Thoracic Outlet Syndrome

Preface
Contents
1: Introduction
	References
Part I: Background and Basic Principles
	2: A Brief History of the Thoracic Outlet Compression Syndromes
		2.1	 Prologue
		2.2	 Historical Evolution
		2.3	 The Scalenectomy Era
		2.4	 The Era of First Rib Resection
		2.5	 The Concept of “Thoracic Outlet Compression Syndrome”
		2.6	 The Venous Abnormality
		2.7	 Where Are We Today?
		References
	3: Embryology of the Thoracic Outlet
		3.1	 Neurovascular Development
		3.2	 Cervical Ribs
		3.3	 Scalene Muscles
		References
	4: Evolutionary and Developmental Issues of Cervical Ribs/Evolutionary Issues of Cervical Ribs
		4.1	 Cervical Ribs Do Not Disappear
		4.2	 A Plethora of Coexisting Malformations
		4.3	 Why Do Cervical Ribs Co-Occur with So Many Abnormalities?
		4.4	 Heterogeneity of Genetic and Environmental Causes for Cervical Ribs
		4.5	 Evolutionary Selection Against Cervical Ribs and Exceptional Mammals
		4.6	 Why Can Birds and Reptiles Have Long Necks?
		4.7	 Cervical Ribs Are Common and Need More Study
		References
	5: Anatomy of the Thoracic Outlet and Related Structures
		5.1	 Introduction
		5.2	 Anatomical Spaces
		5.3	 Cervical Ribs
		5.4	 Ligaments and Bands
		5.5	 Nerves
		5.6	 Subclavian and Axillary Vessels
		5.7	 Scalene and Pectoralis Minor Muscles
		5.8	 Thoracic Duct
		5.9	 Distribution of Pathology
		5.10	 Conclusion
		References
	6: TOS: Clinical Incidence and Scope of the Problem
		6.1	 Introduction
		6.2	 What Data Exist?
		6.3	 The University of South Florida Experience
		6.4	 Conclusions
		References
Part II: Neurogenic TOS: General Principles and Diagnosis
	7: Pathology and Pathophysiology of NTOS
		7.1	 Introduction
		7.2	 Predisposing Factors
		7.3	 Scalene Muscle Variations Associated with NTOS
		7.4	 Scalene Muscle Variations that Do Not Correlate with NTOS
		7.5	 Cervical Ribs, Anomalous First Ribs, and Elongated Transverse Processes of C7
		7.6	 Pathology
		7.7	 Pathophysiology
			7.7.1	 Post-Traumatic Onset
			7.7.2	 Repetitive Stress Injury (RSI)
			7.7.3	 Role of First Rib
		7.8	 Muscle Spasm
		7.9	 Pectoralis Minor Syndrome
			7.9.1	 Non-Traumatic Onset
		References
	8: NTOS for the Primary Care Team: When to Consider the Diagnosis?
		8.1	 Introduction
		8.2	 Epidemiology
		8.3	 Diagnosis
		8.4	 History
		8.5	 Physical Examination
		8.6	 Exclusion of Other Problems
		8.7	 What to Do Next
		8.8	 What Not to Order
		8.9	 Summary
		References
	9: Diagnosis of Neurogenic Thoracic Outlet Syndrome: 2016 Consensus Guidelines and Other Strategies
		9.1	 Introduction
		9.2	 Spectrum of Clinical Presentation and Differential Diagnosis
			9.2.1	 Referral Screening
			9.2.2	 Clinical History
				9.2.2.1	 Pattern of Pain
				9.2.2.2	 Pattern of Paresthesia
				9.2.2.3	 Weakness and Muscle Atrophy
				9.2.2.4	 Dynamic Positional Effects
				9.2.2.5	 Vascular Symptoms
			9.2.3	 Physical Examination
				9.2.3.1	 Neck, Shoulder, and Peripheral Nerves
				9.2.3.2	 Vascular Examination
				9.2.3.3	 Supraclavicular and Subcoracoid Palpation
				9.2.3.4	 Provocative Maneuvers
			9.2.4	 Assessment of Disability and Outcome Measures
				9.2.4.1	 Disability Assessment
				9.2.4.2	 Outcome Measures
				9.2.4.3	 Assessment of Cause
			9.2.5	 Adjunctive Testing
				9.2.5.1	 Chest Radiography
				9.2.5.2	 Electrodiagnostic Testing
				9.2.5.3	 Cervical Spine Imaging
				9.2.5.4	 Shoulder Imaging
				9.2.5.5	 Vascular Laboratory Studies
				9.2.5.6	 Brachial Plexus Imaging
				9.2.5.7	 Scalene/Pectoralis Minor Muscle Blocks
			9.2.6	 Summary of Clinical Diagnosis
		9.3	 Development and Application of Clinical Diagnostic Criteria
			9.3.1	 Initial Development of Consensus-Based Diagnostic Criteria
			9.3.2	 Society for Vascular Surgery Reporting Standards
			9.3.3	 Application and Validation of Diagnostic Criteria
		9.4	 Summary
		References
	10: Differential Diagnosis in Patients with Possible NTOS
		10.1	 Introduction
			10.1.1	 Cervical Spine Disorders
			10.1.2	 Cervical Dystonia and Other Segmental Dystonias
			10.1.3	 Rotator Cuff Pathology
			10.1.4	 Suprascapular Nerve Entrapment
			10.1.5	 Neurogenic Pectoralis Minor Syndrome
			10.1.6	 Brachial Neuritis (Parsonage-Turner Syndrome)
			10.1.7	 Carpal Tunnel Syndrome
			10.1.8	 Ulnar Entrapment Syndrome
			10.1.9	 Peripheral Nerve Tumors
		10.2	 Coexisting or Complicating Factors
			10.2.1	 Myofascial Pain
			10.2.2	 Chronic Headache
			10.2.3	 Depression, Somatization and Iatrogenicity
			10.2.4	 Complex Regional Pain Syndrome
			10.2.5	 Fibromyalgia
			10.2.6	 Opioid Hyperalgesia
		10.3	 Summary
		References
	11: Increasing Objectivity in the Diagnosis of NTOS: The Standardized EAST-Meter
		11.1	 Introduction
		11.2	 The ‘Classic’ EAST
			11.2.1	 Role of the EAST in Scalene and Minor Pectoral Muscle Test Injection
			11.2.2	 Limitations of the ‘Classic’ EAST
		11.3	 The EAST-Meter
			11.3.1	 Standardization of Attitude and Compressions
			11.3.2	 EAST Measurement and Outcome
			11.3.3	 First Outcomes of the Prototype
		11.4	 Future Perspectives
		11.5	 Conclusion
		References
	12: A Closer Look at QuickDASH and CBSQ: What Do they Tell us?
		12.1	 Introduction
		12.2	 Goals
		12.3	 QuickDASH
		12.4	 CBSQ
		12.5	 Our Goals
		12.6	 Subjective Assessment
		12.7	 Empiric Data
		12.8	 Putting it all Together
		12.9	 A Final Thought
		References
	13: Scalene Test Blocks in Patients with Possible Neurogenic TOS
		13.1	 Introduction
		13.2	 Evolution of the Scalene Test Block and Presently Utilized Protocols
			13.2.1	 TOS Test Blocks: Single Site Injection, Surface Landmarks (Early 1990s)
			13.2.2	 Single Site Injection, EMG Guidance (Late 1990s)
			13.2.3	 Multiple Site Injection, Fluoroscopic and EMG Guidance (2000–2007)
			13.2.4	 Multiple Site Injection, Double Blinding, Randomized Comparative Intramuscular Nerve Blockade with Ultrasound and EMG Guidance and a Specific Instruction Set
		13.3	 Conclusions
		References
	14: Electrophysiological Assessment and Nerve Function in NTOS
		14.1	 Historical Perspective
		14.2	 Traditional Electrophysiologic Nerve Testing
		14.3	 Cervical Root Stimulation (CRS)
		14.4	 Medial Antebrachial Cutaneous Nerve (MACN) Testing
		14.5	 Re-Assessing Classical Electrodiagnosic Techniques
		14.6	 Selecting the Most Productive Electrodiagnostic Approach
		14.7	 Summary
		References
	15: Pectoralis Minor Syndrome
		15.1	 Introduction
		15.2	 Diagnosis and Indications for Procedure
		15.3	 Surgical Techniques
			15.3.1	 Transaxillary (Lateral) Approach
			15.3.2	 Deltopectoral (Anterior) Approach
			15.3.3	 Infraclavicular/Subclavicular (Anterior) Approach
			15.3.4	 Reoperations
		15.4	 Followup Care
		References
	16: Double Crush Syndrome
		16.1	 Introduction
		16.2	 Etiology
		16.3	 Thoracic Outlet Syndrome and Double Crush Syndrome
		16.4	 Conclusion
		References
	17: Unusual Nerve Entrapments and Neuropathic Syndromes of the Neck and Shoulder
		17.1	 Introduction
		17.2	 Anatomy and Relationships to Thoracic Outlet Syndrome
		17.3	 Suprascapular Nerve (SSN)
			17.3.1	 Symptoms
			17.3.2	 Anatomy
			17.3.3	 Entrapment
			17.3.4	 Diagnosis
			17.3.5	 Types of Treatment
		17.4	 Axillary Nerve (AN)
			17.4.1	 Symptoms
			17.4.2	 Anatomy
			17.4.3	 Entrapment
			17.4.4	 Diagnosis
			17.4.5	 Types of Treatment
		17.5	 Dorsal Scapular Nerve
			17.5.1	 Symptoms
			17.5.2	 Anatomy
			17.5.3	 Entrapment
			17.5.4	 Diagnosis
			17.5.5	 Types of Treatment
		17.6	 Long Thoracic Nerve (LTN)
			17.6.1	 Symptoms
			17.6.2	 Anatomy
			17.6.3	 Entrapment
			17.6.4	 Diagnosis
			17.6.5	 Types of Treatment
		17.7	 Spinal Accessory Nerve (SAN)
			17.7.1	 Symptoms
			17.7.2	 Anatomy
			17.7.3	 Entrapment
			17.7.4	 Diagnosis
			17.7.5	 Diagnostic Injections
			17.7.6	 Types of Treatment
		17.8	 Winged Scapula
		17.9	 Who Diagnoses and Treats These Problems, and How to Identify When Referral Is Needed?
		17.10	 Conclusion
		References
	18: Cross-Sectional Imaging in Thoracic Outlet Syndrome
		18.1	 Introduction
		18.2	 Anatomy of the Thoracic Outlet
		18.3	 Cross-Sectional Imaging in Thoracic Outlet Syndrome
			18.3.1	 Magnetic Resonance Imaging and Protocols
			18.3.2	 Computed Tomographic Imaging and Protocols
		18.4	 Image Interpretation and Pathologic Findings
			18.4.1	 Venous Thoracic Outlet Syndrome
			18.4.2	 Arterial Thoracic Outlet Syndrome
			18.4.3	 Neurogenic Thoracic Outlet Syndrome
		18.5	 Conclusion
		References
	19: Ergonomic, Postural Issues, and Repetitive Stress Issues in NTOS
		19.1	 Ergonomics and Postural Issues
			19.1.1	 What Is Ergonomics?
			19.1.2	 Principle Factors Related to Ergonomics
			19.1.3	 Work or Recreational Computer Set-Up
			19.1.4	 TOS and Role of Ergonomics
		19.2	 Repetitive Motion and TOS
			19.2.1	 What Is a Repetitive Motion Injury?
			19.2.2	 Repetitive Motion Injuries in the Workplace
			19.2.3	 Repetitive Motion Injuries in Sports
			19.2.4	 Repetitive Motion Injuries and Physical Therapy
		19.3	 Conclusions
		References
	20: Psychiatric and Psychologic Issues in NTOS
		20.1	 Introduction
		20.2	 The Impact of NTOS on Mental Health
		20.3	 Treatment Considerations
		20.4	 Conclusions
		References
Part III: Neurogenic TOS: Treatment
	21: Pathways of Care and Treatment Options for Patients with Neurogenic TOS
		21.1	 Introduction
		21.2	 Initial Presentation
		21.3	 Anterior Scalene/Pectoralis Minor Muscle Blocks
		21.4	 Complex Regional Pain Syndrome (CRPS)
		21.5	 Physical Therapy and Occupational Therapy Evaluation and Treatment
		21.6	 Surgical Treatment
		21.7	 Follow-Up Care
		21.8	 The “Center” Approach to NTOS
		21.9	 Conclusions
		References
	22: Physical Therapy as Primary Treatment for Neurogenic TOS
		22.1	 Introduction
		22.2	 Anatomy and Pathophysiology
		22.3	 Anatomic Versus Functional Issues
		22.4	 Evaluation of the Patient
			22.4.1	 Subjective
			22.4.2	 Objective
		22.5	 Provocative Testing
		22.6	 Diagnostic Imaging
		22.7	 Muscle Blocks
		22.8	 Differential Diagnosis
		22.9	 Conservative (Non-Surgical) Treatment of Neurogenic Thoracic Outlet Syndrome
		22.10	 Hisamoto-Illig Thoracic Outlet Program (HI-TOP): The Pro-Active Approach
		22.11	 Step 1 Treatment Progression (Sessions 1–2)
			22.11.1 Other Interventions
		22.12	 Step 2 Treatment Progression (Sessions 2–4)
		22.13	 Step 3: Scapular Strengthening Phase
		22.14	 Step 4: Dynamic Strengthening Program
		22.15	 Step 5: Return to Sports, Discharge Planning, Functional Progressions
		22.16	 Conclusion
		References
	23: Chiropractic and Nontraditional Treatment of NTOS
		23.1	 Introduction
		23.2	 Methods
		23.3	 Joint and Soft-Tissue Based Therapies
			23.3.1	 Patient Selection
			23.3.2	 Joint Manipulation and Mobilization
				23.3.2.1	 First Rib
				23.3.2.2	 Cervical Spine
				23.3.2.3	 Sternoclavicular Joint
				23.3.2.4	 Thoracic Spine
			23.3.3	 Soft Tissue Manipulation
				23.3.3.1	 Scalenes
				23.3.3.2	 Pectorals
		23.4	 Complementary and Alternative Medicine
			23.4.1	 Needling Therapies
				23.4.1.1	 Sternocleidomastoid
				23.4.1.2	 Shoulder Muscles
			23.4.2	 Nutraceuticals
			23.4.3	 Kinesiology Taping
		23.5	 Conclusion
		References
	24: Anesthesia for Thoracic Outlet Decompression
		24.1	 Introduction
		24.2	 Preoperative Considerations
		24.3	 Intraoperative Considerations
		24.4	 Postoperative Considerations
		24.5	 Conclusions
		References
	25: Regional Anesthesia for Thoracic Outlet Decompression
		25.1	 Challenges of Conventional Anesthesia and Analgesia
		25.2	 Introduction of Regional Anesthesia as a Supplement to General Anesthesia
		25.3	 Risks of Regional Anesthesia and Its Management
		25.4	 Relevant Anatomy for Regional Anesthesia Techniques in Thoracic Outlet Decompression
		25.5	 Regional Anesthesia for Thoracic Outlet Decompression
		25.6	 Pecs II Block for Trans-Axillary Approach in TOD Surgery
			25.6.1	 Indications
			25.6.2	 Ultrasound Probe Positioning and Sonography
			25.6.3	 Clinical Application
		25.7	 Superficial Cervical Plexus Block for Supraclavicular Approach in TOD Surgery
			25.7.1	 Indications
			25.7.2	 Ultrasound Probe Positioning and Sonography
			25.7.3	 Our Clinical Application
			25.7.4	 Limitations
		25.8	 Conclusions
		References
	26: Surgical Techniques: Operative Decompression Using the Transaxillary Approach for NTOS
		26.1	 Introduction
		26.2	 Operative Technique
			26.2.1	 Pre-Operative Considerations
			26.2.2	 Positioning
			26.2.3	 Exposure
			26.2.4	 Mobilization of the Rib
			26.2.5	 Resection of the Rib
			26.2.6	 Closure
			26.2.7	 Postoperative Care
			26.2.8	 Postoperative Complications
				26.2.8.1	 Pneumothorax
				26.2.8.2	 Nerve Injuries
				26.2.8.3	 Injury to the Subclavian Artery and Vein
				26.2.8.4	 Lymphatic Leaks
		26.3	 Conclusion
		References
	27: Surgical Techniques: Operative Decompression Using the Supraclavicular Approach for Neurogenic Thoracic Outlet Syndrome
		27.1	 Introduction
		27.2	 Surgical Technique
		27.3	 Potential Complications and Postoperative Care
		27.4	 Results
		27.5	 Conclusion
		References
	28: Surgical Techniques: Operative Decompression Using Thoracoscopic Approach for Neurogenic Thoracic Outlet Syndrome
		28.1	 Introduction
		28.2	 Common Approaches to FRR
		28.3	 Transthoracic Approaches to First Rib Resection
			28.3.1	 Technique of Robotic FRR
		28.4	 Short-Term Outcomes for Transthoracic FRR
		28.5	 Long-Term Outcomes for Transthoracic FRR
		28.6	 Conclusion
		References
	29: Surgical Techniques: Pectoralis Minor Tenotomy for NTOS
		29.1	 Introduction
		29.2	 Diagnosis and Indications for Procedure
		29.3	 Surgical Techniques
			29.3.1	 Deltopectoral (Anterior) Approach
			29.3.2	 Infraclavicular/Subclavicular (Anterior) Approach
			29.3.3	 Transaxillary (Lateral) Approach
		29.4	 Followup Care
		References
	30: Surgical Techniques: Dorsal Cervico-Thoracic Sympathectomy
		30.1	 Introduction
		30.2	 Indications
		30.3	 Surgical Technique
		30.4	 Postoperative Care, Potential Complications, and Results
		30.5	 Summary
		References
	31: Botulinim Toxin Injection and Advanced Interventional Techniques for NTOS and Cervical Brachial Syndrome
		31.1	 Botulinum Chemodenervation
		31.2	 Ultrasound Guided Brachial Plexus Blocks
		31.3	 Ultrasound-Guided Stellate Blocks
		31.4	 Suprascapular and Axillary Blocks
		31.5	 Facet Blocks
			31.5.1	 Myofascial Pain
		31.6	 Conclusion
		References
	32: NTOS in the Competitive Athlete
		32.1	 Introduction
		32.2	 Athletic Activities Predisposing to NTOS
		32.3	 Misdiagnosed Condition in Athletes with NTOS
		32.4	 Treatment and Results
		32.5	 Conclusion
		References
	33: Neurogenic TOS in Children
		33.1	 Introduction
		33.2	 Epidemiology
		33.3	 Presentation and Exam
		33.4	 Imaging Studies
			33.4.1	 Xray and CT
			33.4.2	 MRI
			33.4.3	 Ultrasound
		33.5	 Conservative Management
		33.6	 Surgical Management
			33.6.1	 Indications
			33.6.2	 Outcomes
			33.6.3	 Surgical Techniques
			33.6.4	 Complications
		33.7	 Conclusion
		References
	34: Recurrent and Residual Neurogenic Thoracic Outlet Syndrome
		34.1	 Introduction
		34.2	 Etiology and Types
		34.3	 Time of Recurrence
		34.4	 Differential Diagnosis and Associated Conditions
		34.5	 Symptoms
		34.6	 Physical Examination
		34.7	 Diagnostic Tests
			34.7.1	 Imaging
			34.7.2	 Muscle Blocks
			34.7.3	 Electrodiagnostic Studies
		34.8	 Treatment: Nonoperative
			34.8.1	 Verify the Diagnosis
			34.8.2	 Physical Therapy
			34.8.3	 Work Place and Lifestyle Changes
			34.8.4	 Pain Management
		34.9	 Surgical Treatment for Recurrent NTOS
		34.10	 Choice of Operation
			34.10.1 Pectoralis Minor Tenotomy
			34.10.2 Transaxillary First Rib Resection & Neurolysis C8 and T1
			34.10.3 Supraclavicular (SC) Scalenectomy with Neurolysis
		34.11	 Combined Transaxillary (TA) and Supraclavicular (SC) Approaches
		34.12	 Posterior Subscapular Approach to Brachial the Plexus
		34.13	 Transaxillary and Supraclavicular Neurolysis, and Latissimus Dorsi Muscle Transfer Flap
		34.14	 Amnion Membrane (AM) to Reduce Recurrence
		References
Part IV: Neurogenic TOS: Unanswered Questions
	35: Controversies in Neurogenic Thoracic Outlet Syndrome (NTOS): What Testing Is Needed to Establish the Diagnosis?
		35.1	 Introduction
		35.2	 Medical Imaging Studies
		35.3	 Noninvasive Vascular Laboratory Evaluation
		35.4	 Electrodiagnostic Studies
		35.5	 Other Laboratory Studies
		35.6	 Discussion
		35.7	 Conclusions
		References
	36: Botulinum Toxin Injections for Neurogenic Thoracic Outlet Syndrome
		36.1	 Introduction
		36.2	 Mechanism of Action
		36.3	 Technical Considerations
			36.3.1	 Potency and Formulation
			36.3.2	 Dosing and Injection Technique
			36.3.3	 Onset and Duration of BTX Effect
			36.3.4	 Safety and Potential Side Effects
		36.4	 Indications
		36.5	 Conclusions
		References
	37: What Do the Results of Conservative Therapy Tell Us About the Need for Surgery: Lack of Improvement Means Surgery Is Indicated
		37.1	 Lack of Improvement Means Surgery Is Indicated
		37.2	 Rationale for Physical Therapy
		37.3	 Use of Response to Physical Therapy as a Clinical Decision
		37.4	 Conclusion
		References
	38: Point/Counterpoint: What Does the Result of Conservative Therapy Tell Us About the Need for Surgery? Improvement Means Surgery Is Indicated
		38.1	 Introduction
		38.2	 Diagnostic and Treatment Algorithm for NTOS at Stanford
		38.3	 The Edgelow Protocol PT
		38.4	 Predicting a Positive Response to Rib Resection in TOS Patients
		38.5	 Conclusion
		References
	39: Controversies in NTOS: Transaxillary or Supraclavicular First Rib Resection in NTOS? Arguments Pro and Con the Transaxillary Approach in Favor of Transaxillary First Rib Resection
		39.1	 Introduction
		39.2	 Advantages of TAFRR
			39.2.1	 TAFRR Avoids Nerve Injury
			39.2.2	 TAFRR Avoids Damaging Other Muscle Groups
			39.2.3	 TAFRR Is a Very Effective Operation
			39.2.4	 An Advantage Less Frequently Employed
		39.3	 Disadvantages of TAFRR
			39.3.1	 Most Physicians Are Not Familiar with the Anatomy
			39.3.2	 Teaching the Operation Is Difficult
			39.3.3	 Special Equipment Is Not Widely Available
			39.3.4	 TAFRR Does Not Allow Complete Scalene Muscle Resection
			39.3.5	 Misconceptions of TAFRR
			39.3.6	 Arterial Reconstruction Is Difficult
		39.4	 Conclusion
		References
	40: Point/Counterpoint: Supraclavicular Decompression Is the Best Approach for Neurogenic Thoracic Outlet Syndrome
		40.1	 Introduction
		40.2	 Indications and Goals of Surgical Treatment
		40.3	 Transaxillary First Rib Resection
		40.4	 Supraclavicular Decompression
		40.5	 Potential Complications and Results
		40.6	 Conclusions
		References
	41: Does the First Rib Always Need to Be Removed?
		41.1	 Introduction
		41.2	 The Pathology Is in the Scalene Muscles
		41.3	 Advantage of Sparing the First Rib
		41.4	 Conclusion
		References
	42: Controversies in NTOS: What Is the Evidence Supporting Brachial Plexus Neurolysis and Wrapping
		42.1	 Introduction
		42.2	 Neuroloysis
		42.3	 Wrapping
		References
Part V: Neurogenic TOS: Outcomes and Future Directions
	43: Neurogenic TOS: Early Postoperative Care
		43.1	 Introduction
		43.2	 Surgical Floor
		43.3	 Hospital Discharge
		43.4	 Office Follow-Up
		43.5	 Conclusion
		References
	44: Perioperative Pain Management for Thoracic Outlet Syndrome Surgery
		44.1	 General Concepts
			44.1.1	 Non-opioid Adjuvant Medications
			44.1.2	 Opioids
			44.1.3	 Nerve Block Procedures
		44.2	 Preoperative Strategies
		44.3	 Intraoperative Strategies
		44.4	 Postoperative Strategies
		44.5	 Conclusion
		References
	45: Rehabilitation After First Rib Resection
		45.1	 Introduction
		45.2	 Timetable for Rehabilitation
			45.2.1	 Immediate Postoperative Rehabilitation
			45.2.2	 Months 1 to 3 Rehabilitation
			45.2.3	 Long-Term Maintenance
		45.3	 Special Considerations
		45.4	 Physical Therapy Results from FRR Surgery
		45.5	 Conclusion
		References
	46: Outcomes After Treatment of NTOS
		46.1	 Introduction
		46.2	 Assessment of Outcomes
		46.3	 Predictors of Surgical Outcomes
		46.4	 Postoperative Complications
		46.5	 Late Term Outcome
		46.6	 Conclusion
		References
	47: Management of Nerve Dysfunction after First Rib Resection
		47.1	 Introduction
		47.2	 Phrenic Nerve Injury
		47.3	 Long Thoracic Nerve Injury
		47.4	 Brachial Plexus Injury
		47.5	 Conclusion
		References
	48: Management of Coexisting Factors Complicating NTOS
		48.1	 Coexisting, Confusing, and Complicating Factors
			48.1.1	 Cervical Spine Disorders
			48.1.2	 Cervical Dystonia and Other Segmental Dystonias
			48.1.3	 Myofascial Pain
			48.1.4	 Musculoskeletal Conditions of the Shoulder, Elbow and Hand
			48.1.5	 Carpal Tunnel Syndrome
			48.1.6	 Patients with Ulnar Neuropathy
			48.1.7	 Chronic Headache
			48.1.8	 Depression, Somatization and Iatrogenicity
		48.2	 Conditions that Drastically Change Management: Conditions Characterized by Sensitization
			48.2.1	 Complex Regional Pain Syndrome
			48.2.2	 Fibromyalgia
			48.2.3	 Opioid Hyperalgesia
			48.2.4	 Post-Operative Neuropathic Pain Due to Epineural Fibrosis
		48.3	 Conclusion
		References
	49: Treatment for Thoracic Outlet Syndrome: A UK Perspective
		49.1	 Introduction
		49.2	 Training
		49.3	 Techniques
		49.4	 Diagnosis
		49.5	 Surgical Approaches
		49.6	 Pectoralis Minor Syndrome (PMS)
		49.7	 Brachial Plexus Neurolysis
		49.8	 Service Development
		49.9	 TOS Registry
		49.10	 Summary
		References
	50: Neurogenic TOS in the United Kingdom: A Consultant Orthopaedic Physiotherapist’s View
		50.1	 A Catalysing Event
		50.2	 A Search for Help
		50.3	 Addressing the Problem
		50.4	 Clinical Implications
		50.5	 Next Steps
		50.6	 Conclusions
		References
	51: Diagnosis and Treatment of Thoracic Outlet Syndrome in The Netherlands
		51.1	 Introduction
		51.2	 Implementation of Guidelines
			51.2.1	 NTOS
			51.2.2	 Standardized EAST (See Chap. 9)
			51.2.3	 VTOS and ATOS
			51.2.4	 VTOS
			51.2.5	 TOD in VTOS
			51.2.6	 ATOS
			51.2.7	 After TOD
		51.3	 Creating a Multidisciplinary Platform
		51.4	 Results of the Dedicated TOS Care Pathway
		51.5	 Conclusion
		References
	52: Research Directions in Neurogenic Thoracic Outlet Syndrome
		52.1	 Introduction
		52.2	 Incidence, Etiology and Pathophysiology of NTOS
		52.3	 Diagnosis
		52.4	 Treatment Approaches
		52.5	 Conclusion
		References
Part VI: Venous TOS: General Principles and Diagnosis
	53: Anatomy and Pathophysiology of Venous Thoracic Outlet Syndrome
		53.1	 Introduction
		53.2	 Anatomy
		53.3	 Pathophysiology
		53.4	 Evidence Based VTOS Practice
		53.5	 Summary
		References
	54: Diagnosis of VTOS: 2016 Consensus Guidelines
		54.1	 Introduction
		54.2	 What Is Venous Thoracic Outlet Syndrome?
		54.3	 How Is VTOS Diagnosed?
		54.4	 Conclusions
		References
	55: Imaging in VTOS
		55.1	 Introduction
		55.2	 Presentation
		55.3	 First Steps: Duplex Ultrasound and Plain Radiography
		55.4	 Cross-Sectional Imaging
		55.5	 Catheter Based Venography
		55.6	 Conclusions
		References
	56: VTOS for the PCP—When to Consider the Diagnosis
		56.1	 Introduction
		56.2	 Natural History of VTOS
		56.3	 History, Physical Exam Findings, and Presenting Symptoms
		56.4	 Initial Evaluation, Diagnostic Testing, and Referral
		56.5	 Conclusion
		References
	57: Hypercoagulable Conditions and VTOS
		57.1	 Does an Underlying Hypercoagulable Disorder Contribute to the Formation of SVT in Patients with VTOS?
		57.2	 Should all Patients Be Tested for Thrombophilia?
		57.3	 What Tests Should Be Ordered When Evaluating Thrombophilia in Patients with VTOS?
		57.4	 Does the Presence of Hypercoagulability Lead to a Differential Outcome with Traditional Therapy? Should Patients with a Documented Hypercoagulable Condition Be Managed Any Differently?
		57.5	 Conclusion
		References
	58: VTOS in the Competitive Athlete
		58.1	 Clinical Presentation, Diagnosis, and Initial Treatment
		58.2	 Treatment Options
		58.3	 Anticoagulation
		58.4	 Surgical Treatment
		58.5	 Special Considerations in the Competitive Athlete
		References
	59: Thoracic Outlet Syndrome in Hemodialysis Patients
		59.1	 Introduction
		59.2	 Epidemiology/Pathology
		59.3	 Clinical Presentation/Diagnosis
		59.4	 Management
		59.5	 Summary
		References
Part VII: Venous TOS: Treatment
	60: Differential Diagnosis, Decision-Making, and Pathways of Care: Acute Thrombosis and Non-thrombotic Positional Compression
		60.1	 Introduction
		60.2	 Venous TOS
		60.3	 Presentation
		60.4	 Differential Diagnosis
		60.5	 Decision-Making
		60.6	 Acute Subclavian Vein Thrombosis: The Role of Anticoagulation
		60.7	 Acute Subclavian Vein Thrombosis: The Role of Thrombolysis
		60.8	 Acute Subclavian Vein Thrombosis: The Role of Surgery
		60.9	 Acute Subclavian Vein Thrombosis: Timing of Surgery
		60.10	 McCleery’s Syndrome: The Role of Surgery
		60.11	 What Surgical Approach Is Best?
		60.12	 What Are the Goals of Surgery?
		60.13	 What are the Roles of Reconstruction, Surgical Venoplasty, Balloon Angioplasty, and Stenting?
		60.14	 Post-operative Imaging
		60.15	 Treatment Algorithms
		60.16	 Summation
			60.16.1 Acute Subclavian Thrombosis
			60.16.2 Intermittent Non-Thrombotic Compression
		60.17	 Conclusion
		References
	61: Management of Chronic Venous Thoracic Outlet Syndrome
		61.1	 Introduction
		61.2	 Diagnosis
		61.3	 Decision-Making in the Chronic VTOS Patient
		61.4	 Clinical Management of the Chronic VTOS Patient
		61.5	 Results
		61.6	 Conclusions
		References
	62: Conservative (Non-Operative) Treatment of VTOS
		62.1	 Introduction
		62.2	 Historical Data
		62.3	 Contemporary Natural History Data
		62.4	 The Physiologic Consequences of Subclavian DVT and Its Treatment
		62.5	 Comment
		62.6	 Conclusion
		References
	63: Thrombolysis and Balloon Venoplasty for Subclavian Vein Thrombosis
		63.1	 Introduction
		63.2	 Pre Thrombolysis
		63.3	 Rationale for Lysis
		63.4	 Thrombolysis Technique
		63.5	 Catheter-Directed Thrombolysis (CDT)
		63.6	 Pharmacomechanical Thrombolysis (PMT) and Mechanical Thrombectomy
		63.7	 Devices
		63.8	 Ultrasound Accelerated Thrombolysis
		63.9	 Mechanical Fragmentation Devices
		63.10	 Suction and Mechanical Removal Devices
		63.11	 After Thrombolysis
		63.12	 Results of Thrombolysis
		63.13	 Post Thrombolysis Management
		63.14	 Conclusion
		References
	64: Surgical Techniques: Operative Decompression Using the Transaxillary Approach for Venous Thoracic Outlet Syndrome
		64.1	 Introduction
		64.2	 Compressive Elements
			64.2.1	 Surgical Strategies
			64.2.2	 Transaxillary First Rib Resection—Overview
			64.2.3	 Transaxillary First Rib Resection—Technique
			64.2.4	 Pitfalls of Transaxillary First Rib Resection for VTOS
				64.2.4.1	 Incomplete Resection of the First Rib
			64.2.5	 Failure to Divide the Subclavius Tendon
			64.2.6	 Entry to the Pleural Space
			64.2.7	 Hemorrhage
			64.2.8	 Brachial Plexus Injury
			64.2.9	 Inadvertent Second Rib Resection
		64.3	 Post-Operative Management
			64.3.1	 Venography
			64.3.2	 Anticoagulation
			64.3.3	 Persistent or Recurrent Symptoms
		64.4	 Conclusion
		64.5	 Equipment
		64.6	 First Rib Arm Holder
		64.7	 Figure 64.3
			64.7.1	 Fiber-Optic Lighted Retractors
		64.8	 Figure 64.4
			64.8.1	 High-Definition Video-Endoscopy
		References
	65: Surgical Techniques: Operative Decompression Using the Infraclavicular Approach for VTOS with Intraoperative Venography
		65.1	 Introduction
		65.2	 Technique
		65.3	 Postoperative Management
		65.4	 Outcomes
		65.5	 Summary
		References
	66: Surgical Techniques: Operative Decompression Using the Paraclavicular Approach for Venous Thoracic Outlet Syndrome
		66.1	 Introduction
			66.1.1 Diagnosis, Venography and Thrombolysis
			66.1.2 Indications for Surgery
			66.1.3 Goals of Treatment
			66.1.4 Selection of Surgical Approach
			66.1.5 Timing of Surgical Treatment
		66.2	 Surgical Technique
			66.2.1 Patient Preparation
			66.2.2 Supraclavicular Exposure
			66.2.3 Anterior Scalenectomy
			66.2.4 Mobilization of the Brachial Plexus
			66.2.5 Middle Scalenectomy
			66.2.6 Division of the Posterior First Rib
			66.2.7 Infraclavicular Exposure and First Rib Resection
			66.2.8 Exposure of the Subclavian Vein and Subclavius Muscle Resection
			66.2.9 External Subclavian Venolysis and Venography
			66.2.10 Subclavian Vein Reconstruction
			66.2.11 Vein Patch Angioplasty
			66.2.12 Vein Graft Bypass
			66.2.13 Closure, Postoperative Care, and Recovery
		66.3	 Special Circumstances
			66.3.1 Previous Stent Placement
			66.3.2 Long-Segment Axillary-Subclavian Vein Occlusion
			66.3.3 Rethrombosis After Thrombolysis
			66.3.4 Adjunctive Arteriovenous Fistula
			66.3.5 Hemodialysis Access Salvage
			66.3.6 Recurrent Venous TOS After a Previous Operation
		66.4	 Results
		66.5	 Conclusions
		References
	67: The Robotic Transthoracic Approach for Venous Thoracic Outlet Syndrome
		67.1	 Introduction
		67.2	 Management and Surgical Approaches for VTOS
		67.3	 Transthoracic Robotic First Rib Resection for VTOS
		67.4	 Outcomes for Transthoracic FRR for VTOS
		67.5	 Institutional Approach to Patients with VTOS
		References
	68: Medial Claviculectomy for VTOS
		68.1	 Introduction
		68.2	 Technique
		68.3	 Results
		68.4	 Summary
		References
	69: Advanced Surgical Techniques in Venous Thoracic Outlet Syndrome
		69.1	 Introduction
		69.2	 Indications
		69.3	 Exposures
			69.3.1	 Transsternal Extension (“Molina Procedure”)
			69.3.2	 Claviculectomy
		69.4	 Venous Reconstruction
			69.4.1	 Jugular Turndown (Jugular Venous Transposition)
			69.4.2	 Endovenectomy and Patch Angioplasty
			69.4.3	 Venous Bypass
			69.4.4	 Temporary Arteriovenous Fistula
		69.5	 General Considerations
		69.6	 Conclusion
		References
Part VIII: Venous TOS: Unanswered Questions
	70: Point/Counterpoint: Is Thrombolysis Always Required in Patients with Effort Thrombosis?
		70.1	 Introduction
		70.2	 Current Management of VTOS
		70.3	 Role of Thrombolysis
		70.4	 Surgical Decompression Without Thrombolysis
		70.5	 Conclusion
		References
	71: Management of Residual Stenosis after Thrombolysis
		71.1	 Introduction
		71.2	 Management of Stenosis after Thrombolysis
		71.3	 Management of Residual Stenosis after First Rib Resection
		71.4	 Summary
		References
	72: First Rib Resection Is Always Needed After Thrombolysis
		72.1	 Introduction
		72.2	 The Rationale for Surgical Thoracic Outlet Decompression
		72.3	 The Evidence for Surgical Decompression
		72.4	 Outcomes of Primarily Non-operative Management Are Poor
		72.5	 Why Not Remove the First Rib?
		72.6	 Defining a Post-Thrombolysis Treatment Protocol
		72.7	 Conclusions
		References
	73: Controversies in VTOS: Is Thrombolysis Alone Sufficient Treatment for VTOS?—YES
		73.1	 Introduction
		73.2	 Arguments Favoring Decompression of the Costoclavicular Space
		73.3	 Arguments Favoring Alternative Approaches to the Management of VTOS
		73.4	 Comment
		References
	74: Controversies in Venous Thoracic Outlet Syndrome: Timing of First Rib Resection After Thrombolysis
		74.1	 Introduction
		74.2	 Initial Treatment
		74.3	 Delayed First Rib Resection
		74.4	 Early First Rib Resection
		74.5	 Selective First Rib Resection
		74.6	 Summary
		References
	75: Controversies in VTOS: What Is the Best Approach for VTOS?
		75.1	 Initial Description
		References
	76: Controversies in VTOS: What Is the Best Approach to the First Rib in VTOS?
		76.1	 Introduction
		76.2	 The Patient with a Normal Subclavian Vein
		76.3	 The Patient with a Diseased Subclavian Vein
		76.4	 The Patient with an Occluded Vein
		76.5	 Summary
		References
	77: Point/Counterpoint: Paraclavicular Decompression Is the Best Approach for Venous Thoracic Outlet Syndrome
		77.1	 Introduction
		77.2	 Transaxillary Approach
		77.3	 Infraclavicular Approach
		77.4	 Disadvantages of the Transaxillary and Infraclavicular Approaches
		77.5	 Paraclavicular Approach
		77.6	 Results and Comparative Advantages of the Paraclavicular Approach
		77.7	 Conclusions
		References
	78: Controversies in Venous Thoracic Outlet Syndrome: Is There a Role for Venous Stents?
		78.1	 Background
		78.2	 Stenting Without Bony Decompression
		78.3	 Stenting After Bony Decompression
		78.4	 Our Experience
		78.5	 The Patient with Ipsilateral AV Access
		78.6	 Conclusions
		References
Part IX: Venous TOS: Outcomes and Future Directions
	79: Venous TOS: Early Postoperative Care
		79.1	 Introduction
		79.2	 General Aspects of Postoperative Care
		79.3	 Anticoagulation and Venous Thrombosis
		79.4	 Bleeding and Hemothorax
		79.5	 Lymph Leak
		79.6	 Hospital Discharge
		79.7	 Office Follow-Up
		79.8	 Late Venous Stenosis or Occlusion
		79.9	 Conclusion
		References
	80: Controversies in VTOS: How Long Should Anticoagulation Be Used in VTOS?
		80.1	 Introduction
		80.2	 Pathophysiology
		80.3	 Goals of Anticoagulation
		80.4	 Chest Guidelines
		80.5	 Duration of Therapy in Patients with VTOS
		80.6	 Imaging
		80.7	 Thrombophilia
		80.8	 Condition of the Subclavian Vein Following Decompression
		80.9	 Recommendations Based on Presentation
		80.10	 Conclusions
		References
	81: VTOS: Management of the Contralateral Side and Asymptomatic Compression
		81.1	 Introduction
		81.2	 VTOS Pathology
		81.3	 Intermittent Positional Obstruction
		81.4	 VTOS: The Contralateral Side Review of Literature
		81.5	 Summary and Recommendations
		References
	82: Outcomes After Treatment of VTOS
		82.1	 Introduction
		82.2	 Limitations
		82.3	 Conservative Treatment of VTOS: Symptom Management, Anticoagulation
		82.4	 Pre-decompression Catheter-Directed Thrombolysis and Venoplasty
		82.5	 Definitive Treatment with Decompressive Surgery
		82.6	 Anticoagulation Following Decompression
		82.7	 Post-decompression Angioplasty, Stenting, and Reconstruction
		82.8	 Best Practices
		82.9	 Conclusion
		References
	83: Assessment and Treatment of Recurrent Venous Thoracic Outlet Syndrome
		83.1	 Introduction
		83.2	 Clinical Characterization of Symptoms
		83.3	 Further Evaluation and Treatment Options
			83.3.1	 Persistent Primary and Secondary Neurogenic TOS
			83.3.2	 Persistent/Recurrent Venous TOS
		83.4	 Reoperations for Venous TOS
		83.5	 Conclusions
		References
Part X: Arterial TOS: General Principles and Diagnosis
	84: Anatomy and Pathophysiology of ATOS
		84.1	 Introduction
		84.2	 Etiology
		84.3	 Anatomy
			84.3.1	 Cervical Ribs
			84.3.2	 Anomalies of the First Thoracic Ribs
			84.3.3	 Anomalies of the Transverse Process of the Seventh Cervical Vertebra
		84.4	 Pathophysiology
		84.5	 Conclusion
		References
	85: Clinical Presentation and Patient Evaluation in ATOS
		85.1	 Introduction
		85.2	 Epidemiology
		85.3	 Clinical Presentation
		85.4	 Patient Evaluation
			85.4.1	 History
			85.4.2	 Physical Examination
		85.5	 Provocative Testing
		85.6	 Imaging Studies
		85.7	 Conclusion
		References
	86: ATOS Consensus Guidelines
		86.1	 Introduction
		86.2	 Confusion in Concept of ATOS
		86.3	 SVS Reporting Standards
		86.4	 Imaging
		86.5	 Exclusions
			86.5.1	 Humeral Head Syndrome
			86.5.2	 Arterial Quadrilateral Space Syndrome
		86.6	 Conclusion
		References
	87: The Axillary Artery and Humeral Head in ATOS
		87.1	 Introduction
		87.2	 Anatomy/Pathophysiology
		87.3	 Evaluation and Management
		87.4	 Summary
		References
	88: Quadrilateral Space Syndrome
		88.1	 Introduction
		88.2	 Etiology
		88.3	 Pathogenesis
		88.4	 Clinical Features
		88.5	 Diagnosis
		88.6	 Treatment
			88.6.1	 Case Report (Neurogenic QSS)
			88.6.2	 Case Report (Vascular QSS)
		88.7	 Prognosis
		88.8	 Conclusion
		References
	89: Arterial Thoracic Outlet Syndrome in the Competitive Athlete
		89.1	 Introduction
		89.2	 Clinical Recognition
		89.3	 Arterial TOS: Subclavian Artery
		89.4	 Arterial TOS: Axillary Artery and its Branches
		89.5	 Quadrilateral Space Syndrome: Distal PCHA
		89.6	 Special Considerations in the Competitive Athlete
		89.7	 Conclusions
		References
Part XI: Arterial TOS: Treatment
	90: Decision-Making and Pathways of Care for ATOS
		90.1	 Introduction
		90.2	 Clinical Decision Making
		90.3	 Clinical Pathways
		90.4	 Conclusions
		References
	91: Surgical Techniques: Endovascular Intervention for Arterial Thoracic outlet Syndrome
		91.1	 Introduction
		91.2	 Diagnosis
		91.3	 Imaging
		91.4	 Interventional Management
		91.5	 Special Considerations
		91.6	 Results
		91.7	 Summary
		References
	92: Axillosubclavian Artery Repair and Reconstruction
		92.1	 Etiology of Axillary Artery Injury
		92.2	 Preoperative Imaging and Planning
		92.3	 Surgical Preparation
		92.4	 Exposure
			92.4.1	 Supraclavicular Approach to the Subclavian Artery
			92.4.2	 Infraclavicular Approach to the Axillary Artery
			92.4.3	 Distal Axillary Exposure
		92.5	 Surgical Repair
			92.5.1	 Axillosubclavian Artery Aneurysms
			92.5.2	 Isolated Axillary Artery or Branch Aneurysms
			92.5.3	 Intraoperative Imaging
		92.6	 Postoperative Care
		92.7	 Conclusion
		References
	93: Upper Extremity Fasciotomy After Arterial Embolization
		93.1	 Introduction
		93.2	 Diagnosis
		93.3	 Surgical Technique
		93.4	 Post-operative Care
		93.5	 Complications
		93.6	 Conclusions
		References
	94: Quadrilateral Space Syndrome and Management of the Posterior Circumflex Humeral Artery
		94.1	 Introduction and Background
		94.2	 Diagnosis/Imaging
		94.3	 Quadrilateral Space Decompression
		94.4	 Outcomes
		94.5	 Conclusion
		References
	95: Management of Digital Emboli, Vasospasm, and Ischemia
		95.1	 Clinical Presentation
		95.2	 Diagnosis
		95.3	 Treatment
		95.4	 Intraoperative Administration of Thrombolytic and Vasodilator Agents
		95.5	 Cervical Sympathectomy
		95.6	 Periarterial Digital Sympathectomy
		95.7	 Botulinum Toxin
		95.8	 Prognosis
		95.9	 Conclusions
		References
Part XII: Arterial TOS: Outcomes and Future Directions
	96: Outcomes After Treatment of Arterial Thoracic Outlet Syndrome
		96.1	 Introduction
		96.2	 Literature Review
		96.3	 The Baylor Dallas Experience
		96.4	 Cumulative Results
		96.5	 Summary
		References
	97: Recurrent and Residual ATOS
		97.1	 Introduction
		97.2	 Etiology
		97.3	 Pathology
		97.4	 Symptoms
		97.5	 Physical Findings
		97.6	 Diagnostic Tests
		97.7	 Treatment
		97.8	 Treatment of Non-reconstructable Arterial Occlusion in Recurrent ATOS
		97.9	 Neuromodulation
		97.10	 Sympathectomy
		97.11	 Conclusion
		References
Part XIII: Additional Topics Related to Thoracic Outlet Syndrome
	98: Medicolegal Issues in TOS
		98.1	 Physician as Witness
		98.2	 Physician as Defendant
		98.3	 Physician as Expert Witness
		98.4	 Conclusion
		References
	99: Disability and Workers’ Compensation Issues in TOS
		99.1	 Introduction-Workers’ Compensation 101
		99.2	 Outcomes of TOS Surgery in Workers’ Compensation Patients
		99.3	 The Washington Workers Compensation TOS Surgery Guideline: Cervicobrachial Syndrome
		99.4	 Conclusion
		References
	100: Special Considerations in the Elite High Profile Athlete
		100.1	 Introduction
		100.2	 Diagnosis and Treatment
		100.3	 Special Considerations in the Elite/Professional Athlete
		100.4	 Summary
	101: Combined and Secondary Forms of TOS
		101.1	 Introduction
		101.2	 Combined NTOS and VTOS
		101.3	 Does Combined NTOS and ATOS Exist?
			101.3.1 Arterial and Neurogenic Thoracic Outlet Syndromes
			101.3.2 Arterial Occlusive Disease and Neurogenic Thoracic Outlet Syndrome
			101.3.3 Other Arterial Pathologies and Neurogenic Thoracic Outlet Syndrome
		101.4	 Secondary TOS
			101.4.1 Venous Recurrence After Neurogenic Thoracic Outlet Decompression
			101.4.2 Neurogenic Recurrence After Venous Thoracic Outlet Decompression
		101.5	 Conclusions
		References
	102: TOS: The Perspective of the Patient
		102.1	 Vignette 1: An Older Competitive Swimmer with NTOS
		102.2	 Vignette 2: A Teen-Aged Swimmer’s Story
		102.3	 Vignette 3: Redo Surgery
		102.4	 From the First Edition
			102.4.1 Vignette 4: A Motor Vehicle Accident and Physical Therapy
			102.4.2 Vignette 5: Repetitive Data Entry and Physical Therapy
			102.4.3 Vignette 6: Recurrent NTOS in a Physician
			102.4.4 Vignette 7: An NTOS Journey
	103: Venous TOS: The Perspective of the Patient
		103.1	 Vignette 1: Classic Paget-Schroetter Syndrome
		103.2	 Vignette 2: Confusion, Ignorance, and Patient Empowerment
		103.3	 From the First Edition
			103.3.1 Vignette #3: Venous TOS and Surgery
			103.3.2 Vignette #4: Bilateral VTOS and Secondary NTOS and Surgery
	104: TOS, the Internet and Social Media
		104.1	 Turning to the Internet and the TOS Shuffle
		104.2	 Searching the Internet and Inaccurate Information
		104.3	 Examples of Trusted Sites with Informative Information
		104.4	 Some Help Identifying “Problem” Websites
		104.5	 Social Media Support Groups
		104.6	 Finding the Right Doctor
		104.7	 Conclusion
	105: Establishing a TOS-Focused Practice
		105.1	 Introduction
		105.2	 Concentration of Resources
		105.3	 Other Benefits
		105.4	 Practical Considerations
		105.5	 A Practical Example
		105.6	 Summary
		References
Index