First, TOS is diagnosed by experienced specialists in experienced centers around the country (and around the world). This doesn’t occur through a single doctor, a single medical center, or a single city. While there is no uniform agreement on the best diagnostic test, TOS specialists use MRI, ultrasound, CT and other tests on a regular basis. And while there are multiple specialists and centers with different opinions and experience, they all diagnose TOS confidently according to their standards and experience. TOS specialists have understandable disagreements as they learn more about the disease, and as they work to move forward on diagnosis and treatment. But nobody considers the diagnosis of neurogenic TOS out of reach.
Second, MRI is not ‘inadequate.’ A physician can easily find peer-reviewed articles supporting the value of MRI and other forms of imaging in the diagnosis of thoracic outlet syndrome. I have read thousands of TOS cases personally. And we have used MRI for the diagnosis of other nerve entrapments in the body for decades.
Third, if a patient does have neurogenic TOS, by definition there exists a focal area of compression or tension on the brachial plexus. That is the confirmed and agreed-upon pathology of TOS. Nobody argues that. We should ask, why would a surgeon operate if there is no anatomic abnormality?
It is the nature of surgery to alter anatomy or to remove pathology. There is no sense in diagnosing a patient with neurogenic TOS and then refuting the diagnosis by saying there is no compression of the brachial plexus. By definition, patients with neurogenic TOS have compression of the brachial plexus.