Supraclavicular approach for thoracic outlet syndrome

Anterior Scalene Muscle Block Response Predicts Outcomes Following Thoracic Outlet Decompression

BACKGROUND

There is no definitive objective measure for diagnosis of thoracic outlet syndrome (TOS), and functional capacity testing on standardized rehabilitation exercises before and after an anterior scalene muscle block (ASMB) has the potential to serve as a predictor of response to surgery and to improve diagnostic accuracy in these cases.

METHODS

Patients evaluated for TOS underwent ASMB as a diagnostic test and were retrospectively reviewed. Functional capacity scores were recorded for patients performing repetitive motion exercises immediately before ASMB, 15 minutes after ASMB, and at a minimum of 6 weeks after thoracic outlet decompression (TOD). The primary outcome of interest was correlation between the pre- to post-ASMB difference and the pre-ASMB to postoperative difference with respect to 3 functional work capacity scores.

RESULTS

The average change in time-to-fatigue and work product between pre- and post-ASMB of all exercises was an increase of 39.5% and 53.8%, respectively. The greatest pre-ASMB to post-TOD difference was seen for the Extremity Abduction Stress Test with an average improvement of 109.7% and 150.4% for time-to-fatigue and work product, respectively. The degree of percent improvement post-ASMB correlated positively with the degree of percent improvement post-TOD for all exercises with respect to work product and time-to-fatigue.

CONCLUSIONS

Patient response to ASMB as measured by functional capacity on rehabilitation exercises predicted objective functional outcomes following TOD. Post-ASMB outcomes correlated with post-TOD outcomes. The ASMB can be used to assist in diagnosing TOS and provide a surrogate for expectation in patients considering undergoing neurogenic TOD.

Thoracic outlet syndrome in overhead athletes

Background

We aimed to retrospectively compare the clinical outcomes of endoscopy-assisted first-rib resection for thoracic outlet syndrome (TOS) between overhead athletes and nonathletes and investigate the return to same-level sports rate in overhead athletes.

Methods

We retrospectively reviewed 181 cases with TOS (75 women, 106 men; mean age, 28.4 years; range, 12-57 years) who underwent endoscopy-assisted first-rib resection. We divided into two groups: 79 overhead athletes and 102 nonathletes groups. A transaxillary approach for first-rib resection and neurovascular decompression was performed under magnified visualization. Endoscopic findings related to the neurovascular bundle, interscalene distance, and scalene muscle were evaluated intraoperatively. We assessed the Roos and Disability of the Arm, Shoulder, and Hand scores, return to same-level sports rate, and ball velocity.

Results

Overhead athletes were significantly more likely to be men, younger, used the dominant side more frequently, and have a larger physique, more shoulder and elbow pain, and shorter symptom duration. The outcomes of the Roos score revealed significant differences in excellent or good results between overhead athletes (91.1%) and nonathletes (62.8%). The two groups significantly differed in preoperative and postoperative Disability of the Arm, Shoulder, and Hand and recovery rate scores (P = .007, < .001, < .001).

Conclusion

Overhead athletes with TOS were more likely to be men, younger, dominant side more frequently, and have more shoulder and elbow pain, and a shorter symptom duration. Endoscopy-assisted transaxillary first-rib resection and neurolysis provided superior clinical outcomes in overhead athletes with TOS compared with nonathletes and a high return-to-same-level-play rate in sports.

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review

Thoracic outlet syndrome is a constellation of signs and symptoms due to compression of the neurovascular bundle of the upper limb. In particular, neurogenic thoracic outlet syndrome can present with a wide constellation of clinical manifestations ranging from pain to paresthesia of the upper extremity, resulting in a challenge to correctly diagnose this syndrome. Treatment options range from nonoperative treatment, such as rehabilitation and physical therapy, to surgical correction, such as decompression of the neurovascular bundle.

Methods

Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome.

Results

Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS.

Conclusions

In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

Thoracic outlet syndrome: a review for the primary care provider

CONTEXT

Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS.

OBJECTIVES

This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options.

METHODS

The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS.

RESULTS

The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS.

CONCLUSIONS

The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.

Subclavian Artery Flow Dynamics Evaluated by Analytical Intraoperative Indocyanine Green Videoangiography During Surgical Treatment of Thoracic Outlet Syndrome: A Case Series

BACKGROUND

Indocyanine green (ICG) videoangiography is rarely used during the surgical treatment of thoracic outlet syndrome (TOS).

OBJECTIVE

To evaluate subclavian artery (SA) flow dynamics using the analytical ICG videoangiography during TOS surgeries.

METHODS

We examined patients with neurogenic TOS who received surgical treatment and whose SA blood flow at the interscalene space was evaluated using ICG videoangiography equipped with an analytical function (FLOW800). Anterior scalenectomy with or without middle scalenectomy and first rib resection were conducted for decompression of the brachial plexus. ICG videoangiography was performed before and after decompression of the brachial plexus. After acquisition of grayscale and color-coded maps, a region of interest was placed in the SA to obtain time-intensity diagrams. Maximum intensity (MI), rise time (RT), and blood flow index (BFi) were calculated from the diagram, in arbitrary intensity (AI) units. We compared values before and after decompression. Comparisons of the three parameters before and after decompression were assessed statistically using the paired t-tests and Wilcoxon signed-rank test.

RESULTS

We evaluated nine procedures in consecutively presenting patients. The observed mean values of MI, RT, and BFi before decompression were 174.1 ± 61.5 AI, 5.2 ± 1.1 s, and 35.2 ± 13.5 AI/s, respectively, and the observed mean values of MI, RT, and BFi after decompression were 299.3 ± 167.4 AI, 6.6 ± 0.8 s, and 44.6 ± 28.3 AI/s, respectively. These parameters showed higher values after decompression than before decompression, and the increase in MI and RT was statistically significant (P < .05).

CONCLUSION

ICG videoangiography allows semiquantitative evaluation of hemodynamic changes during TOS surgery. A marked decrease in the velocity of SA flow was observed after decompression.

Endoscopic-Assisted Transaxillary Approach for First Rib Resection in Thoracic Outlet Syndrome

Purpose

To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach.

Methods

We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores.

Results

We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score.

Conclusions

An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure.

Level of Evidence

IV, therapeutic case series.

Endoscopic-Assisted Transaxillary Approach for First-Rib Resection and Neurolysis in Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a complex disorder with signs and symptoms resulting from compression of the brachial plexus and subclavian vessels. Although transaxillary first-rib resection is a well-established surgical treatment for patients with symptomatic TOS, this approach sometimes does not allow adequate exposure of the insertion point of the middle scalene muscle to the posterior part of the first rib and neurovascular bundle. The objective of this Technical Note is to describe an endoscopic-assisted transaxillary approach for first-rib resection and neurolysis. An endoscopic-assisted transaxillary approach for first-rib resection in TOS can provide excellent magnified visualization and safely allow sufficient decompression of the neurovascular bundle.

Arm Numbness at 45 Degrees Abduction: A Case Report of Thoracic Outlet Syndrome After Brachial Neuritis

Objective

To describe a case of nerve kinking correlating with surgical findings in neurogenic thoracic outlet syndrome in a patient with history of brachial neuritis. Thoracic outlet syndrome and brachial neuritis are briefly reviewed.

Case report

A 32-year-old woman with a history of bilateral brachial neuritis presented with paraesthesias in her hand when abducting her shoulder to 45° or higher. A kink in the superior trunk of the brachial plexus, as well as asymmetrically narrowed costoclavicular space, was found on magnetic resonance imaging with the shoulder abducted. Conservative measures failed, leading to partial anterior scalenectomy and neurolysis, which led to improvement in her symptoms.

Conclusion

Anatomical variations in combination with biomechanical changes after brachial neuritis can be associated with neurogenic thoracic outlet syndrome.

Measurement of Outlet Pressures Favors Rib Resection for Decompression of Thoracic Outlet Syndrome

BACKGROUND

When conservative therapy for thoracic outlet syndrome fails, scalenectomy with or without first-rib resection (FRR) is the treatment of choice. We measured pressure in the costoclavicular space before and after FRR at time of neurogenic thoracic outlet syndrome release to evaluate whether FRR is required to completely decompress the costoclavicular space.

METHODS

Using a supraclavicular exposure for anterior-middle scalenectomy with FRR, costoclavicular space pressures were measured using a balloon catheter with the patient's arm in neutral anatomic position, secondarily, the arm abducted and externally rotated. Pressures were recorded in both arm positions before scalenectomy, after scalenectomy, and after FRR. Paired Student's t test was used to compare differences in group means for paired samples. Patient-reported outcomes were reported using the Derkash classification and quick disabilities of the arm, shoulder, and hand (qDASH) questionnaire.

RESULTS

Fifteen patients (16 cases) surgically treated for neurogenic thoracic outlet syndrome were included in this retrospective study. There was no significant difference in pressure change between arm positions before scalenectomy (161.56 ± 71.65 mm Hg difference) or after scalenectomy (148.5 ± 80.24 mm Hg difference). There was a significant difference in pressure change between post-scalenectomy and post-FRR arm positions; mean pressure change between arm positions after FRR was 50.56 ± 40.28 mm Hg. Mean postoperative qDASH score was 20 ± 23.2. All patients reported improvement in symptoms and functional status.

CONCLUSIONS

Supraclavicular first rib resection for management of neurogenic thoracic outlet syndrome can be safely performed with favorable outcomes. The pressure increase in the costoclavicular space caused by arm abduction and external rotation was significantly reduced only after FRR, raising concerns about potential incomplete costoclavicular space decompression with scalenectomy alone for neurogenic thoracic outlet syndrome management.

Paget-Schroetter syndrome: A contemporary review of the controversies in management

Aim

To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome.

Materials and methods

We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome.

Results

There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed.

Conclusions

Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.

Posterior Upper Rib Excision for Neurogenic Thoracic Outlet Syndrome---Feasibility and Early Outcomes

BACKGROUND

There are several surgical treatment options for neurogenic thoracic outlet syndrome (n-TOS). However, the first rib has been shown to be the common denominator of all TOS forms and the degree of its resection has been shown to correlate with the long-term success.

OBJECTIVE

To demonstrate the feasibility of posterior upper rib excision (PURE) and report early outcomes.

METHODS

Nine patients presented with signs and symptoms of n-TOS. Preoperative evaluation involved physical and neurological examination, arm visual analog score (VAS), cervical X-ray, magnetic resonance imaging (MRI) of the cervical spine, and brachial plexus MRI. All patients were operated at a single institution by a single surgeon. Postoperatively, clinical and radiological data were collected.

RESULTS

There were 2 men and 7 women in the study with 10 procedures performed. The age range was 18 to 45 with mean of 36.6 yr. Mean preoperative arm visual analog scale score was 7.8. The patients underwent posterior upper rib excision (PURE) by a single surgeon. One patient had bilateral surgery. The causes of TOS were fibrous bands, enlarged C7 transverse processes, narrow scalene triangle, and accessory ribs. All patients improved after surgery in terms of arm pain and quality of life. Postoperative mean visual analog scale score was 1.1 at 6 mo. In addition, neurological examination was normal at 6 mo postoperatively and all patients returned to their previous full-time jobs.

CONCLUSION

Posterior upper rib excision is a feasible surgical option for n-TOS.

Video-assisted thoracoscopic surgery for intrathoracic first rib resection in thoracic outlet syndrome

BACKGROUND

First rib resection is a surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, extrathoracic approaches have used a posterior, supraclavicular, or transaxillary incision to remove the first rib. In this report, we demonstrate video-assisted thoracoscopic surgery for intrathoracic first rib resection (VATS-IFRR).

METHODS

Between 2009 and 2014, eight patients underwent VATS-IFRR for TOS. Surgery was performed through two 5-mm ports and one 10-mm port. Endoscopic graspers, a hook-type electrocautery probe, a long peapod intervertebral disc rongeur, and Kerrison punches were used. The types of disease, operative times, chest tube indwelling days, lengths of hospital stay after operation, perioperative complications, postoperative pain scale ratings, and postoperative symptom recurrence rates at provocation tests were reviewed. The surgical outcomes were compared to published outcomes of extrathoracic approaches and other VATS approaches.

RESULTS

The eight patients (3 right ribs, 5 left ribs) exhibited neurogenic (1 patient), combined type (2 patients), arterial (4 patients), and venous type (1 patient) TOS. The mean operative time was 190 (range 155-310) minutes. No mortalities or major complications occurred. The mean chest tube indwelling duration was 6 (range 3-10) days, and the mean postoperative hospital stay was 9 (range 4-21) days. The mean immediate postoperative pain numeric rating scale (NRS) score was 2.7/10 (range 2-4). No recurrence was observed during follow-up (median 25.5 months, range 10-64 months) in any patient.

CONCLUSIONS

VATS-IFRR was safe and had several advantages. Thus, VATS-IFRR is a minimally invasive surgical option suitable for treating selective cases of TOS.

Thoracic outlet syndrome

Thoracic outlet syndrome is a well-described disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. Neurogenic thoracic outlet syndrome is the most common manifestation, presenting with pain, numbness, tingling, weakness, and vasomotor changes of the upper extremity. Vascular complications of thoracic outlet syndrome are uncommon and include thromboembolic phenomena and swelling. The clinical presentation is highly variable, and no reproducible study exists to confirm the diagnosis; instead, the diagnosis is based on a physician's judgment after a meticulous history and physical examination. Both nonsurgical and surgical treatment methods are available for thoracic outlet syndrome. Whereas nonsurgical management appears to be effective in some persons, surgical treatment has been shown to provide predictable long-term cure rates for carefully selected patients. In addition, physicians who do not regularly treat patients with thoracic outlet syndrome may not have an accurate view of this disorder, its treatment, or the possible success rate of treatment.

[Complications in brachial plexus surgery]

OBJECTIVE

Although traumatic brachial plexus injuries are relatively rare in trauma patients, their effects on the functionality of the upper limb can be very disabling. The authors' objective was to assess the complications in a series of patients operated for brachial plexus injuries.

MATERIAL AND METHOD

This was a retrospective evaluation of patients operated on by the authors between August 2009 and March 2013.

RESULTS

We performed 36 surgeries on 33 patients. The incidence of complications was 27.7%. Of these, only 1 (2.7%) was considered serious and associated with the procedure (iatrogenic injury of brachial artery). There was another serious complication (hypoxia in patients with airway injury) but it was not directly related to the surgical procedure. All other complications were considered minor (wound dehiscence, hematoma, infection). There was no mortality in our series.

CONCLUSIONS

The complications in our series are similar to those reported in the literature. Serious complications (vascular, neural) are rare and represent less than 5% in all the different series. Given the rate of surgical complications and the poor functional perspective for a brachial plexus injury without surgery, we believe that surgery should be the treatment of choice.