain clinics have TOS or TMJ coexisting as their chief complaints. In addition, the frequency of these syndromes is rapidly increasing in *Professor of Neurology, Thomas Jefferson Medical College, 1025 Walnut Street, Philadelphia , Pennsylvania 19107. Mailing address: 48 Omega Drive, Omega Professional Center , Newark, Delaware 19713.© 1990 by The University of Chicago. AU rights reserved. 003 1-5982/90/3304-0676$0 1 .00 Perspectives in Biology and Medicine, 33, 4 ¦ Summer 1990 | 567 most neurological and dental practices. It is important to review these two together because many thousands of patients are unfortunately caught in the middle of present-day vindictive and vituperative medical and dental conflicts—scientific disagreements that have divided many neurologists from thoracic and vascular surgeons, and quarrels that have divided some neuroscientists (including psychologists and psychiatrists ) from dentists and dental surgeons. Just what are the major points of strife and disagreement? They are that some basic diagnostic tests have been factitious laboratory simulations, that oral tricyclic therapy is more efficacious than surgery, that surgical complication rates are so serious that there should be a moratorium on operations, that postoperative examination results are much more sanguine when reported by a surgeon (as compared with a medical neurologist), and that one of the major predictors of poor prognosis is surgery itself. These divergent opinions are now appearing in the media; this has encouraged patients to ask their physicians some very hard and cogent questions. It is obvious that, from the viewpoint of patients facing surgery (with unusually high failure rates) or from the viewpoint of surgeons who are just beginning to understand the controversy, the conflicts are very real indeed. Recently, a new phenomenon and a new disease have been added to these unsettled issues. Neurologists are seeing large numbers of patients with cervical and lumbar strain as well as TOS, to which TMJ has been later appended by various referring individuals. This recent trend is interesting because a diagnosis of TMJ is usually added to minor injuries 6-12 months after the "whiplash" or the TOS, and many diagnoses are first made by physical therapists and persons other than physicians or dentists. In most major population centers clinics have appeared that are devoted to treating a new disease, "TMJ-Whiplash." These clinics are run by "TMJ orthopedists" who teach that nearly every type of accident can produce an immediate or delayed syndrome in or near the jaw or neck. These dentists also claim that accidents (usually minor rear-end collisions) produce syndromes over wide anatomical regions of all parts of the cranium and spine, that the injuries are usually permanent, and that the damage can be "proved" by a...