Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients

Purpose: Neurogenic thoracic outlet syndrome (NTOS) in the absence of bony and electrodiagnostic abnormalities, often referred to as disputed NTOS, remains enigmatic. Optimal treatment, especially the role of surgery, is controversial. The long-term functional outcome of a cohort of patients undergoing independent medical examination for disputed NTOS with symptoms sufficiently severe to cause inability to work forms the basis for this report. Methods: Patients with disputed NTOS and symptoms sufficiently severe to cause at least temporary inability, to work seen for independent medical examinations from 1990-1998 formed the study group. None of the patients were treated by our group. Functional outcome was assessed with information from a standardized telephone interview or patient questionnaire. The patients' ability to return to work and an assessment of their current level of symptoms and symptom progression since the time of onset were determined. Results: Seventy-nine patients were reevaluated at a mean follow-up of 4.2 years (range, 2-7.5 years) after our initial evaluation. Fifteen patients (19%) underwent first rib resection surgery performed by others, whereas 64 (81%) had no surgery. Patients undergoing surgery had missed more work time than those undergoing conservative management (27.6 ± 6.0 months vs 14.9 ± 2.6 months, P < .04). Return to work was achieved in nine patients who were operated on (60%) and in 50 patients who were not operated on (78%) (P = not significant [NS]). Among operated patients, current assessment of symptom severity was severe, moderate, mild, and asymptomatic in 7%, 47%, 40% and 7%, respectively. This distribution did not differ significantly from that observed in nonoperated patients (11%, 55%, 30%, 5%; P = NS). When asked about changes in symptomatic status since onset, 7% of the operated group had complete resolution, 27% had marked improvement, 40% had minimal improvement, 13% had no improvement, and 13% were worse. This did not differ significantly from the change in symptoms reported by the nonoperated group (2%, 30%, 22%, 31%, 16%; P = NS). Conclusion: Most patients with disputed NTOS in this nonrandomized series were able to return to work and demonstrated an improvement of symptoms with long-term follow-up. First rib resection did not improve functional outcome in this group.