New Paradigms for Thoracic Outlet Compression and Thoracic Outlet Syndrome, with or without Complications or Sequelae: A Trans-Continental and Trans-Disciplinary Opinion Paper

Abstract

The anatomy of the human shoulder predisposes the neurovascular bundle to compression at different levels of the thoracic outlet during abduction of the arm. There are four possible levels of compression at the thoracic outlet pathway: at the costo-clavicular angle, the inter-scalenic angle, under the pectoralis minor muscle or at the level of the humeral head. The positional thoracic outlet compression (TOC) often remains completely asymptomatic. When symptomatic, compressions are collectively referred to as thoracic outlet syndrome (TOS) and may require surgery if physical therapy fails to improve symptoms. The “thoracic outlet compression with complications or sequelae” (the acronym of which is “TOC-CS”, which can be simplified as “TOX”) will almost invariably lead to surgery to release the compression, and other possible treatment targeting the complications as required. There is a continuum between TOC, TOS and TOX, which are simply different clinical stages of the same mechanical issue, just like the Rutherford grades represent different stages of lower extremity arterial disease. We believe that discriminating between TOC, TOS and TOX clarifies clinical definitions and their respective treatment options. TOC is to be considered as a physiological positional phenomenon, TOS requires medical or surgical treatment and surgery should be considered as a primary option in TOX.