Minimally Invasive First Rib Resection: 50 Years Later Is A Positive Elevated Arm Stress Test An Indication For Surgery ?
Alastair Ian Munro, George Duncan McPherson, W.R. Eric Jamieson.
University of British Columbia, Vancouver BC, BC, Canada.
OBJECTIVE: In 1966 Roos published a revolutionary minimally invasive trans-axillary approach for first rib resection "to relieve thoracic outlet syndrome" (TOS) and the same year Roos and Owens described a modification of the abduction external rotation test which they called a "claudication test" for TOS, now widely know as the Elevated Arm Stress Test (EAST). Because this test has never been validated we have analysed a population alleged to have neuro-genic thoracic outlet syndrome (N-TOS) to determine whether or not the EAST is a reliable test for N-TOS.
METHODS: During the 10 year period January 2001 through December 2010 we examined a total of 263 patients alleged to have N-TOS following a motor vehicle accident. We graded the accuracy of the diagnosis made from the objective data from our physical examination and from the results of investigations. We recorded the results of the EAST but did not use them to make our diagnosis instead using them later to assess the value of the EAST.
RESULTS: At the highest grade of accuracy there were 56 cases of ulnar entrapment syndrome (UES), 40 with carpal tunnel syndrome (CTS), 55 with non-organic disease (NOD) and 3 with cervical radiculopathy for a total of 154 (58.5%) patients in whom the diagnosis of N-TOS was excluded with reasonable certainty. The EAST had reproduced the symptoms of UES in 33 of the 56 patients with UES (58.9%) and in 18 of the 40 (45.0%) patients with CTS. We did not find any case with involvement of the dermatomes or of the myotomes of C8 and T1 which would justify a diagnosis of N-TOS.
CONCLUSIONS: The EAST appears to be a test for UES and for CTS and a "positive" test should not be used as an indication for trans-axillary resection as originally suggested in 1966. There appears to be a high incidence of misdiagnosis of N-TOS after motor vehicle accidents and the use of the EAST as a test for N-TOS can only contribute to these misdiagnoses.
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