NTOS for the primary care team: When to consider the diagnosis?

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.