Invited commentary

I would like to offer a few comments on the excellent article by Dr. Harold Urschel entitled “Thoracic outlet syndrome: a 50-year experience at Baylor University Medical Center.” Dr. Urschel gives a comprehensive discussion of a neurovascular compressive syndrome, which is still poorly understood by many clinicians. He adds an interesting anecdote regarding himself when he, as a student athlete at Princeton, was affected by nerve compression during “the glory days” of Ivy League football. The role of muscle spasm in this syndrome should be emphasized since many patients become symptomatic after an athletic endeavor, fall, or accident. The resulting narrowing of the bony thoracic outlet interval produces a “pincer effect” on the nerves or blood vessels as they make their way out of the neck or chest to the arm. Relaxation of the muscle spasm gives relief of symptoms and accounts for the improvement that many patients get with physical therapy and without surgical intervention.

Roos, who described the transaxillary approach for surgical relief (1), wrote extensively about the role of anomalous scalene muscles in initiating muscle spasm and the resulting symptoms (2). Clagett (3) proposed a posterior paraspinous surgical approach, which was much like a first-stage thoracoplasty and was popular with older thoracic surgeons with experience in treating tuberculosis. The supraclavicular approach (4) has been particularly appealing to vascular surgeons since the involved vessels (and nerves) are literally under their fingertips. Regardless of the surgical approach, the results are equal in those patients who fail to respond to conservative therapy and eventually come to operation. Dr. Urschel is to be congratulated on his thorough coverage of this not uncommon and poorly understood condition.