Reply

Abstract

We read with interest Dr Molina's letter regarding our recent article1Landry GJ Moneta GL Taylor Jr, LM et al.Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients.J Vasc Surg. 2001; 33: 312-319Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar and would like to respond to his comments. While we agree with many of Dr Molina's criticisms, it is perhaps redundant to discuss them all as most were addressed in the original manuscript. It should be reiterated that the patients in the study were sent to us largely for independent medical evaluation and not for treatment. The focus of this study was therefore to evaluate the long-term outcomes of patients evaluated but not treated by us, thereby removing this group from our own treatment biases. In response to Dr Molina's criticisms, first, we agree that computerized tomography and magnetic resonance imaging are noncontributory in diagnosing neurogenic thoracic outlet syndrome. In most cases, these tests had been obtained prior to the patient being seen by us. We disagree that neurogenic thoracic outlet syndrome cannot be diagnosed with electrodiagnostic testing. “True” neurogenic thoracic outlet syndrome, as stated in the manuscript, is characterized by decreased action potentials in the median motor and ulnar sensory nerves on nerve conduction studies, and by denervation of the abductor pollicis brevis muscle on electromyography.2Gilliatt RW Le Quesne PM Logue V et al.Wasting of the hand associated with a cervical rib or band.J Neurol Neurosurg Psychiatry. 1970; 33: 615-624Crossref PubMed Scopus (175) Google Scholar, 3Wilbourn AJ Thoracic outlet syndrome, syllabus course D: controversies in entrapment neuropathies.in: American Association of Electromyography and Electrodiagnosis, Rochester (MN)1984: 28-38Google Scholar Patients with the “disputed” form of thoracic outlet syndrome, the patient group studied, lack these findings. These tests were performed to identify patients with true neurogenic thoracic outlet syndrome. Second, as stated in the manuscript, since we did not perform the operations on the surgical group, we do not know the details of the surgical procedures used. Interestingly, however, as stated in the manuscript, Franklin et al4Franklin GM Fulton-Kehoe D Bradley C Smith-Weller T Outcome of surgery for thoracic outlet syndrome in Washington state worker's compensation.Neurology. 2000; 54: 1252-1257Crossref PubMed Google Scholar reported that long-term functional outcome in patients undergoing first-rib resection did not depend on the experience of the surgeon performing the procedure. Dr Molina correctly points out that several different procedures exist for first-rib resection. Perhaps the explanation for this is that no single procedure is able to distinguish itself as superior. If there was a procedure that gave reliably good results, its application would have likely become widespread. The length of time of disability and ability to return to work was addressed in the manuscript. We agree that the ideal method of evaluation would be a randomized, prospective trial of conservative versus surgical therapy. As we have a relatively small volume of patients with neurogenic thoracic outlet syndrome, our ability to carry out such a trial is limited. It is a source of continued dismay to us that those centers with adequate volume have not carried out such a trial. 24/41/117883