Strategies for Work-up and Treatment of Case Scenarios in Neurogenic Thoracic Outlet Syndrome

PURPOSE: Considerable variation exists in strategies for the diagnosis and treatment of neurogenic thoracic outlet syndrome (NTOS). Additionally, different subtypes of NTOS present with different constellations of symptoms and signs. The aim of this study was to gather and evaluate different treatment plans from high-volume NTOS surgeons for standardized case scenarios. METHODS: Six case scenarios were distributed to 19 self-designated level IV expert NTOS surgeons. These included standardized patients presenting with Gilliat-Sumner hand, upper plexus involvement with scapular winging, pectoralis minor syndrome, electrically negative TOS with pain and sensory changes only, NTOS with concomitant distal double crush compression neuropathies, and recurrent NTOS following previous first rib resection. Each surgeon independently reviewed case information and formulated an investigative and treatment plan using a free-text response. RESULTS: The most common investigation ordered was a cervical spine or brachial plexus magnetic resonance imaging. Where exposure of the supraclavicular brachial plexus was indicated, the preferred surgical approach was a supraclavicular approach, with the majority of experts also recommending a concomitant pectoralis minor tenotomy. In the presence of scapular winging, some surgeons would perform a long thoracic nerve neurolysis or nerve transfer. In the absence of motor symptoms, all experts would recommend surgery only after failure of conservative treatment. With findings suggesting concomitant distal nerve compression sites, the most common recommendation was a comprehensive surgical approach to decompress the brachial plexus and distal sites simultaneously. A smaller proportion of experts preferred a "distal first" approach. CONCLUSIONS: Consistent trends were seen in recommendations for work-up and treatment of NTOS patients. Compared with other surgical specialties treating NTOS, hand surgeons have a tendency toward (1) a supraclavicular approach for brachial plexus decompression, (2) increased preference for rib-sparing scalenectomy over first rib resection, and (3) consideration of concomitant or staged surgery to address distal nerve compression sites. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.