Criteria

Consensus-based diagnostic criteria for all three types of thoracic outlet syndrome (TOS) were developed by the Society for Vascular Surgery (SVS) as part of a 2016 publication on reporting standards for thoracic outlet syndrome.[1] An additional set of diagnostic criteria for neurogenic TOS was developed by the Consortium for Research and Education on Thoracic Outlet Syndrome (CORE-TOS).[96]​ Both SVS and CORE-TOS criteria have been used in validation studies as a basis for clinical research on TOS.[122][136][137]​​​​[138]

Neurogenic TOS

The SVS criteria for a diagnosis of neurogenic TOS include the presence of three of the following four criteria:[1]

  1. Local findings: (a) history of symptoms consistent with irritation or inflammation at the site of compression- scalene triangle and/or pectoralis minor insertion site- along with symptoms due to referred pain in the areas near the thoracic outlet. Patients may complain of pain in the chest wall, axilla, upper back, shoulder, trapezius region, neck, or head (including headache); (b) examination with pain on palpation of the affected area as above.

  2. Peripheral findings: (a) history of arm or hand symptoms consistent with central nerve compression. Such symptoms can include numbness, pain, paresthesia, vasomotor changes, and weakness (with muscle wasting in extreme cases). These peripheral symptoms are often exacerbated by maneuvers that either narrow the thoracic outlet (lifting the arms overhead) or stretch the brachial plexus (dangling; often driving or walking/running); (b) examination with palpation of the affected area (scalene triangle or pectoralis minor insertion site) often reproduces the peripheral symptoms. These peripheral symptoms are often produced or worsened by provocative maneuvers that are believed to narrow the scalene triangle (EAST) or to stretch the brachial plexus (ULTT). Additionally, it is important to recognize that vasomotor changes, such as intermittent cold sensation and finger discoloration, while potentially indicative of nerve compression, do not necessarily signify arterial TOS. These symptoms can reflect sympathetic overactivity secondary to pain and are more typical of autonomic dysregulation in neurogenic TOS, particularly when symptoms are present with the arm at the side and a normal resting radial pulse.[1][18][97]

  3. Absence of other reasonably likely diagnoses (cervical disc disease, shoulder disease, carpal tunnel syndrome, chronic regional pain syndrome, brachial neuritis) that might explain the majority of symptoms.

  4. In those who undergo it, the response to a properly performed test injection is positive.

In addition, most patients have prolonged symptoms (> 6 months), deteriorate over time, and have a history of trauma, although these factors are not required for diagnosis.

The CORE-TOS criteria for a diagnosis of neurogenic TOS involve upper extremity symptoms extending beyond the distribution of a single cervical nerve root or peripheral nerve, present for at least 12 weeks, not satisfactorily explained by another condition, AND meeting at least 1 criterion in at least 4 of the following 5 categories:[96][122]

  1. Principal symptoms

    • 1A: Pain in the neck, upper back, shoulder, arm and/or hand

    • 1B: Numbness, paresthesia, and/or weakness in the arm, hand, or digits

  2. Symptom characteristics

    • 2A: Pain/paresthesia/weakness exacerbated by elevated arm positions

    • 2B: Pain/paresthesia/weakness exacerbated by prolonged or repetitive arm/hand use,including prolonged work on a keyboard or other repetitive strain tasks

    • 2C: Pain/paresthesia radiate down the arm from the supraclavicular or infraclavicular spaces

  3. Clinical history

    • 3A: Symptoms began after occupational, recreational, or accidental injury of the head, neck, or upper extremity, including repetitive upper extremity strain or overuse

    • 3B: Previous ipsilateral clavicle or first rib fracture, or known cervical rib

    • 3C: Previous cervical spine or ipsilateral peripheral nerve surgery without sustained improvement in symptoms

    • 3D: Previous conservative or surgical treatment for ipsilateral TOS

  4. Physical exam

    • 4A: Local tenderness on palpation over the scalene triangle and/or subcoracoid space

    • 4B: Arm/hand/digit paresthesia on palpation over the scalene triangle and/or subcoracoid space

    • 4C: Objectively weak handgrip, intrinsic muscles, or digit 5, or thenar/hypothenar atrophy

  5. Provocative maneuvers

    • 5A: Positive upper limb tension test (ULTT)

    • 5B: Positive 3-minute elevated arm stress test (EAST)

Venous TOS

The SVS criteria for a diagnosis of venous TOS generally involve all three of the following elements, but even if the patient is asymptomatic, ultrasonic or venographic documentation of axillosubclavian vein thrombus in the absence of other factors is sufficient for the diagnosis:[1]

  1. History: (a) arm swelling, usually with discoloration and heaviness (i) this can occur with the arms overhead only, suggesting nonthrombotic venous TOS, or present as a fixed symptoms, suggesting subclavian vein thrombosis; (b) absence of inciting cause (indwelling catheter, malignant neoplasm).

  2. Examination: (a) visible arm swelling at rest, although if the arm swelling is reported only with exertion or arms overhead, the arm may be normal at rest; (b) arm discoloration; (c) shoulder, upper arm, or chest wall venous collaterals.

  3. Imaging: (a) documentation of venous compression at the costoclavicular junction by ultrasound, venography, or cross-sectional imaging; (i) if the vein is occluded from mid upper arm to the innominate in the setting of appropriate symptoms (and no secondary cause is present), venous TOS may be assumed; (ii) if the vein is patent but abnormal, the location of the abnormality (costoclavicular junction or pectoralis minor space) should be documented; (iii) if the vein appears normal at rest, results of ultrasound or venography with the arm abducted >90° should be reported; (iv) if all cases, every attempt should be made to obtain venography through the brachial or basilic veins rather than the cephalic vein as disease sometimes extends lateral to the cephalic arch.

Arterial TOS

The SVS criteria for arterial TOS define this condition as “an objective abnormality of the subclavian artery caused by extrinsic compression and subsequent damage by an anomalous first rib or analogous abnormal structure (cervical rib or band) at the base of the scalene triangle. Such an abnormality can be symptomatic (ischemia or embolization) or asymptomatic (aneurysm, occlusion, or silent embolization). Loss of pulses or discoloration with provocative maneuvers in patients with neurogenic TOS does not mean that arterial TOS is present; documented injury to the subclavian artery or symptomatic arm ischemia with arms elevated must be present for this diagnosis to be made."[1]

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