Whiplash injury. TOS and double crush syndrome. Forensic medical aspects

Efficacy of Supraclavicular Scalenotomy Followed by External Neurolysis without Rib Resection for Post-traumatic Neurogenic Thoracic Outlet Syndrome

Most patients with neurogenic thoracic outlet syndrome (NTOS) have a history of trauma. Scar tissue formation within the scalene muscle and around the nerves after injury cause arm and hand symptoms. We report that supraclavicular scalenotomy followed by external neurolysis without rib resection is very effective as the surgical treatment.

Post-traumatic thoracic outlet syndrome

BACKGROUND

To evaluate the clinical presentation, diagnostic and therapeutic management and outcome of 27 cases of post-traumatic thoracic outlet syndrome (PT TOS).

METHODS

Retrospective chart analysis.

RESULTS

Nineteen women and eight men were included in this study. Involvement in a traffic accident was the most common scenario. Fracture of either the first rib or the clavicle was reported in eight patients at the time of injury; in others, the diagnosis was cervical or shoulder soft tissue trauma. Upon presentation at our clinic at a mean 41 months after injury, four patients had bilateral symptoms and 17 reported decreased function of either the arm or hand. Two patients presented with severe lower trunk deficits including one who had received surgical intervention at both the cervical spine and elbow before diagnosis of TOS was made. Sixteen and 15 patients were suffering from some degree of anxiety and/or depression. Upon diagnosis of neurogenic TOS, the two patients with atrophy of the hand musculature were treated surgically. Conservative treatment was applied to all other patients. Six months after presentation to our clinic, nine patients demonstrated a significant improvement. The remainder that reported incapacitating symptoms were offered surgical treatment. Three patients declined the latter. Fifteen patients received surgical treatment via an anterior supraclavicular approach with resection of the anterior scalene muscles. Eleven patients had resection of the middle scalene muscle while five had resection of an osseous structure (partial claviculectomy, C7 transverse process or a cervical rib). The two patients with atrophy of the hand only slightly improved their motor deficit but had a notable relief of symptoms of pain. Postoperative improvement occurred in 80% of surgically treated patients.

CONCLUSIONS

The majority of patients suffering from a post-traumatic TOS present a neurogenic, usually subjective syndrome. Prompt therapeutic management is necessary, addressing both physical and psychological complaints. Most patients are cured or well improved by conservative and/or surgical treatment.

Thoracic outlet syndrome: a review

BACKGROUND

: Arterial and venous thoracic outlet syndrome (TOS) were recognized in the late 1800s and neurogenic TOS in the early 1900s. Diagnosis and treatment of the 2 vascular forms of TOS are generally accepted in all medical circles. On the other hand, neurogenic TOS is more difficult to diagnose because there is no standard objective test to confirm clinical impressions.

REVIEW SUMMARY

: The clinical features of arterial, venous, and neurogenic TOS are described. Because neurogenic TOS is by far the most common type, the pathology, pathophysiology, diagnostic tests, differential and associate diagnoses, and treatment are detailed and discussed. The controversial area of objective and subjective diagnostic criteria is addressed.

CONCLUSION

: Arterial and venous TOS are usually not difficult to recognize and the diagnosis can be confirmed by angiography. The diagnosis of neurogenic TOS is more challenging because its symptoms of nerve compression are not unique. The clinical diagnosis relies on documenting several positive findings on physical examination. To date there is still no reliable objective test to confirm the diagnosis, but measurements of the medial antebrachial cutaneous nerve appear promising.