Decline of neurogenic thoracic outlet surgery in Washington State workers’ compensation: Effective use of a medical treatment guideline

In Washington workers’ compensation, population-based outcomes from neurogenic thoracic outlet syndrome surgery (nTOS) have been very poor, including long-term disability, severe adverse events, and substantially increased cost. Data is reported here on temporal trends in the incidence of approvals to conduct surgery for nTOS. An earlier population-based study of outcomes for nTOS surgery in Washington workers’ compensation revealed that approximately 26 cases per year had been conducted between 1986-1991. Following implementation of a medical treatment guideline that requires objective evidence of brachial plexus involvement, denials of the surgery increased. In more recent years, only 3 cases per year have been approved. Surgery for nTOS has dramatically declined in Washington workers’ compensation, likely as a result of a high denial rate as well as a sentinel effect on prospective nTOS surgery requests.