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Somatoform disorders in non‐specific neurogenic thoracic outlet syndrome patients

We read with interest the article by Passero et al. (1). The authors have thoroughly documented the electrophysiological findings in a large group of patients with “true”, or “classic”, neurogenic thoracic outlet syndrome (TOS). True neurogenic TOS is an uncommon condition (2); the authors’ identification of 30 patients over an 11-year period supports this concept. Passero et al. were careful to exclude patients with “non-specific” (aspecific, disputed) neurogenic thoracic outlet syndrome from their study. Nonspecific neurogenic TOS is a controversial diagnosis given to patients that have symptoms of true neurogenic TOS, but lack objective neurological and electrophysiological findings (2). Unlike true neurogenic TOS, non-specific neurogenic TOS is a frequently diagnosed condition in some parts of the world, especially the United States of America. Surgical treatment is indicated in essentially all patients with true neurogenic TOS, but the role of surgical therapy in nonspecific neurogenic TOS is uncertain (2, 3). We have adopted a more conservative treatment approach to non-specific TOS than that recommended by many surgeons (4). In our experience, patients with somatoform disorders (hypochondriasis, DSM-111-R 300.70 and somatization disorder, DSM-111-R 300.8 1) ( 5 ) have unfavorable outcomes after surgery. We have retrospectively identified a high frequency of somatization features in surgically treated nonspecific neurogenic TOS patients (6). Although other authors share this impression (7, 8), there is a paucity of published data to corrobarate our findings. Some investigators have used psychological testing to select patients for surgery (9, 10). Unfortunately, this has met with limited practical success . The work of Passero et al. provides useful guidelines for the electrophysiological assessment of true neurogenic TOS. If similar diagnostic guidelines could be developed for non-specific neurogenic TOS, it would no longer be a controversial entity. Until that time, the management of non-specific neurogenic TOS will be hampered by diagnostic uncertainty, and by an inability to evaluate the role of somatoform disorders in the genesis of symptoms.