Thoracic Outlet Syndrome: Diagnostic Accuracy of MRI

T1WI Radiomics Analysis of Anterior Scalene Muscle: A Preliminary Application in Neurogenic Thoracic Outlet Syndrome

AIM

This study aimed to analyze the differences in radiomic features of the anterior scalene muscle and evaluate the diagnostic performance of MRI-based radiomics model for neurogenic thoracic outlet syndrome (NTOS).

MATERIALS AND METHODS

Imaging data of patients with NTOS who underwent preoperative brachial plexus magnetic resonance neurography were collected and were randomly divided into training and test groups. The anterior scalene muscle area was sliced in the T1WI sequence as the region of interest for the extraction of radiomics features. The most significant features were identified using feature selection and dimensionality-reduction methods. Various machine learning algorithms were applied to construct regression models. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC).

RESULTS

Totally, 267 radiomics features were extracted, of which 57 showed significant differences ( P  ≤ 0.05) between the abnormal and normal anterior scalene muscle groups. The least absolute shrinkage and selection operator regression model identified 13 optimal radiomic features with nonzero coefficients for constructing the model. In the training set, the AUROCs of diagnostic models built by different machine learning algorithms, ranked from highest to lowest, were as follows: support vector machine (SVM), 0.953; multilayer perception (MLP), 0.936; logistic regression (LR), 0.926; light gradient boosting machine (LightGBM), 0.906; and K-nearest neighbors (KNN), 0.813. In the testing set, the rankings were as follows: LR, 0.933; SVM, 0.886; KNN, 0.843; LightGBM, 0.824; and MLP, 0.706.

CONCLUSIONS

NTOS is attributed to anterior scalene muscle abnormalities and exhibits distinct radiomic features. Integrating these features with machine learning can improve traditional manual image interpretation, offering further clarity in NTOS diagnosis.

Can Vascular Flow Change During Provocation Maneuvers Predict Surgical Failure in Neurogenic Thoracic Outlet Syndrome?

BACKGROUND

The need for simultaneous first rib resection during supraclavicular scalenectomy in patients with neurogenic thoracic outlet syndrome (NTOS) remains controversial. We have routinely evaluated vascular flow changes during provocation maneuvers through digital photoplethysmography. We asked whether the vascular flow change during provocation maneuvers can predict surgical failure after isolated supraclavicular scalenectomy for NTOS.

METHODS

For 50 patients (mean age of 42.0 ± 16.5 years) who underwent supraclavicular scalenectomy for NTOS, we evaluated vascular flow change through digital photoplethysmography during several provocation maneuvers including Roos test, costoclavicular maneuver, and Adson maneuver before surgery. We calculated the adjusted odds ratio (OR) for surgical failure in association with the vascular flow change during each maneuvers with age, symptom duration, electrodiagnostic study findings, and the number of visible vertebrae as covariates.

RESULTS

Compared to the resting position, mean vascular flow during Roos test, costoclavicular maneuver, and Adson maneuver was 46.0 ± 51.3%, 42.9 ± 48.2%, and 85.4 ± 64.1%, respectively. Twelve patients (24%) were classified into surgical failure, and symptom duration (adjusted OR = 1.04, P = 0.04) and absent vascular flow during costoclavicular maneuver (adjusted OR = 23.30, P = 0.01) were significantly associated with failure.

CONCLUSION

A quantitative evaluation of the vascular flow changes that occur during provocation maneuvers can aid not only the diagnosis of NTOS but also help determine the optimal surgical treatment. In particular, if patients show absent blood flow during the costoclavicular maneuver, simultaneous scalenectomy and first rib resection should be considered.

Extreme variability of vascular responses to slightly different abduction angles during abduction and external rotation tests, in patients with suspected thoracic outlet syndrome

Objective.Patients may not always perform a perfect 90° upper limb abduction when doing an abduction, external rotation test for the evaluation of thoracic outlet syndrome (TOS). We aimed to study the vascular responses to three slightly different abduction angles.Approach.We recorded fingertip arterial (A-PPG) and forearm venous (V-PPG) photo-plethysmography in 111 patients referred for suspicion or follow up of TOS. The measurements were made bilaterally during a 30 s surrender position, followed by moving elbows in the frontal plane without changing elbow and hand level to open the costo-clavicular angle (prayer position) to standardize venous results, either: slightly below (<90°), at the same level of (∼90°), or slightly above (>90°) the shoulder level, in a random order.Main results.With abnormal results defined as A-PPG <5%rest and V-PPG < 70%max in the surrender position, 54 of the 222 upper limbs were normal at all three tests. The proportion of abnormal tests decreased with the increase in abduction angle (CochranQ< 0.05), 135 upper limbs showed impaired venous outflow for one (n= 74), two (n= 47) or the three angles (n= 14) without arterial inflow impairment at any of the three tests.Significance.Slight changes from a 'perfect' 90° abduction angle gave unreliable results during elevation, abduction, external rotation stress tests. A venous outflow impairment should probably be considered a physiologic response at <90° abduction.

Novel Diagnosis and Treatment for Neurogenic Thoracic Outlet Syndrome

This article presents a unique diagnostic test for the neurogenic thoracic outlet syndrome (nTOS). nTOS is one of the most misdiagnosed and controversial medical problems; the diagnosis is clinical, and there are few specific diagnostic criteria for this condition. We would like to share this unique diagnostic modality, the Tafler test, with medical professionals. The Tafler test helps diagnose nTOS, differentiate it from cervical radiculopathy and carpal tunnel syndrome, and effectively tailor treatment for its symptoms. The following case series aims to describe several patients with nTOS who had failed previous treatment with surgery, physical therapy, and analgesics. The implementation of the Tafler test as a treatment modality in combination with osteopathic manipulative treatment (OMT) and physical therapeutic modalities led to significant improvements in treatment efficiency.

Pediatric thoracic outlet syndrome: a systematic review with metadata

INTRODUCTION

Thoracic outlet syndrome (TOS) typically considered a condition of the adult population; it is often disregarded in children and adolescents due to its limited recognition within the pediatrics. The current study aims to systematically review and provide insights into TOS among pediatric patients.

METHODS

PubMed, Scopus, Web of Science, and Google Scholar databases were thoroughly searched for English language studies published until March 15th, 2024. The study included those articles focusing on pediatric or adolescent individuals diagnosed with TOS. Data collected from studies encompassed date of publication, number of participants or reported cases, age (years), gender of participants, type of TOS, affected side, type of treatment, surgical approach, bony abnormality, duration of symptoms (months), outcome, and follow-up time duration (months).

RESULTS

The current study comprised 33 articles, 21 of which were case reports, 10 of which were case series, and the remaining were cohort studies. In this study, 356 patients were included. Females constituted 234 (65.73%) of the patient population. Among TOS types, neurogenic TOS was found among 201 (56.5%) patients. Sporting-related activity or physical activity was present in 193 (54%) patients, followed by a history of trauma in 27 (7%) patients.

CONCLUSIONS

Pediatric patients exhibited a higher percentage of vascular TOS than their adult counterparts, with the supraclavicular approach emerging as the preferred treatment method. Sports-related activities were identified as the primary risk factor associated with pediatric TOS.

Scapular Elevation Sign - A New Sign in Evaluation of Thoracic Outlet Syndrome

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic).

Sports-related peripheral nerve injuries of the upper limb

Peripheral nerve injuries in athletes affect the upper limb more commonly than the lower limb. Common mechanisms include compression, traction, laceration, and ischemia. Specific sports can have unique mechanisms of injury and are more likely to be associated with certain neuropathies. Familiarity with these sport-specific variables and recognition of the common presentations of upper limb neuropathic syndromes are important in assessing an athlete with a suspected peripheral nerve injury. Evaluation may require imaging modalities and/or electrodiagnostic testing to confirm a nerve injury. In some cases, diagnostic injections may be needed to differentiate neuropathic versus musculoskeletal etiology. Early and accurate diagnosis is essential for treatment/management and increases the likelihood of a safe return-to-sport and avoidance of long-term functional consequences. Most nerve injuries can be treated conservatively, however, severe or persistent cases may require surgical intervention. This monograph reviews key diagnostic, management, and preventative strategies for sports-related peripheral nerve injuries involving the upper limb.

Thoracic Outlet Syndrome in the Pediatric and Young Adult Population

PURPOSE

This study aimed to assess both nonsurgical and operative treatment outcomes of pediatric and young adult patients with thoracic outlet syndrome (TOS) at a tertiary care pediatric hospital.

METHODS

A retrospective chart review of patients diagnosed with TOS, who were seen between January 2010 and August 2022 at a tertiary care pediatric hospital, was conducted. Collected pre- and postoperative data included symptoms, provocative testing (ie, Roo's, Wright's, and Adson's tests), participation in sports or upper-extremity activities, additional operations, and surgical complications. Assessment of operative treatment efficacy was based on pre- and post-provocative testing, pain, venogram results, alleviation of symptoms, and return to previous activity level 6 months after surgery.

RESULTS

Ninety-six patients, (70 females and 26 males) with an average age at onset of 15 ± 4 (4-25) years, met the inclusion criteria for TOS. Among them, 27 had neurogenic TOS, 29 had neurogenic and vasculogenic TOS, 20 had vasculogenic TOS, 19 had Paget-Schroetter Syndrome, and one was asymptomatic. Twenty-six patients were excluded because of less than 6 months of follow-up. Of the remaining 70, 6 (8.6%) patients (4 bilateral and 2 unilateral) underwent nonoperative management with activity modification and physical therapy only, and one was fully discharged because of complete relief of symptoms. Sixty-four (90.1%) patients (45 bilateral and 19 unilateral) underwent surgery. A total of 102 operations were performed. Substantial improvements were observed in provocative maneuvers after surgery. Before surgery, 79.7% were involved in sports or playing musical instruments with repetitive overhead activity, and after surgery, 86.2% of these patients returned to their previous activity level.

CONCLUSIONS

Few patients were successfully managed with nonoperative activity modification and physical therapy. In those requiring surgical intervention, first or cervical rib resection with scalenectomy using a supraclavicular approach provided resolution of symptoms with 86.2% of patients being able to return to presymptom sport or activity level.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Role of Lifestyle in Thoracic Outlet Syndrome: A Narrative Review

INTRODUCTION

The presence of a positional compression of the neurovascular bundle in the outlet between the thorax and the upper limb during arm movements (mainly abduction) is common but remains asymptomatic in most adults. Nevertheless, a certain number of subjects with thoracic outlet positional compression will develop incapacitating symptoms or clinical complications as a result of this condition. Symptomatic forms of positional neurovascular bundle compression are referred to as "thoracic outlet syndrome" (TOS).

MATERIALS AND METHODS

This paper aims to review the literature and discuss the interactions between aspects of patients' lifestyles in TOS. The manuscript will be organized to report (1) the historical importance of lifestyle evolution on TOS; (2) the evaluation of lifestyle in the clinical routine of TOS-suspected patients, with a description of both the methods for lifestyle evaluation in the clinical routine and the role of lifestyle in the occurrence and characteristics of TOS; and (3) the influence of lifestyle on the treatment options of TOS, with a description of both the treatment of TOS through lifestyle changes and the influence of lifestyle on the invasive treatment options of TOS.

RESULTS

We report that in patients with TOS, lifestyle (1) is closely related to anatomical changes with human evolution; (2) is poorly evaluated by questionnaires and is one of the factors that may induce symptoms; (3) influences the sex ratio in symptomatic athletes and likely explains why so many people with positional compression remain asymptomatic; and (4) can sometimes be modified to improve symptoms and potentially alter the range of interventional treatment options available.

CONCLUSIONS

Detailed descriptions of the lifestyles of patients with suspected TOS should be carefully analysed and reported.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

Magnetic resonance imaging for diagnosis of suspected neurogenic thoracic outlet syndrome-a systematic scoping review

Background: Neurogenic Thoracic Outlet Syndrome (nTOS) is a rare pathology caused by dynamic conditions or compression of neurovascular structures in the thoracic outlet region. nTOS can be difficult to diagnose due to nonspecific symptoms and magnetic resonance imaging (MRI) techniques are increasingly used to aid the diagnosis and surgical planning. This scoping systematic review explores how MRI is used for diagnosing nTOS and summarizes details of published MRI protocols. Methods: A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in September 2022 to include full-text English papers on MRI and nTOS. Inclusion criteria involved studies describing MRI protocols for the diagnosis of TOS, with a focus on the imaging sequences and protocols. Results: 6289 papers were screened to include 28 papers containing details of MRI protocols. The details of MRI protocols in the analyzed articles were incomplete in all studies. Most authors used 1.5T systems and included T1 and T2-weighted sequences. Most studies applied fat suppression, mainly with STIR. Positioning of the arm differed between studies, including neutral, hyperabducted and abducted and externally rotated positions. Conclusion: Our review highlights a prevalent lack of detailed MRI protocol documentation for brachial plexus. Authors primarily rely on conventional 1.5T systems, employing standard T1 and T2-weighted sequences. The adoption of novel MRI sequences is notably lacking, and fat suppression techniques predominantly adhere to older methods as STIR. There is a clear imperative for authors to provide more comprehensive reporting of the MRI protocols utilized in their studies, ultimately enhancing comparability and clinical applicability. Establishing clear protocol reporting guidelines is crucial to allow for comparison between studies.

Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography

BACKGROUND

Thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus (BP) is difficult to diagnosis. This study aimed to summarize the features of thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus observed on high-frequency ultrasonography (HFUS).

METHODS

The ultrasound data of 27 patients who had TOS with the lower trunk compression of brachial plexus were collected and eventually confirmed by surgery. The imaging data were compared, and the pathogenesis of TOS was analyzed on the basis of surgical data.

RESULTS

TOS occurred predominantly in females (70.4%). Most cases had unilateral involvement (92.6%), mainly on the right side (66.7%). The HFUS features of TOS can be summarized as follows: (1) Lower trunk compression. HFUS revealed focal thinning that reflected compression at the level of the lower trunk; furthermore, the distal part of the nerve was thickened for edema (Affected side: 0.49 ± 0.12 cm vs. Healthy side: 0.38 ± 0.06, P = 0.009), and the cross-sectional area of brachial plexus cords was markedly greater on the injured side than on the healthy side (0.95 ± 0.08 cm² vs. 0.65 ± 0.11 cm², P = 0.004). (2) Hyperechoic fibromuscular bands behind the compressed nerve (mostly the scalenus minimus muscle). (3) Abnormal bony structures: cervical ribs or elongated transverse processes of the 7th cervical vertebra (C7). Surgical results showed that the etiological factors contributing to TOS were (1) muscle hypertrophy and/or fibrosis (100%) and (2) cervical ribs/elongated C7 transverse processes (20.7%).

CONCLUSION

TOS with the lower trunk compression of brachial plexus can be diagnosed accurately and reliably by high-frequency ultrasound.

A Procedure for Measuring Anterior Scalene Morphology and Quality with Ultrasound Imaging: An Intra- and Inter-rater Reliability Study

OBJECTIVE

Ultrasound (US) imaging is an essential tool for clinicians because of its cost-effectiveness and accessibility for assessing multiple muscle metrics including muscle quality, size and shape. Although previous studies highlighted the importance of the anterior scalene muscle (AS) in patients with neck pain, studies analyzing the reliability of US measurements for this muscle are lacking. This study aimed to develop a protocol for assessing AS muscle shape and quality measured with US and investigating its intra- and inter-examiner reliability.

METHODS

Through use of a linear transducer, B-mode images of the anterolateral neck region at the C7 level were acquired in 28 healthy volunteers by two examiners (one experienced and one novel). Cross-sectional area, perimeter, shape descriptors and mean echo-intensity were measured twice by each examiner in randomized order. Intra-class correlation coefficients (ICCs), standard errors of measurement and minimal detectable changes were calculated.

RESULTS

Results indicated no muscle side-to-side asymmetries (p > 0.05). Gender differences were found for muscle size (p < 0.01), but muscle shape and brightness were comparable (p > 0.05). Intra-examiner reliability was good to excellent for all metrics for the experienced and (ICC >0.846) and novel (ICC >780) examiners. Although inter-examiner reliability was good for most of the metrics (ICC >0.709), the estimates for assessing solidity and circularity were unacceptable (ICC <0.70).

CONCLUSION

This study found that the described ultrasound procedure for locating and measuring anterior scalene muscle morphology and quality is highly reliable in asymptomatic individuals.

Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome

The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Anatomy and Pathogenesis of Vascular Thoracic Outlet Syndrome

The current literature review article describes the anatomy and pathogenesis of the vascular nature of thoracic outlet syndrome (TOS), as well as gathers the latest and most important information concerning its diagnostic methods and treatment. This syndrome's subcategory includes the venous and the arterial. Data for this review was accumulated through the PubMed database in which only scientific studies published in the last decade (2012-2022) were searched. PubMed offered 347 results, of which 23 were judged suitable and used. Non-invasive methods both for the diagnosis and the treatment of vascular TOS are gaining ground. Medicine, at this point, finds itself on the verge of slowly putting aside the previous invasive gold-standard methods, to be used only in the most urgent situations. The vascular thoracic outlet condition is a rare form of TOS but is also the most trouble-causing one and the deadliest. Fortunately, it can be more efficiently managed because of the current medical innovations. However, further research is needed to establish their already confirmed effectiveness, so they can be even more widely trusted and used.

Chronic Pain Considerations in Patients with Cardiovascular Disease

Cardiovascular disease affects close to half of the United States population and many of these patients will develop chronic pain syndromes as a result of their disease process. This article provides an overview of several pain syndromes that result, directly or indirectly, from cardiovascular disease including peripheral arterial disease, angina, thoracic outlet syndrome, postamputation pain, complex regional pain syndrome, and poststroke pain. Psychological and medical comorbidities that affect the medical decision-making process in the treatment of chronic pain associated with cardiovascular disease are also discussed.

Outcomes of 53 thoracic outlet syndrome cases with confirmed neurological deficit

INTRODUCTION

Neurogenic thoracic outlet syndromes (TOS) are dominated by the nonspecific forms. This study focuses only on the rarer true forms related to proximal nerve compression in the thoracic outlet, with the presence of motor (atrophy of the hand's intrinsic muscles) and/or sensory (hypoesthesia in the territory of the medial antebrachial cutaneous nerve) deficits. The objectives of this study were to define the clinical characteristics, anatomical causes and surgical results of this condition.

PATIENTS AND METHODS

Single-center retrospective study of 53 consecutive cases in 50 patients with an objective clinical deficit confirmed by nerve conduction studies. The population consisted of 47 adults and 3 children, 9 males and 41 females, with a mean age of 39 years (9-80 years), diagnosed between July 1994 and December 2019. An objective motor deficit was present in 50 cases, with the remaining 3 having a sensory deficit only. Forty cases underwent surgery, most often via the supraclavicular approach, while 13 cases did not undergo surgery because their deficit was longstanding and non-progressive.

RESULTS

One operated patient was lost in follow-up. An analysis of the medical records of 18 cases, including 15 operated cases found complete recovery in 4 cases, significant improvement in 9 cases and small improvement in 2 cases at a mean follow-up of 53 months (1-162 months). Thirty-four cases were reviewed in person, including 24 operated cases and evaluated with a mean follow-up of 135 months (36-284 months): the pain had disappeared in 21 cases, thenar atrophy persisted in 17 cases, which was associated with a claw-hand deformity in 3 cases, while 2 cases had an isolated claw-hand deformity. The patients were very satisfied with the procedure in 15 cases and satisfied in 9 cases. They evaluated the benefit of surgery at 87% and their upper limb function increased from 38% (10-60%) preoperatively to 77% (60-100%) at the review.

CONCLUSION

Few studies in the literature have focused on true neurogenic TOS cases. The treatment is surgical in progressive cases; an anatomical anomaly is always present. Surgical treatment eliminates the pain and helps to stabilize or even partially resolve the deficit. Despite a moderate objective gain, the patients' feeling of functional improvement is important with a high satisfaction rate.

LEVEL OF EVIDENCE

IV, retrospective.

[Please Don't Forget the Neurogenic Thoracic Outlet Syndrome]

Please Don't Forget the Neurogenic Thoracic Outlet Syndrome Abstract. We report the case of a 52-year-old patient who was treated for years for headaches, pain in the neck and arms, and sweating. Despite various therapeutic approaches there was no improvement in the symptoms. Further investigations showed a bilateral thoracic outlet syndrome in the status after multiple bilateral rib fractures after a fall from a window at the age of 18. After the operation of a bilateral thoracic outlet syndrome, the headache disappeared almost completely and there was no more sweating.

Imaging to intervention: Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.

Novel Use of Ali Shahab Score as a Diagnostic Tool and Decision of Surgical Management in Scalenus Syndrome: A Case Series

BACKGROUND: Scalenus syndrome is a collection of symptoms as the consequences of nerve and vascular compression within the scalene triangle. However, the entity has long been forgotten in publications and is difficult to recognize. The diagnosis of scalenus syndrome is mainly based on clinical findings. The Ali Shahab score is a new scoring system, generated based on clinical symptoms of scalenus syndrome. AIM: In this study, we presented a case series of scalenus syndrome patients who were diagnosed and decide to be managed surgically based on Ali Shahab score. We also reported post-operative outcomes following scalenectomy in our series. METHODS: This was a case series including patients with scalenus syndrome in Gatot Soebroto Army Hospital, Indonesia, and Siloam Asri Hospital, Indonesia, between 2016 and 2021. The diagnosis of scalenus syndrome was made based on Ali Shahab score with a value of more than 7. All patients were performed scalenectomy to decompress the stenotic subclavian artery and brachial plexus from surrounding fibrotic tissue. Eligible subjects were assessed for sex, side of symptoms, pre-operative and post-operative Ali Shahab score, and post-operative outcome. RESULTS: We included 96 patients with scalenus syndrome in this case series. Most of the included patients were male (59.4%) and experienced scalenus syndrome on the right side (76%). The average pre-operative Ali Shahab score in our series was 7.12 ± 0.48 and the post-operative score was 0.11 ± 0. Regarding post-operative outcomes, more than half of the patients experienced symptoms reduction with 38.5% of patients experiencing complete resolution of symptoms following scalenectomy. CONCLUSION: The application of the Ali Shahab score may be used as a diagnostic tool and decision of surgical management for scalenus syndrome patients. Decompression of the subclavian artery and releasing brachial plexus from surrounding fibrotic tissue can improve clinical symptoms in scalenus syndrome patients.

Vascular compression syndromes: a pictorial review

Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians’ poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions’ characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.

Update on the thoracic outlet syndrome and plexus brachial syndrome: Specific clinical examination (for all) and rehabilitation protocol

The diagnosis of uncomplicated forms of thoracobrachial outlet syndrome (TOS) and brachial plexus stretching syndrome (BPSS) is imprecise due to the lack of clear differentiation between dynamic vascular or neurological compression and brachial plexus stretching without vascular compression. After a review of literature, we propose and describe a simple way for clinical assessment of TOS, BPSS or association of both comprising 1 clinical sign and 2 manoeuvres. This clinical assessment can be performed by the medical doctor, the physiotherapist and the surgeon. The clinical diagnosis is essential because it will dictate the rehabilitation treatment. We propose and describe also a rehabilitation protocol comprising 10 phases with modulation of exercises according to clinical form (TOS, BPSS or association) and/or severity of symptoms. The physiotherapist has a capital role and is the guarantor of the effectiveness of the medical treatment. In France, a training is now available thanks to personal continuous development for diagnosis and treatment of TOS and BPSS. This is essential in order to propose an optimal care to patients.

A Thoracic Outlet Syndrome That Concealed a Glioblastoma. Findings from a Case Report

Background: Glioblastoma is the most frequent and aggressive malignant brain tumor among adults. Unfortunately, its symptoms can vary considerably depending on the size, location and the anatomic structures of the involved brain. Case report: A 58-year-old male amateur cyclist who suffered from sharp arm pain was examined for a thoracic outlet syndrome due to a previous clavicle fracture. Because of ambiguous results of the neck and nerve plexus imaging, he was referred to a neurosurgeon who properly suspected a brain tumor. The neuroimaging of the brain shown a 3 cm disploriferative mass with a blood enhancement within the left parietal lobe. The mass was urgently removed, and its histologic analysis stated a grade 4 glioblastoma. Conclusion: This case report highlights the differential diagnosis process and the teamwork approach needed to diagnose a rare presentation of a brain glioblastoma, which started its symptoms mimicking a thoracic outlet syndrome caused by a previous bone fracture.

Variability in electrodiagnostic findings associated with neurogenic thoracic outlet syndrome

Introduction/Aims

Neurogenic thoracic outlet syndrome (NTOS) is a heterogeneous and often disputed entity. An electrodiagnostic pattern of T1 > C8 axon involvement is considered characteristic for the diagnosis of NTOS. However, since the advent of high‐resolution nerve ultrasound (US) imaging, we have encountered several patients with a proven entrapment of the lower brachial plexus who showed a different, variable electrodiagnostic pattern.

Methods

In this retrospective case series, 14 patients with an NTOS diagnosis with a verified source of compression of the lower brachial plexus and abnormal findings on their electrodiagnostic testing were included. Their medical records were reviewed to obtain clinical, imaging, and electrodiagnostic data.

Results

Seven patients showed results consistent with the “classic” T1 axon  > C8 pattern of involvement. Less typical findings included equally severe involvement of T1 and C8 axons, more severe C8 involvement, pure motor abnormalities, neurogenic changes on needle electromyography in the flexor carpi radialis and biceps brachii muscles, and one patient with an abnormal sensory nerve action potential (SNAP) amplitude for the median sensory response recorded from the third digit. Patients with atypical findings on electrodiagnostic testing underwent nerve imaging more often compared to patients with classic findings (seven of seven patients vs. five of seven respectively), especially nerve ultrasound.

Discussion

When there is a clinical suspicion of NTOS, an electrodiagnostic finding other than the classic T1 > C8 pattern of involvement does not rule out the diagnosis. High resolution nerve imaging is valuable to diagnose additional patients with this treatable condition.

See Editorial on pages 4‐6 in this issue.

Concurrent Validity of Digital Vascular Auscultation for the Assessment of Blood Flow Obliteration on the Radial Artery in Healthy Subjects

This study aimed to determine the validity of digital vascular auscultation for the assessment of changes in the radial pulse in healthy subjects, using Doppler sonography as a validated test referent. Sixty-one non-symptomatic subjects (mean age of 52.5 ± 16.1 years) were assigned and evaluated under one of the following conditions: In condition 1, blood flow of the radial artery was not modified; for condition 2, blood flow of the radial artery was modified using a pressure sleeve around the humerus. The radial pulse was then measured three times with each diagnostic tool by three different blinded evaluators. Both instruments demonstrated a high association between the identification of blood flow modifications or not and the assigned condition (p < 0.001). A strong concordance between the two devices when detecting the “changes” or “no changes” in blood flow was demonstrated (k = 0.936, p < 0.001). Stethoscope sensitivity was 95%, and specificity was 99%. In conclusion, digital vascular auscultation seems to be a valid technique to examine blood flow changes of the radial artery in non-symptomatic subjects, and it could be useful for physical therapists when combined with provocative tests for the screening of possible thoracic outlet syndrome in patients.