Thoracic Outlet Syndrome: To Operate or not to Operate in Light of the Montgomery Ruling

Introduction:

In March 2015 the UK Supreme Court ruled that “a doctor has a duty to take reasonable care to ensure that the patient is aware of any material risk involved in any suggested treatment and of any reasonable alternative or variant treatments”.  Furthermore, it requires that the test of materiality is whether in the chances of the particular case a reasonable person in the patient's position would be likely to attach significance to it”. With this in mind we thought it appropriate to revisit the last Cochrane review on treatment of thoracic outlet syndrome (TOS). We note that 1) no randomized control trials were found where the outcomes of surgical management were superior to conservative management, but 2) surgical management carries significant risks. These 2 points have important implications on consent and treatment in the post-Montgomery era. Before the Montgomery ruling, the Bolam test of “whether the treatment delivered would have been acceptable to a responsible body of medical opinion” ruled.

This meant that as long as the procedure was generally acceptable and its main risks listed, consent was valid. However, post-Montgomery valid consent must take into account all risks that the patient, rather than the doctor, would consider significant, as well as the details of any reasonable alternative treatments. In conclusion, we are of the opinion that in light of the Montgomery ruling it is ill advised that surgery is performed prior to a period of conservative treatment.

Thoracic outlet disorder (TOS) is an oftentimes ignored fringe nerve pressure that makes troubles for the clinician in regards to analysis and the board. The term 'thoracic outlet disorder' was initially authored in 1956 by Peet to demonstrate pressure of the neurovascular structures in the interscalene triangle comparing to the conceivable etiology of the symptoms.2–4 Since Peet gave this definition, the condition has developed as one of the most dubious subjects in musculoskeletal medication and recovery. This discussion reaches out to pretty much every part of the pathology including the definition, the rate, the pathoanatomical commitments, analysis and treatment.

The neural holder depicted as the 'thoracic outlet' is involved a few parts. Proximally, the cervicoaxillary channel is partitioned by the principal rib into two segments. The proximal part of this waterway is involved the interscalene triangle and the costoclavicular space, while the axilla contains the distal part of the trench. The proximal segment is all the more clinically important, because of its job in neurovascular compression.

12 More explicitly, the thoracic outlet incorporates three bound spaces stretching out from the cervical spine and mediastinum to the lower fringe of the pectoralis minor muscle (Fig. 1). The three compartments incorporate the interscalene triangle, the costoclavicular space and the thoraco-coraco-pectoral space or retropectoralis minor space.4,13 The interscalene triangle is flanked by the foremost scalene muscle anteriorly, the center scalene muscle posteriorly, and the average surface of the main rib poorly.

Author(s):

Sebastian Povlsen* and Bo Povlsen

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