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Consensus Recommendations for Diagnosis and Treatment of Neurogenic Thoracic Outlet Syndrome
Harvey W Chim, MD
1; Robert R Hagan, MD
2; INTOS Workgroup Members, MD
3
1Division of Plastic Surgery, University of Florida, Gainesville, FL; 2Neuropax, St. Louis, MO; 3Different Institutions, Different Cities, FL
Background: There is significant variation in methods used for diagnosis and treatment of neurogenic thoracic outlet syndrome (NTOS). The lack of definitions and criteria for diagnosis as well as controversy in treatment options hampers standardized reporting of outcomes. In the orthopedic and plastic hand surgery literature, there are not standardized guidelines to direct evidence-based practice for hand surgeons relating to NTOS. Hence, expert consensus may provide guidance for clinical practice.
Methods: An international workgroup of 21 expert hand surgeons with cumulative experience with 5519 NTOS surgeries was assembled. The Delphi method was used to arrive at consensus recommendations to guide diagnosis, treatment, surgery and postoperative management of patients with NTOS.
Results: The workgroup achieved majority (>75%) consensus with 17 statements. A modified version of the Society for Vascular Surgery (SVS) and Clinical Diagnostic Criteria (CDC) is recommended for diagnosis of NTOS. The elevated arm stress test (EAST) and Tinel's sign are recommended as provocative maneuvers. A cervical spine or chest radiograph should be routinely obtained preoperatively. Conservative management should be first line for NTOS, except in patients with significant muscle atrophy or weakness. An anterior supraclavicular approach is recommended for exposure of the supraclavicular brachial plexus, with the necessity for an additional infraclavicular approach or adjunctive surgeries indicated for specific patients.
Conclusions: Standardized consensus guidelines help to guide management of NTOS by specialized hand surgeons, with an aim towards standardizing criteria for diagnosis and treatment of patients as well as measures and tools used for research and reporting of outcomes.
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