Neurosurgical considerations in thoracic outlet syndrome

The neurosurgeon is often consulted in cases of shoulder-arm pain that have as their cause compression of the neurovascular bundle in the thoracic outlet. He or she should, therefore, be familiar with the clinical presentation and differential diagnosis of this syndrome, as well as the electrographic and angiographic findings that may be present in this condition. If the diagnosis is established and the patient proves refractory to conservative treatment with physical therapy, medication, exercises, and modification of activities, the neurosurgeon may elect to perform scalenotomy, paying particular attention to the fibrous bands and anomalies in the scalene group of muscles that may play a major role in the compression of the brachial plexus and brachial vessels. Resection of a cervical rib or anomalous first rib may also prove necessary. Primary arterial and venous problems, which occur in approximately ten percent of these cases, are best left to the thoracic surgeon, but the transthoracic approach plus sympathectomy, if indicated, may be carried out by the neurosurgeon if he has been trained in this procedure. Emotional problems are often present in patients with this syndrome, but careful selection of surgical candidates will lead to a favorable outcome in 80% or better of such cases.