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Thoracic outlet syndrome (TOS) is a condition that arises from the compression of one or more of the neurovascular structures that traverse the superior aperture of the chest. The name was previously designated according to the etiology of the compression, that is, scalenus anticus, costoclavicular, hyperabduction, cervical rib, or first rib syndrome. Most compressive factors operate against the first rib and produce a variety of symptoms, depending on which neurovascular structures are compressed. These factors, along with common etiologies and symptoms, are illustrated in Figure 143-1. My introduction (H.U.) to TOS came in 1947 at Princeton University, where, as a member of the undefeated freshman football team, my neck was knocked severely to the right, paralyzing my arm for several days. After the season, I was sent by train to Johns Hopkins Hospital to be evaluated by Dr. George Bennett, the eminent orthopedic surgeon who had recently operated on Joe DiMaggio's knee. He made the diagnosis of a cervical rib syndrome on the right and offered me an operation or a brace. Recognizing early that surgery was for others, I tried the brace. A piece of stainless steel covered only with leather was fashioned on my shoulder pad. It extended up past my right ear to prevent my neck from being driven to the right. I used this for the next year. However, in those days, no one wore a facemask, and I was often chagrined to find a piece of nose or face or teeth on the ground after a substantial block from the single-wing formation. For this reason, the NCAA ultimately outlawed the brace. Subsequently, the foam rubber “doughnut” was developed to prevent the neck from being forced to extremes in any direction. It is commonly used today. Conservative treatment, then as now, is usually effective. With no surgery, I contributed significantly to our undefeated team, which produced “Coach of the Year” Charles W. Caldwell, Jr., and the last Heisman Trophy winner in the Ivy League, Richard W. Kazmaier, Jr.
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Since my diagnosis in 1947, many changes in the recognition and management of these multiple conditions have evolved. This chapter elucidates the improvements in the diagnosis and management of thoracic outlet neurovascular compression that have transpired over the past 50 years. Recognizing that such procedures as breast implantation and median sternotomy may produce TOS has been revealing. Prompt thrombolysis followed by surgical venous decompression for the Paget–Schroetter syndrome (i.e., effort thrombosis of the axillary–subclavian vein) has improved results in this condition significantly as compared with the conservative anticoagulation approach. Complete first rib extirpation at the initial operation reduces the incidence of recurrent neurologic symptoms or the need for reoperation. Well over 20,000 patients have been evaluated for TOS in my experience; 4914 underwent neurovascular decompression operations, ...