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Hock G, Johnson A, Barber P, Papa C. Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome. J Athl Train 2024; 59:683-695. [PMID: 39048118 PMCID: PMC11277273 DOI: 10.4085/1062-6050-0138.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Thoracic outlet syndrome (TOS) involves inconsistent symptoms, presenting a challenge for medical providers to diagnose and treat. Thoracic outlet syndrome is defined as a compression injury to the brachial plexus, subclavian artery or vein, or axillary artery or vein occurring between the cervical spine and upper extremity. Three common subcategories are now used for clinical diagnosis: neurogenic, arterial, and venous. Postural position and repetitive motions such as throwing, weightlifting, and manual labor can lead to symptoms. Generally, TOS is considered a diagnosis of exclusion for athletes due to the poor accuracy of clinical testing, including sensitivity and specificity. Thus, determining a definitive diagnosis and reporting injury is difficult. Current literature suggests there is not a gold standard diagnostic test. Rehabilitation has been shown to be a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations.
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Affiliation(s)
- Greg Hock
- Department of Sports Medicine Physical Therapy, Ohio State University Wexner Medical Center, Columbus
| | - Andrew Johnson
- Department of Orthopedics and Sports Medicine, Mayo Clinic, Rochester, MN
| | - Patrick Barber
- Department of Orthopedics and Physical Performance, University of Rochester, NY
| | - Cassidy Papa
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles
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Mulatti GC, Dalio MB, de Moraes TM, Attie GA, Brito-Queiroz A, Joviliano EE. Thoracic outlet syndrome in women. Semin Vasc Surg 2024; 37:44-49. [PMID: 38704183 DOI: 10.1053/j.semvascsurg.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/13/2023] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
Thoracic outlet syndrome (TOS) is observed more frequently in women, although the exact causes of this sex disparity remain unclear. By investigating the three types of TOS-arterial, neurogenic, and venous-regarding symptoms, diagnosis, and treatment, this article aims to shed light on the current understanding of TOS, focusing on its variations in women.
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Affiliation(s)
- Grace Carvajal Mulatti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, R. Dr. Ovídio Pires de Campos, 225 Cerqueira César, São Paulo, SP, 05403-010, Brasil.
| | - Marcelo Bellini Dalio
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil
| | - Tayrine Mazotti de Moraes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, R. Dr. Ovídio Pires de Campos, 225 Cerqueira César, São Paulo, SP, 05403-010, Brasil
| | - Gabriela Araújo Attie
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, R. Dr. Ovídio Pires de Campos, 225 Cerqueira César, São Paulo, SP, 05403-010, Brasil
| | | | - Edwaldo Edner Joviliano
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil
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Fisher AT, Lee JT. Diagnosis and management of thoracic outlet syndrome in athletes. Semin Vasc Surg 2024; 37:35-43. [PMID: 38704182 DOI: 10.1053/j.semvascsurg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 05/06/2024]
Abstract
The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use-related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA.
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Weninger JT, Pruidze P, Didava G, Rossmann T, Geyer SH, Meng S, Weninger WJ. Axillary arch (of Langer): A large-scale dissection and simulation study based on unembalmed cadavers of body donors. J Anat 2024; 244:448-457. [PMID: 37965841 PMCID: PMC10862185 DOI: 10.1111/joa.13976] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/16/2023] Open
Abstract
Connective or muscular tissue crossing the axilla is named axillary arch (of Langer). It is known to complicate axillary surgery and to compress nerves and vessels transiting from the axilla to the arm. Our study aims at systematically researching the frequency, insertions, tissue composition and dimension of axillary arches in a large cohort of individuals with regard to gender and bilaterality. In addition, it aims at evaluating the ability of axillary arches to cause compression of the axillary neurovascular bundle. Four hundred axillae from 200 unembalmed and previously unharmed cadavers were investigated by careful anatomical dissection. Identified axillary arches were examined for tissue composition and insertion. Length, width and thickness were measured. The relation of the axillary arch and the neurovascular axillary bundle was recorded after passive arm movements. Twenty-seven axillae of 18 cadavers featured axillary arches. Macroscopically, 15 solely comprised muscular tissue, six connective tissue and six both. Their average length was 79.56 mm, width 7.44 mm and thickness 2.30 mm. One to three distinct insertions were observed. After passive abduction and external rotation of the arm, 17 arches (63%) touched the neurovascular axillary bundle. According to our results, 9% of the Central European population feature an axillary arch. Approximately 50% of it bilaterally. A total of 40.74% of the arches have a thickness of 3 mm or more and 63% bear the potential of touching or compressing the neuromuscular axillary bundle upon arm movement.
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Affiliation(s)
| | - Paata Pruidze
- Division of AnatomyMedical University of ViennaViennaAustria
| | - Giorgi Didava
- Division of AnatomyMedical University of ViennaViennaAustria
| | - Tobias Rossmann
- Division of AnatomyMedical University of ViennaViennaAustria
- Department of Neurosurgery, Neuromed CampusKepler University HospitalLinzAustria
| | - Stefan H. Geyer
- Division of AnatomyMedical University of ViennaViennaAustria
| | - Stefan Meng
- Division of AnatomyMedical University of ViennaViennaAustria
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Davies MG, Hart JP. Endovascular management of acute and subacute venous thoracic outlet syndrome. Front Surg 2024; 11:1302568. [PMID: 38440414 PMCID: PMC10909919 DOI: 10.3389/fsurg.2024.1302568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Approximately 3% of all patients presenting with Thoracic Outlet Syndrome have a venous etiology (vTOS), which is considered "effort thrombosis". These patients will present with symptomatic deep venous thrombosis or focal subclavian vein (SCV) stenosis. Endovascular management of vTOS occurs in several phases: diagnostic, preoperative therapeutic intervention before decompression, postoperative interventions after decompression, and delayed interventions in the follow-up after decompression. In the diagnostic phase, dynamic SCV venography can establish functional vTOS. Approximately 4,000 patients have been treated for vTOS and reported in the literature since 1970. Declotting of the SCV was followed by surgical decompression in 53% of patients, while in the remainder, surgical decompression alone (18%), endovascular intervention alone (15%), or conservative therapy with anticoagulation (15%) was performed. The initial intervention was predominantly catheter-directed thrombolysis, with <10% of cases undergoing concomitant balloon angioplasty. 93% of cases were successful. In the postoperative phase, balloon angioplasty was performed to correct residual intrinsic SCV disease after vTOS decompression in under 15% of cases. Stents were rarely deployed. Symptom relief was reported as 94 ± 12% (mean ± SD) and 90 ± 23%, respectively for declotting with decompression and declotting alone. In the delayed phase, balloon angioplasty was performed in under 15% of cases to re-establish patency.
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Affiliation(s)
- Mark G. Davies
- Department of Cardiovascular Outcomes, Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
| | - Joseph P. Hart
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Cralle LE, Harris LM, Lum YW, Deery SE, Humphries MD. Thoracic outlet syndrome in females: A systematic review. Semin Vasc Surg 2023; 36:487-491. [PMID: 38030322 DOI: 10.1053/j.semvascsurg.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 12/01/2023]
Abstract
Thoracic outlet syndrome (TOS) is a rare anatomic condition caused by compression of neurovascular structures as they traverse the thoracic outlet. Depending on the primary structure affected by this spatial narrowing, patients present with one of three types of TOS-venous TOS, arterial TOS, or neurogenic TOS. Compression of the subclavian vein, subclavian artery, or brachial plexus leads to a constellation of symptoms, including venous thrombosis, with associated discomfort and swelling; upper extremity ischemia; and chronic pain due to brachial plexopathy. Standard textbooks have reported a predominance of females patients in the TOS population, with females comprising 70%. However, there have been few comparative studies of sex differences in presentation, treatment, and outcomes for the various types of TOS.
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Affiliation(s)
- Lauren E Cralle
- Division of Vascular Surgery, University of California Davis, 2335 Stockton Boulevard, NAOB 5001, Sacramento, CA, 95811.
| | | | | | | | - Misty D Humphries
- Division of Vascular Surgery, University of California Davis, 2335 Stockton Boulevard, NAOB 5001, Sacramento, CA, 95811
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Martínez-Cárdenas EK, Torres-Parlange A, Sotelo-Carbajal J, Hernández-Zamora RE, García-Ledezma A, Torres-Salazar QL. Case report on the diagnosis of vascular thoracic outlet syndrome followed by mechanical thrombectomy. Int J Surg Case Rep 2023; 113:109019. [PMID: 37988987 PMCID: PMC10667732 DOI: 10.1016/j.ijscr.2023.109019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/26/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The thoracic outlet syndrome is characterized by compression of the brachial plexus or subclavian vessels due to anatomical alterations of the thoracic cavity. Vascular presentation is rare and includes thromboembolism and edema in the upper limb, and the diagnosis is often elusive due to its rarity. In this case, we describe a vascular thoracic outlet syndrome presentation whose diagnosis through angiography was achieved after a mechanical thrombectomy. CASE PRESENTATION We report a 43-year-old female patient with pain in the right upper limb, accompanied by edema and mild violet discoloration, without risk factors for hypercoagulability, with D-dimer levels within normal values. Mechanical thrombectomy with AngioJET was performed via an endovascular approach, with the extraction of multiple clots, confirming the presence of thoracic outlet syndrome as the underlying cause of the current condition. CLINICAL DISCUSSION AND CONCLUSIONS Venous thoracic outlet syndrome is a challenging entity to diagnose; however, it should be considered in cases of deep vein thrombosis of the subclavian vein and confirmed by angiography after a thrombectomy.
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Affiliation(s)
| | - Adrian Torres-Parlange
- Hospital General "5 de Diciembre" of the Security Institute for the Service of State Workers, México
| | - Jorge Sotelo-Carbajal
- Hospital General Regional No. 1 Tijuana, Baja California, Mexican Institute of Social Security, México
| | | | - Arnold García-Ledezma
- Hospital General Regional No. 1 Tijuana, Baja California, Mexican Institute of Social Security, México
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Zhou M, Jia W, Jiang P, Cheng Z, Zhang Y, Liu J. Endovascular reconstruction of bilateral upper limbs ischemia in a patient with arterial outlet syndrome: A case report and literature review. Front Surg 2022; 9:951956. [PMID: 36157429 PMCID: PMC9489898 DOI: 10.3389/fsurg.2022.951956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAcute upper limb ischemia in a patient with thoracic outlet syndrome is a rare but serious clinical disorder. If the disease is not treated promptly due to underdiagnosis, it could lead to distal artery embolization and limb-threatening ischemia. Revascularizing upper extremity arteries in a timely manner could rescue ischemic limbs and improve the patient’s quality of life. We reported here a case of a patient who presented with bilateral upper limb ischemia caused by arterial thoracic outlet syndrome.Case presentationA 63-year-old woman who presented with sudden bilateral upper extremity cold, numbness, pulselessness, and altered temperature sensation was first diagnosed with arterial thoracic outlet syndrome. The patient had performed a lot of pull-up and lat pull-down exercises in the 2 months prior to the onset of the above symptoms. Color Doppler ultrasonography showed thrombosis in the right axillary artery and left subclavian and axillary artery. The patient received Rotarex mechanical thrombectomy combined with drug-coated balloon percutaneous transluminal angioplasty (PTA) to complete revascularization of the upper extremities and achieved a full recovery finally.ConclusionsComplete endovascular revascularization for treating arterial thoracic outlet syndrome is a minimally invasive and effective method, especially for upper extremity ischemic lesions caused by nonbone compression.
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Jammeh ML, Yang A, Abuirqeba AA, Ohman JW, Thompson RW. Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series. Oper Neurosurg (Hagerstown) 2022; 23:125-132. [PMID: 35838452 PMCID: PMC9287103 DOI: 10.1227/ons.0000000000000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/16/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge. OBJECTIVE To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS. METHODS From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively. RESULTS The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P < .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P < .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P < .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%. CONCLUSION Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.
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Affiliation(s)
- Momodou L. Jammeh
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alexander Yang
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Division of Neurosurgery, Department of Surgery, Creighton University, Omaha, Nebraska, USA
| | - Ahmmad A. Abuirqeba
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J. Westley Ohman
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert W. Thompson
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Quality Assessment of Online Resources for Thoracic Outlet Syndrome Patients. Ann Vasc Surg 2022; 85:96-104. [DOI: 10.1016/j.avsg.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 11/22/2022]
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