Thoracic outlet syndrome: a 50-year experience.

Y our recent publication of a 50-year experience with the thoracic outlet syndrome (TOS) (1) would have served a valuable purpose if it had been accompanied by an alternative view of the controversies in diagnosis, classification, role of diagnostic testing, management, and outcomes analysis (2–6). As patients and physicians unfamiliar with this controversy increasingly turn to the unedited Internet, it is even more important to provide a gamut of credible information on one of the most contentious topics in the field of peripheral neuropathies and their corollaries. This is in the tradition of medicine as a continuous process of questioning and reevaluating the recommendations physicians make to their patients. In view of the “responsibilities of authorship” (7), it therefore inures to editors of medical journals to be especially vigilant to not limit the debate to a series of self-reported cases, but to include the commentary of critics. This is particularly true for surgical series involving retrospective analyses over long periods of time, when diagnostic and therapeutic techniques may change (especially if not stratified to take this into account), when the opportunity for double-blind studies may not be possible, and especially when controversy exists (1, 8–11). In this day and age of outcomes analysis as a tool that will determine the direction of health care policy (12), with regard to TOS, such outcomes analysis by independent neurologists (as called for in a recently published, combined surgicalneurological study) (13) is currently limited to two studies, each with its own issues (13, 14). Dr. Urschel is to be commended for creating an opportunity to focus attention on the continuing need to assess what we do (even in the midst of the tsunami changes in the health care system) and allow us to point to the need for a prospective, carefully designed, and monitored study so as to 1) decide on a stratification scheme for TOS, 2) decide upon diagnostic criteria, and 3) identify the most cost-effective way to manage TOS and thus be in a position to inform patients and their doctors of what the best practice algorithm for this entity should be.