|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 3 | Page : 346-347
Surgical treatment of thoracic outlet syndrome
Ridvan Alimehmeti, Florian Dashi, Mithat Demneri, Mentor Petrela
Service of Neurosurgery, University Hospital Center "Mother Theresa", Tirana, Albania
|Date of Web Publication||5-Jul-2013|
Service of Neurosurgery, University Hospital Center "Mother Theresa", Dibra Street, 370, Tirana, Albania, Southeastern Europe
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Alimehmeti R, Dashi F, Demneri M, Petrela M. Surgical treatment of thoracic outlet syndrome. Med J DY Patil Univ 2013;6:346-7
We would like to make some observations with reference to the interesting article of Mohamed et al.  and share our experience which we think, would complete the conclusions of the article on this specific topic.
Thoracic outlet syndrome (TOS) is complex and controversial for its diagnosis, surgical indications, and techniques.
Like all other entrapment syndromes TOS usually presents a first irritative stage that may develop toward a second lesional stage.
We often see irritative TOS alone or in association with myofascial pain or other entrapment syndromes of the homolateral hemisoma. Many fibromyalgic patients develop irritative TOS as well.
According to our experience, we share the belief that the incidence of TOS is approximately 1/million inhabitants annually. 
Our surgical series of neurogenic TOS includes prevalently young females with intrinsic hand muscles dystrophy and sensitive deficit along the distribution of lower primary trunk.  In most of the cases, we found cervical rib or tapered elongated C7 transverse process with muscle and fibrous fibers from its tip to the first rib behaving like a cervical rib. Neurovascular conflict between subclavian artery and lower, and sometime middle, primary trunks has been revealed. These two structures are often found adherent to each other and elevated by the obstacle (cervical rib, fibro-muscular band) from underneath entrapping them in a smaller scalene triangle. The anterior scalene muscle most of the time is hypertrophic with taught fibers of its fascia in the postero-lateral portion, which is in contact with the brachial plexus. The pulsation of the artery is transmitted to the nerves. To our experience, this is the scenario of true neurologic TOS. We have always adapted a supraclavicuar approach (10 cm linear incision parallel to the clavicle), removal of cervical rib, or fibrous bands, and postero-lateral anterior scalenotomy, separation of artery from nervous structures. Post-operative improvement has been referred by all these patients. Only in case of recent history, we saw recovery of intrinsic hand muscles. We do not operate irritative TOS in lack of clinical sensory or motor deficit in order to avoid failure, which in our belief is encountered mostly with first rib resection. 
In our experience, electrophysiological study of TOS consists in revealing several abnormalities that suggest an axonal loss pattern such as a low compound motor action potential in both median and ulnar nerves, preferentially affecting the median-innervated thenar muscles (abductor policis brevis) rather than hypothenar muscles (adductor digiti minimi) with normal or relative reduction of distal latencies or conduction velocities, a reduction of sensory nerve action potential (SNAP) of ulnar nerve in the fourth and fifth digits, a markedly reduced or a complete loss of the SNAP of the medial antebrachial cutaneous nerve, and a prolongation of F waves. Needle electromyography abnormalities are found in median-more than ulnar-innervated C8-T1 muscles and less so in radial-innervated C8 muscles. Since, a trans-lesional conduction velocity is not possible to measure with the standard electroneurography techniques because of anatomical reasons, it is unclear in which way conduction velocity only, is able to suggest the diagnosis or utilized as a follow-up parameter of TOS in surgical patients.
| References|| |
|1.||Mohamed OA, Hassan HM, El Samouly HM. Surgical treatment of thoracic outlet syndrome; by supraclavicular approach. Med J DY Patil Univ 2012;5:101-5. |
|2.||Birch R. Thoracic outlet syndrome. In: Surgical disorders of the peripheral nerves. 2 nd ed. London: Springer Verlag; 2011. p. 275-80. |
|3.||Alimehmeti R, Crotti F, Seferi A, Rroji A, Petrela M. La sindrome dell'egresso toracico. Nostra esperienza chirurgica. 58 th Congress of Italian Society of Neurosurgery, 16 October 2009. Lecce, Italy: Abstracts Book. p. 186. |
|4.||Deane L, Giele H, Johnson K. Thoracic outlet syndrome. BMJ 2012;345:e7373. |