Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients

Neurogenic thoracic outlet syndrome and controversies in diagnosis and management

Compression of the neurovascular structures at the level of the scalene triangle and pectoralis minor space is rare, but increasing awareness and understanding is allowing for the treatment of more individuals than in the past. We outlined the recognition, preoperative evaluation, and treatment of patients with neurogenic thoracic outlet syndrome. Recent work has illustrated the role of imaging and centrality of the physical examination on the diagnosis. However, a fuller understanding of the spatial biomechanics of the shoulder, scalene triangle, and pectoralis minor musculotendinous complex has shown that, although physical therapy is a mainstay of treatment, a poor response to physical therapy with a sound diagnosis should not preclude decompression. Modes of failure of surgical decompression stress the importance of full resection of the anterior scalene muscle and all posterior rib impinging elements to minimize the risk of recurrence of symptoms. Neurogenic thoracic outlet syndrome is a rare but critical cause of disability of the upper extremity. Modern understanding of the pathophysiology and evaluation have led to a sounder diagnosis. Although physical therapy is a mainstay, surgical decompression remains the gold standard to preserve and recover function of the upper extremity. Understanding these principles will be central to further developments in the treatment of this patient population.

How I do it. Thoracic outlet syndrome and the transaxillary approach

Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach.

Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis

BACKGROUND

The subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle.

PURPOSE

To provide comprehensive gross anatomy description of the variant "subclavius posticus muscle" and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression.

BASIC PROCEDURES

A scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed.

MAIN FINDINGS

The scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all.

PRINCIPAL CONCLUSIONS

The subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.

True neurogenic thoracic outlet syndrome: late outcomes from a surgical series

BACKGROUND

True neurogenic thoracic outlet syndrome (TNTOS) is rare, and evaluation of surgical treatment is limited to a few studies in the literature. The purpose of this study is to present the results from a surgical series of 21 patients with TNTOS.

METHODS

Retrospective analysis on 21 patients diagnosed with TNTOS who underwent surgery. Demographic data and neurological status were characterized, and patients were classified in accordance with a pre-established scale for assessing the severity of hand impairment before and after surgery. Neuropathic pain was assessed using a visual analogue scale (VAS) and functional disability was quantified using the QuickDASH questionnaire. The results from before and after surgery were compared using the Wilcoxon test, and the significance level was taken to be 5%.

RESULTS

There was a significant difference in VAS values from before to after the operation (Wilcoxon test: p = 0.0001; r = 0.86). Most patients (90%) improved after surgery, and in 85% of these patients, the VAS improvement was greater than 50%. Improvement in hand function occurred in seven patients (33.3%), and in most of these cases (28.6%), this improvement was classified as mild. Most patients (93.3%) showed moderate to very severe functional disability at the end of the follow-up.

CONCLUSION

After surgery, only one-third of the cases showed improvement in motor function and most patients had significant functional disability. However, the improvement regarding pain was significant. Surgery to control this symptom should be recommended, even in cases of late presentation and severe motor impairment.

Neurogenic Thoracic Outlet Syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) refers to a group of disorders in which there is compression of and/or damage to the neurovascular structures at the thoracic outlet, i.e., at the transition from chest to neck. The incidence of neurogenic thoracic outlet syndrome (nTOS) is estimated to be 2-3 / 100 000 / year, with an estimated prevalence of 10 / 100 000. Patients present with upper extremity sensorimotor symptoms that are often related to movement. The aim of the present article is to highlight the clinical presentation patterns of nTOS and to provide an overview of its diagnosis and treatment.

METHODS

Selective literature search for prospective observational studies and RCTs, including systematic reviews and metaanalyses.

RESULTS

There is no multicenter randomized controlled trial available on the treatment of nTOS. Prospective observational studies with a hierarchical study design report a positive effect of physiotherapy in 27-59% of cases. After unsuccessful conservative treatment, up to 56-90% benefit from surgical management. Patients with nTOS are more severely affected compared with those with other forms of TOS and benefit less from transaxillary first rib resection. nTOS patients who underwent supraclavicular decompression without rib resection had excellent surgical outcomes in 27%, good outcomes in 36%, acceptable outcomes in 26%, and poor surgical outcomes in 11% of cases. There is no systematic comparison available of the types of surgical management involved. Also, there is currently no uniform classification available for all medical sub-disciplines. Therefore, interpretation, and comparability of the study results are limited.

CONCLUSION

Although nTOS is the most common form of TOS, studies on its treatment are currently limited in terms of numbers and quality. The type of surgical management varies according to the experience and preference of the surgeon, treating specialty, special anatomic features, and clinical symptoms.

Endovascular reconstruction of bilateral upper limbs ischemia in a patient with arterial outlet syndrome: A case report and literature review

Background

Acute 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 presentation

A 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.

Conclusions

Complete 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.

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.

Neurogenic thoracic outlet syndrome in the overhead and throwing athlete: A narrative review

Thoracic outlet syndrome is an important cause of shoulder pain and dysfunction due to compression of neurovascular structures as they traverse the thoracic outlet. Symptoms are most commonly due to compression of the brachial plexus called neurogenic thoracic outlet syndrome (nTOS). Throwing athletes are at increased risk of nTOS because of a variety of biomechanical factors. However, because nTOS symptoms are often nonspecific, delayed diagnosis is common. Neurogenic thoracic outlet largely remains a diagnosis of exclusion with advanced imaging ruling out vascular involvement and diagnostic injections gaining favor in helping localize sites of compression. Although rehabilitation alone may improve symptoms in some athletes, many require surgical treatment for long-term relief. This generally entails decompression of the thoracic outlet by some combination of muscle release, brachial plexus neurolysis, and first rib resection. Outcomes tend to be successful in athletes with most achieving resolution of symptoms and return to athletic activity. NTOS is an important cause of shoulder pain and dysfunction in throwing athletes. The history and physical examination should focus on activities that exacerbate symptoms. Treatment of nTOS generally requires surgical intervention and allows throwing athletes to return to sport.

Performance in major league baseball pitchers after surgical treatment of thoracic outlet syndrome

INTRODUCTION

Thoracic outlet syndrome (TOS) can be a career-threatening injury for Major League Baseball (MLB) pitchers, often requiring surgical management. The purpose of this study is to determine the efficacy of surgical management for TOS as a function of return to play and quantitative pitching metrics.

METHODS

27 MLB pitchers underwent surgical treatment for TOS between January 2001 and December 2017. Analysis of pre and postoperative pitching metrics were used to assess the effect of surgery on 20 pitchers who returned to pitch in MLB. All pitching metrics were compared via assessing performance two years prior to surgery and two years after surgery. For 20 pitchers who returned to pitch, MLB pitching metrics of earned run average (ERA), walks plus hits per innings pitched (WHIP), wins above replacement (WAR), and average fastball velocity were used to assess a pitcher's ability to return to preoperative performance level.

RESULTS

Of the 27 pitchers, 20 pitchers were diagnosed with neurogenic thoracic outlet syndrome (NTOS) and seven with venous thoracic outlet syndrome (VTOS). The average age of onset of TOS was 28.6 years. There was no significant difference between the age of onset between the NTOS and VTOS populations (p = 0.272). Of the 27 pitchers, 20 (74.1%) were able to return to MLB play at a mean of 297 days (range, 105-638 days) after surgery. Pitching metrics demonstrated that pitcher ERA remained inferior postoperatively compared to baseline preoperative performance (3.66 vs 4.50, p = 0.03). Fastball velocity (p = 0.94) and strike percentage (p = 0.50) were equivalent to pre-injury performance.

CONCLUSION

74% of professional pitchers who undergo surgical intervention for TOS are able to return to play at the MLB level. With regards to performance, the majority of metrics were unchanged from prior to surgery, indicating return at a similar functional level.

Evaluation Of Quality Of Life After Surgical Treatment Of Thoracic Outlet Syndrome

BACKGROUND

To evaluate the quality of life of surgically treated patients for TOS.

METHODS

A prospective observational study including patients treated surgically for TOS, on 2018. Two standardized questionnaires: Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Short-Form 12 (SF-12) were used. The SF-12 consists of a physical and mental component (PCS-SF-12 and MCS-SF-12). The questionnaires were completed during the preoperative and postoperative consultations and at 3, 6, and 12 months.

RESULTS

We performed 53 interventions. The population was mostly female (n = 35, 66.0%) of 40.1±10.0 years. The preoperative DASH score was 46.3±19.7. It was 40.9±21.7 at 6 weeks, 33.5±22.7 at 3 months, 28.9±22.6 at 6 months, and 21.1±20 at 9 to 12 months. The improvement of DASH becomes statistically significant at 3 months (p = 0.036), 6 months (p = 0.002), and 12 months (p = 0.001). The preoperative MCS-SF-12 was 36.6±9.4. It was 41.6±10.9 at 6 weeks, 43.8±11.1 at 3 months, 46.2±11.8 at 6 months, and 51.4±8 at 8 to 12 months. The improvement of MCS-SF-12 became significant at 3 months (p=0.009), 6 months (p=0.001), and 12 months (p=0.001). The preoperative PCS-SF-12 was 35.5±6.4. It was 37.1±8.7 at 6 weeks, 39.9±8.7 at 3 months, 41.6±8.4 at 6 months, and 46.1±8.1 to 12 months. The improvement of PCS-SF-12 became significant at 6 months (p=0.005) and 12 months (p=0.001).

CONCLUSION

The surgical management of TOS allows an improvement of quality of life in short and medium term.

Digital Biomarkers for the Objective Assessment of Disability in Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (nTOS) is a musculoskeletal disorder in which compression of the brachial plexus between the scalene muscles of the neck and the first rib results in disabling upper extremity pain and paresthesia. Currently there are no objective metrics for assessing the disability of nTOS or for monitoring response to its therapy. We aimed to develop digital biomarkers of upper extremity motor capacity that could objectively measure the disability of nTOS using an upper arm inertial sensor and a 20-s upper extremity task that provokes nTOS symptoms. We found that digital biomarkers of slowness, power, and rigidity statistically differentiated the affected extremities of patients with nTOS from their contralateral extremities (n = 16) and from the extremities of healthy controls (n = 13); speed and power had the highest effect sizes. Digital biomarkers representing slowness, power, and rigidity correlated with patient-reported outcomes collected with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the visual analog scale of pain (VAS); speed had the highest correlation. Digital biomarkers of exhaustion correlated with failure of physical therapy in treating nTOS; and digital biomarkers of slowness, power, and exhaustion correlated with favorable response to nTOS surgery. In conclusion, sensor-derived digital biomarkers can objectively assess the impairment of motor capacity resultant from nTOS, and correlate with patient-reported symptoms and response to therapy.

Diagnosis of Neurogenic Thoracic Outlet Syndrome Based on the Clinical Status

OBJECTIVES

At our institute, we devised a clinical algorithm for diagnosis of neurogenic thoracic outlet syndrome (TOS). Our approach assisted in the accurate diagnosis and in detection of patients likely to benefit from surgical treatment. The purposes of this study were to propose our diagnostic approach to neurogenic TOS, and to describe the outcomes of surgical and conservative treatment.

METHODS

Patients (n = 91) who were suspected to have neurogenic TOS, and therefore, underwent a routine clinical protocol from January 2012 to January 2018 were reviewed. Through the clinical protocol, diagnosis of "true neurologic TOS", "symptomatic TOS", and "not likely TOS" was made. The visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder and Hand (DASH) score were used to assess the treatment outcomes. Satisfaction with surgery was assessed according to the Derkash classification as excellent, good, fair, or poor.

RESULTS

Among 91 patients with presumed neurogenic TOS, 25 patients were "true neurologic TOS", 61 patients were "symptomatic TOS", and five patients were "not likely TOS". Nineteen patients underwent supraclavicular decompression of the brachial plexus whose mean age at the time of surgery was 36.4 years. The VAS average pain score improved from 3.6 to 0.8, and the DASH score improved from 38.4 to 17.1. According to the Derkash classification, ten patients (53%) rated their recovery as excellent, four (21%) as good, and five (26%) as fair. Sixty-seven patients underwent conservative treatment. At the last follow-up visit, their VAS and DASH score were 2.3 and 11.8, respectively.

CONCLUSIONS

By using an algorithm, we diagnosed the patients suspected to have neurogenic TOS into three groups based on clinical status. We surgically treated 19 patients using supraclavicular approach, and achieved favorable outcomes.

Neurogenic Thoracic Outlet Syndrome with Supraclavicular Release: Long-Term Outcome without Rib Resection

Our aim was to define clinical long-term outcome of surgery for neurogenic thoracic outlet syndrome without rib resection, and to find factors predicting long-term results. For the 94 patients, the main outcomes were pain, numbness, weakness, and upper-extremity function. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a numerical rating system served as functional outcome measures. Mean follow-up was 12.9 years. Preoperative pain diminished from 7.8 to 2.2, numbness from 7.4 to 4.0, and weakness from 7.3 to 3.8. Grip strength increased from 25.7 to 31.8 kg. QuickDASH averaged at follow-up 37.1 and CBSQ 51.5. No correlation appeared between smoking and long-term results regarding pain, numbness, weakness, or functioning. Positive TOS provocative tests or intraoperative anatomical findings like consistency of the scaleni muscles showed no correlation with outcome. 82% of female and 57% of male patients reported that aid from this surgery had been excellent or good; 69% reported that surgery helped considerably for at least a mean 9.9 years. The risk for worse self-reported long-term outcome was higher among men, but neither BMI nor age at surgery associated with self-reported outcome. Pain, numbness, and weakness significantly decreased and function improved after supraclavicular release without rib resection. We found no significant preoperative nor per-operative factors predicting long-term results.

Thoracic Outlet Syndrome: A Narrative Review

Thoracic outlet syndrome comprises a group of disorders that result in compression of the brachial plexus and subclavian vessels exiting the thoracic outlet. Symptoms include pain, paresthesia, pallor, and weakness depending upon the compromised structures. While consensus in diagnostic criteria has not yet been established, a thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis. General first-line therapy for thoracic outlet syndrome is a conservative treatment, and may include physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids. Patients who have failed conservative therapy are considered for surgical decompression. This article aims to review the epidemiology, etiology, relevant anatomy, clinical presentations, diagnosis, and management of thoracic outlet syndrome.

Epidemiology of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) describes a complex disease process with three anatomic variations each with their own individual characteristics. Understanding the prevalence, diagnosis, and treatment of TOS is challenging for many providers. For this reason, the establishment of comprehensive care models and expert leadership by dedicated vascular surgeons with TOS experience has been invaluable.

Effects of Kinesio Taping on pain, paresthesia, functional status, and overall health status in patients with symptomatic thoracic outlet syndrome: A single-blind, randomized, placebo-controlled study

OBJECTIVE

This study aimed to assess the effects of kinesio taping (KT) on pain, paresthesia, functional status, and overall health status in patients with symptomatic thoracic outlet syndrome (sTOS).

METHODS

A single-blind placebo-controlled design was employed in this study. The study duration was defined as 12 months. Analyses were performed on 60 patients with sTOS randomly assigned to KT (4 men and 26 women; mean age=33.5 years, range=20-46 years) and control groups (5 men and 25 women; mean age=26 years, range=20-43 years). KT was applied to the KT group three times. The control group received placebo taping. Pain and paresthesia were evaluated using the visual analogue scale (VAS) pain (10 cm) and VAS paresthesia (10 cm). The upper limb function was assessed using the disabilities of the arm, shoulder, and hand (DASH) questionnaire. The overall health status was evaluated based on the Nottingham Health Profile (NHP). Each assessment was carried out at baseline (t0), posttreatment (t1), and 8 weeks after baseline (t2).

RESULTS

In the KT group, except the social isolation domain of the NHP, all outcome measures showed improvement from t0 to t1. At the second follow-up visit (t2), improvements remained visible compared with baseline. However, none of the variables improved from t1 to t2. Otherwise, all measures deteriorated slightly, and the deteriorations in VAS for pain, NHP pain, NHP sleep, and NHP physical abilities were statistically significant (p=0.041, p=0.048, p=0.013, and p=0.016, respectively). In the control group, only VAS for paresthesia and NHP emotional reaction showed improvement over time (p=0.002 and p=0.044, respectively). When changes in outcome measures between the two groups were compared, except NHP emotional reaction and NHP social isolation, median changes (from t0 to t1) were higher in the KT group than in the control group (p<0.05 for all variables). Regarding VAS pain, VAS paresthesia, DASH, and three NHP domains (energy level, pain, and physical abilities), changes from t0 to t2 were also higher in the KT group (p<0.05 for all variables).

CONCLUSION

KT can provide benefits in terms of relieving pain and paresthesia, as well as improving the upper limb function and quality of life in patients with sTOS.

LEVEL OF EVIDENCE

Level II, Therapeutic study.

Long-term Functional Outcomes Follow-up after 188 Rib Resections in Patients with TOS

BACKGROUND

Short-term outcomes in patients with all forms of TOS have been widely reported in the literature and have established that rib resection can be beneficial in decompressing the thoracic outlet and relieving pressure on traversing structures. We sought to determine long-term functional outcomes using the Disability of the Arm, Shoulder, and Hand (QuickDASH) survey in patients with TOS who underwent rib resection.

METHODS

Clinical records for patients who underwent rib resection for TOS at a single institution were retrospectively reviewed. All patients were contacted via telephone and long-term functional outcome was assessed at latest follow-up via the 11-item version of the QuickDASH questionnaire. Demographics, TOS type, preoperative QuickDASH score, and athletic status were recorded. Patients were asked if they returned to baseline activity since their surgery, would have the procedure again, and if they were subjectively better postoperatively.

RESULTS

From 2000 to 2018, 261 patients underwent rib resection surgery. One hundred seventy patients (65.1%) were able to be contacted via telephone for long-term follow-up. A total of 188 surgeries (102 neurogenic thoracic outlet syndrome, 82 venous thoracic outlet syndrome, 4 arterial thoracic outlet syndrome) were performed in these 170 patients. The mean follow-up time for the cohort was 5.3 years (range 1-18). Overall, 167 (88.9%) patients returned to baseline activity postoperatively. Postop QuickDASH decreased to 12 from 44 preoperatively for the cohort.

CONCLUSIONS

First rib resection and thoracic outlet decompression for all forms of TOS is a durable surgical treatment which results in excellent long-term functional outcomes as determined by both the QuickDASH score and subjective patient reporting.

Thirty-Day Outcomes Following Surgical Decompression of Thoracic Outlet Syndrome

BACKGROUND

Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013.

RESULTS

There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays ( P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9).

CONCLUSIONS

Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.

Residual Symptom Analysis After the Subtotal Anterior and Middle Scalenectomy for Disputed Thoracic Outlet Syndrome: Comparison Between Surgical and Untreated Patients

OBJECTIVE

There are significant differences in the results on disputed thoracic outlet syndrome (TOS) surgery, which reflect that not all patients with disputed TOS are amenable to surgery. It is necessary to find out appropriate indicators for screening of patients who are suitable for surgery. Pain and paresthesia are 2 prominent symptoms of disputed TOS. The purpose of this study was to identify which symptoms could be removed by surgery.

METHODS

Data for all patients with disputed TOS who were admitted and prepared for surgical treatment between July 2008 and April 2012 were collected. The patients were divided into the surgical group and untreated group. The patients in the untreated group actively gave up surgical treatment due to fear of surgery after admission. The follow-up was obtained by standard visits with the clinician and by telephone interviews.

RESULTS

There were 10 patients (unilateral TOS) in the surgical group and 5 (3 bilateral TOS) in the untreated group. Statistical analysis showed no significant differences in age, sex, duration of symptoms, the types of symptoms, positive signs and provocative tests on physical exam, and length of follow-up between 2 groups. As for paresthesia, statistically significant difference was detected between the preoperative and postoperative surgical group (P < 0.001) and between the surgical and untreated group (P = 0.002). With regard to pain, there was no statistically significant difference between the preoperative and postoperative surgical group (P = 0.350) and between the surgical and untreated group (P = 0.251). However, the degree of pain was tolerable in both groups.

CONCLUSIONS

Our preliminary results revealed that the surgery is effective for the paresthesia as the main symptoms of the patients, but is invalid for the pain as the main symptoms.

Perioperative Outcomes of Thoracic Outlet Syndrome Surgical Repair in a Nationally Validated Database

We evaluated the occurrence of thoracic outlet syndrome (TOS) and 30-day postoperative outcomes. Patients undergoing cervical/first rib resection surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Thoracic outlet syndrome types were then examined. Propensity score matching was performed to account for potential confounders; 1180 patients were explored during the study period, 1007 (85.3%) were of the neurogenic TOS (NTOS), 32 (2.7%) patients had arterial TOS (ATOS), and 141 (12.0%) patients had venous TOS (VTOS). Patients with ATOS were significantly older (median age [interquartile range, IQR]—NTOS: 34 [25-44], ATOS: 49.5 [42.5-57], VTOS: 34 [23-43]; P < .001). Median operating time was significantly longer for patients with ATOS. Median in-hospital stay was also longer for patients with ATOS (median length of in-hospital stay [LOS; IQR]—NTOS: 2 [1-4]; ATOS: 6 [3-7]; and VTOS: 5 [2-7] days; P < .001). Patients with VTOS showed twice longer LOS when compared to NTOS after matching. Presentation and treatment of TOS have been studied extensively at highly experienced centers.

Outcome of Surgical Treatment for Thoracic Outlet Syndrome: Systematic Review and Meta-Analysis

BACKGROUND

Many publications report outcomes of surgical treatment for thoracic outlet syndrome (TOS); however, high-quality reviews and meta-analyses are lacking. This systematic review and meta-analysis summarizes and compares the outcomes and major complications of the surgical procedures for the 3 types of TOS: arterial, venous, and neurogenic.

METHODS

MEDLINE, EMBASE, and CINAHL databases, and the Cochrane Database of Systematic Reviews were searched for papers published between January 1980 and February 2015, using the keywords thoracic outlet syndrome, and treatment and surgical. Articles were eligible for inclusion if the following criteria were met: studies describing outcomes of surgery for TOS, published in English, human studies, and available full-text. The exclusion criteria were case-series and case reports (n < 5), reviews, abstracts, and studies of endoscopic-assisted or robotic endoscopic-assisted transaxillary first rib resection.

RESULTS

A total of 12 papers met our inclusion criteria and were finally included in this systematic review. All included articles showed improvement of complaints after surgical treatment. In our meta-analysis, improvement to Derkash's classification category excellent/good was achieved in 90% of the arterial and venous TOS groups. Preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand scores show improvement of 28.3 points after operative treatment of neurogenic TOS.

CONCLUSIONS

In conclusion, surgical treatment of TOS seems to be beneficial in most patients and is relatively safe. The largest challenge remains the diagnosis of TOS, especially neurogenic TOS, because standardized diagnostic criteria are lacking. Future studies should focus on the diagnostic work-up of TOS.

Work-Related Neurogenic Thoracic Outlet Syndrome: Diagnosis and Treatment

Outcomes of surgery for neurogenic thoracic outlet syndrome (NTOS) in workers' compensation are poor in a majority of patients, partly due to nonspecificity of diagnosis. Most cases have no objective evidence of the presence of brachial plexus dysfunction. Up to 20% of patients experience a new adverse event. Objective neurologic signs and electrodiagnostic evidence of brachial plexus dysfunction must be present before proceeding with invasive procedures. This guideline includes objective criteria that must be met before thoracic outlet syndrome surgery can be approved in Washington State. Evidence does not support the use of scalene blocks, botulinum toxin therapy, or vascular studies to diagnose NTOS.

Treatment for thoracic outlet syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) is one of the most controversial diagnoses in clinical medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence-based management is lacking. This is the first update of a review first published in 2010.

OBJECTIVES

To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of TOS a minimum of six months after the intervention.

SEARCH METHODS

On 23 June 2014 we searched the Cochrane Neuromuscular Disease Group Trials Specialized Register, CENTRAL, The Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL Plus and AMED. We also searched reference lists of the identified trials.

SELECTION CRITERIA

We selected randomized or quasi-randomized studies involving participants with the diagnosis of TOS of any type (neurogenic, vascular, and 'disputed'), without limitations as to language of publication.We accepted studies that examined any intervention aimed at treating TOS.The primary outcome measure was change in pain rating, measured on a validated visual analog or similar scale at least six months after the intervention.The secondary outcomes were change in muscle strength, disability, experiences of paresthesias (numbness and tingling sensations), and adverse effects of the interventions.

DATA COLLECTION AND ANALYSIS

Three authors independently selected the trials to be included and extracted data. Authors rated included studies for risk of bias, according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. We identified one study comparing natural progression with an active intervention. We found three randomized controlled trials (RCTs), but only two of them had a follow-up of six months or more, which was the minimum required follow-up for inclusion in the review. The first trial that met our requirements involved 55 participants with the 'disputed type' of TOS and compared transaxillary first rib resection (TFRR) with supraclavicular neuroplasty of the brachial plexus (SNBP). The trial had a high risk of bias. TFRR decreased pain more than SNBP. There were no adverse effects in either group. The second trial that met these requirements analyzed 37 people with TOS of any type, comparing treatment with a botulinum toxin (BTX) injection into the scalene muscles with a saline placebo injection. This trial had a low risk of bias. There was no significant effect of treatment with the BTX injection over placebo in terms of pain relief or improvements in disability, but it did significantly improve paresthesias at six months' follow-up. There were no adverse events of the BTX treatment above saline injection.

AUTHORS' CONCLUSIONS

This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty, but no randomized evidence that either is better than no treatment. There is moderate evidence to suggest that treatment with BTX injections yielded no great improvements over placebo injections of saline. There is no evidence from RCTs for the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures, and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

[Thoracic Outlet Syndrome: is it always a surgical condition? Analysis of a series of 31 cases operated by the supraclavicular route]

Introducción:

El síndrome de outlet torácico es una compresión del plexo braquial que suscita polémica. Se clasifica en Outlet Torácico Verdadero o neurogénico (OTV) y Outlet Torácico Disputado o no neurogénico (OTD). El primero presenta síntomas motores en la mano, mientras que el segundo sólo síntomas sensitivos en el miembro superior. El objetivo de este trabajo es analizar los resultados obtenidos en una serie de 31 cirugías.

Métodos:

Se analizaron las cirugías de nervios efectuadas entre 2003-2012, tomando los diagnósticos de outlet torácico cuyo período de seguimiento post-operatorio mínimo fuera de 6 meses. Se buscaron los siguientes datos: edad, sexo, presencia de síntomas sensitivos y/o motores, clasificación, resultado de los estudios neurofisiológicos y de imágenes, resultado de la cirugía, complicaciones post-operatorias y recidivas.

Resultados:

Se incluyeron 31 cirugías realizadas en 30 pacientes, 9 OTV (8 mujeres) de 24.3 años, y 21 con OTD (18 mujeres) de 37.4 años de edad en promedio. Un 90% presentaron alteraciones neurofisiológicas preoperatorias, y 66,6% imagenológicas. En el intraoperatorio, el 100% de los OTV presentó una alteración anatómica relacionada con la sintomatología, hecho observado sólo en el 36.7% de los OTD operados. El 87,5% de los OTV mejoraron sensitivamente, mientras que 77,7% mejoraron la atrofia. Por el contrario, 45.4% de los OTD mejoraron permanentemente, 36.3% no tuvieron cambios, 13.6% mejoraron transitoriamente y 4.5% (un caso) empeoró. Las complicaciones post-operatorias fueron más frecuentes aunque transitorias en el grupo de OTV (3 casos sobre 9 operados, 33.3%) que en los OTD (3 casos sobre 22, un 13.6%).

Conclusión:

El OTV suele mayormente mejorar luego de la cirugía, igual que el OTD aunque en una proporción mucho menor. Estos hallazgos coinciden con otros reportes recientes de esta patología.

NTOS symptoms and mobility: a case study on neurogenic thoracic outlet syndrome involving massage therapy

Neurogenic thoracic outlet syndrome (NTOS) is a neuromuscular condition affecting brachial plexus functionality. NTOS is characterized by paresthesia, pain, muscle fatigue, and restricted mobility in the upper extremity. This study quantified massage therapy's possible contribution to treatment of NTOS. A 24-year-old female with NTOS received eight treatments over 35 days. Treatment included myofascial release, trigger point therapy, cross fiber friction, muscle stripping, and gentle passive stretching. Abduction and lateral rotation at the glenohumeral (GH joint) assessments measured range of motion (ROM). A resisted muscle test evaluated upper extremity strength. The client rated symptoms daily via a visual analog scale (VAS). Findings showed improvement in ROM at the GH joint. VAS ratings revealed a reduction in muscle weakness, pain, numbness, and 'paresthesia'. Results suggest massage may be useful as part of a broad approach to managing NTOS symptoms and improving mobility.

Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy

OBJECTIVE

First rib resection and scalenectomy (FRRS) has been shown to improve short-term quality of life (QOL) in the treatment of neurogenic thoracic outlet syndrome (NTOS). Long-term benefits are not well studied but are believed to decrease over time. Our objective was to evaluate long-term NTOS outcomes using validated QOL instruments.

METHODS

We identified 162 NTOS patients aged ≥18 years treated by FRRS from 2003 to 2010 after they had not responded to conservative management. The patients were mailed three surveys to assess QOL (Short-Form 12 [SF-12], Brief Pain Inventory [BPI], and Cervical Brachial Symptom Questionnaire [CBSQ]), with five total outcomes measures including the SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS), BPI severity, BPI interference, and CBSQ score. Demographic and clinical data were extracted from patient records. Each FRRS was categorized based on postoperative clinical assessment as successful, failed, or leading to recurrent symptoms.

RESULTS

Survey yield was 53.7% (n = 87) with mean follow-up of 44.7 months (range, 12.4-91.9 months). There was no significant difference in QOL scores associated with long-term compared with short-term follow-up. Significantly poorer scores on all instruments were associated with comorbid chronic pain syndromes, opioid use, and unfavorable clinical assessment (P < .05). Significantly poorer scores on select instruments were associated with smoking (BPI both; P < .02), age ≥40 years (SF-12 PCS, BPI interference, CBSQ; P < .03), neck and/or shoulder disease (SF-12 both, BPI both; P < .01), postoperative injections (BPI both, CBSQ; P < .05), and complications (SF-12 PCS, CBSQ; P < .05). A positive preoperative scalene block was not significantly associated with long-term QOL scores.

CONCLUSIONS

The QOL after FRRS shows no significant difference with longer follow-up. Clinical assessment reflects patient-reported outcomes and can gauge postoperative improvement. Patient factors, particularly comorbidities and opioid use, are more predictive of long-term QOL than is preoperative scalene block and should also be considered when selecting patients for surgical intervention.

Thoracic outlet syndrome

Of the many clinical entities involving the neck region, one of the most intriguing is thoracic outlet syndrome (TOS). TOS is an array of disorders that involves injury to the neurovascular structures in the cervicobrachial region. A classification system based on etiology, symptoms, clinical presentation, and anatomy is supported by most physicians. The first type of TOS is vascular, involving compression of either the subclavian artery or vein. The second type is true neurogenic TOS, which involves injury to the brachial plexus. Finally, the third and most controversial type is referred to as disputed neurogenic TOS. This article aims to provide the reader some understanding of the pathophysiology, workup, and treatment of this fascinating clinical entity.

Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management

BACKGROUND

Proper management of thoracic outlet syndrome (TOS) requires an understanding of the underlying causes of the disorder. A comprehensive examination process, as described in Part 1 of this review, can reveal the bony and soft tissue abnormalities and mechanical dysfunctions contributing to an individual's TOS symptoms.

OBJECTIVE

Part 2 of this review focuses on management of TOS.

CONCLUSION

The clinician uses clinical examination results to design a rehabilitation program that focuses on correcting specific problems that were previously identified. Disputed neurogenic TOS is best managed with a trial of conservative therapy before surgical treatment options are considered. Cases that are resistant to conservative treatment may require surgical intervention. True neurogenic TOS may require surgical intervention to relieve compression of the neural structures in the thoracic outlet. Surgical management is required for cases of vascular TOS because of the potentially serious complications that may arise from venous or arterial compromise. Post-operative rehabilitation is recommended after surgical decompression to address factors that could lead to a reoccurrence of the patient's symptoms.

Long-Term Functional Results for the Surgical Management of Neurogenic Thoracic Outlet Syndrome

Objective: To document long-term functional outcomes in patients treated for neurogenic thoracic outlet syndrome (NTOS). Methods: Records of all patients undergoing treatment for NTOS at our center were reviewed. Patient demographics and co-morbidities were recorded. End-points included symptomatic relief, peri-operative adjunctive procedures, functional outcome and employment continuity. Results: From 1988-2008, 26 patients were operated upon for NTOS. Hallmarks of the diagnosis in operated patients included symptom duration less than 1 year and a positive Roos test. Patients receiving disability and those with cervical spine pathology or carpal tunnel syndrome were not considered for surgery. Mean patient age was 39.2 years (range 14-60 years) with a mean follow-up of 104.4 months. Eleven patients (42.3%) engaged in pre-operative physical therapy programs. 7 of 9 patients (26.9%) received adjunctive peri-procedural scalene block with temporary symptom relief. All patients underwent thoracic outlet decompression by either 1st rib resection [18 total: 8 (44%) transaxillary and 10 (66%) supraclavicular)], cervical rib resection [6 (26.1%)] and/or scalenectomy [12 (46.2%)]. Of the 22 patients available for follow-up, six patients (27.3%) have required continued post-operative narcotic analgesics. Sixteen patients (72.7%) returned to work and reported being at an equivalent or better functional outcome than their pre-operative status. Conclusions: Durable long-term functional outcomes can be achieved predicated on a highly selective approach to the surgical management of patients with NTOS. A majority of operated patients will not require adjunctive procedures or chronic narcotic utilization. Patients who undergo surgery can expect to return to work with little or no functional impairment.

Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome

OBJECTIVE

To examine pain relief in patients with neurogenic thoracic outlet syndrome (NTOS) after a single, low dose injection of botulinum toxin A (Botox) into the anterior scalene muscle (ASM) under computed tomographic (CT) guidance.

DESIGN

Prospective longitudinal study.

SETTING

Academic medical institution.

PATIENTS

Patients 18 years of age and older were evaluated for potential scalenectomy and first rib resection using the transaxillary approach at the study institution between 2005 and 2008. All patients had failed physical therapy. A total of 29 procedures on 27 participants were studied.

INTERVENTIONS

A single, 20-unit injection of Botox into the ASM under CT-guidance.

OUTCOME MEASURES

Short-form McGill Pain Questionnaire (SF-MPQ) prior to and at 1, 2, and 3 months post-Botox toxin injection.

RESULTS

There was a decline in pain during the 3 months subsequent to Botox injection as noted by the following components of the SF-MPQ: sensory (P = 0.02), total (P = 0.05), visual analog scale (VAS [P = 0.04]), and present pain intensity (PPI) score (P = 0.06). The proportion of patients reporting more intense pain scores did not return to the pre-intervention level at 3 months post-Botox injection.

CONCLUSION

Patients experienced substantial pain relief in months 1 and 2 following a single Botox injection into the ASM under CT guidance. Significant pain reduction was noted for 3 months after Botox injection with respect to both sensory and VAS scores, and the total and PPI scores approximated statistical significance. After 3 months, patients experienced a 29% decrease in the sensory component of their pain as well as an approximate 15% reduction in their VAS score. A single, CT-guided Botox injection into the ASM may offer an effective, minimally invasive treatment for NTOS.

Treatment for thoracic outlet syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence based management is lacking.

OBJECTIVES

To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of thoracic outlet syndrome.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (July 2009), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), CINAHL (January 1981 to June 2009 ), AMED (January 1985 to June 2009 ) and reference lists of articles.

SELECTION CRITERIA

We selected randomized or quasi-randomized studies in any language of participants with the diagnosis of any type of thoracic outlet syndrome (neurogenic, vascular, and 'disputed'). The primary outcome measure was change in pain rating on a validated visual analog or similar scale at least six months after the intervention. The secondary outcomes were change in muscle strength and adverse effects of the interventions.

DATA COLLECTION AND ANALYSIS

Four authors independently selected the trials to be included and extracted data. The one included study was rated for risk of bias according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. There were no studies comparing natural progression with any active intervention. In one trial with a high risk of bias involving 55 participants transaxillary first rib resection decreased pain more than supraclavicular neuroplasty of the brachial plexus. There were no adverse effects in either group.

AUTHORS' CONCLUSIONS

This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty but no randomized evidence that either is better than no treatment. There is no randomized evidence to support the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Neurogenic thoracic outlet syndromes: a comparison of true and nonspecific syndromes after surgical treatment

BACKGROUND

Neurogenic thoracic outlet syndrome (NTOS) is attributed to compression of the brachial plexus at the scalene hiatus. Patients with true NTOS (TNTOS) have typical clinical and electrophysiological changes and are considered to respond well to surgical treatment, but patients with nonspecific NTOS (NNTOS) have predominantly sensory signs, not well-defined electrophysiological changes, and are thought not to respond favorably to surgical treatment. The postsurgical outcome of patients with cervicobrachialgia diagnosed as TNTOS and as NNTOS is analyzed.

METHODS

Seven patients with typical electrophysiological features of TNTOS and 11 with nonspecific signs (NNTOS--extraspinal compression of C5-T1) were treated from 1986 to 2001. Age, duration of symptoms, and follow-up were similar in both groups. All patients underwent unilateral (14) or bilateral (4) supraclavicular decompression of the brachial plexus, for a total of 22 procedures. Clinical outcome was evaluated based on sensory and motor signs and on functional capacity. The Mann-Whitney U test and Fisher exact test were used to compare demographic data and proportions, respectively.

RESULTS

Improvement of pain/paresthesias, sensory loss, atrophy, and muscular weakness after surgery was similar in the two groups. Regarding functional capacity, 57.1% of patients with TNTOS and 63.6% of patients with NNTOS became normal or reacquired their previous condition with slight limitation. Surgery-related complications were paresthesias and paresis in the arm, sympathetic dystrophy, pneumothorax, and lymphatic collections, all in patients with NNTOS.

CONCLUSIONS

Patients with NNTOS with electrophysiological signs of extraspinal radicular impairment had the same chances of improvement after surgical treatment as patients with TNTOS.

Thoracic outlet syndrome

OBJECTIVE

Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. We provide a review of this difficult-to-treat disorder, including a brief overview, clinical presentations, surgical anatomy, treatment options, and outcomes.

METHODS

TOS represents a spectrum of disorders encompassing three related syndromes: compression of the brachial plexus (neurogenic TOS), compression of the subclavian artery or vein (vascular TOS), and the nonspecific or disputed type of TOS. Neurovascular compression may be observed most commonly in the interscalene triangle, but it also has been described in the costoclavicular space and in the subcoracoid space. Patients present with symptoms and signs of arterial insufficiency, venous obstruction, painless wasting of intrinsic hand muscles, paresthesia, and pain. A careful and detailed medical history and physical examination are the most important diagnostic tools for proper identification of TOS. Electromyography, nerve conduction studies, and imaging of the cervical spine and the chest also can provide helpful information regarding diagnosis. Clinical management usually starts with conservative treatment including exercise programs and physical therapy; when these therapies fail, patients are considered for surgery. Two of the most commonly used surgical approaches are the supraclavicular exposure and the transaxillary approach with first rib resection. On occasion, these approaches may be combined or, alternatively, posterior subscapular exposure may be used in selected patients.

CONCLUSION

TOS is perhaps the most difficult entrapment neuropathy encountered by neurosurgeons. Surgical intervention is indicated for vascular and true neurogenic TOS and for some patients with the common or nonspecific type of TOS in whom nonoperative therapies fail. With careful patient selection, operative intervention usually yields satisfactory results.

Evaluation of MR angiographic technique in the assessment of thoracic outlet syndrome

AIM

To evaluate two-dimensional time of flight (2D TOF) and three-dimensional contrast-enhanced magnetic resonance angiographic (3DCE MRA) techniques in the assessment of patients with suspected thoracic outlet syndrome (TOS) of vascular origin.

MATERIALS AND METHODS

Fifty-five consecutive examinations, in 51 patients with suspected TOS of vascular origin, were examined using either a 1T or 1.5T Siemens magnetic resonance imaging (MRI) unit, using either 2D TOF (n=13) or 3DCE MRA (n=42). Examinations were performed with the arms abducted (n=27) or both abducted and adducted (n=28). The source images and MIPs were reviewed retrospectively and assessed for image quality and the presence of significant persistent stenosis or impingement (a >60% reduction in the diameter of the subclavian vessels at the thoracic outlet or evidence of post-stenotic dilatation). When significant impingement was identified, the images were reformatted with multiplanar reconstruction to determine the cause.

RESULTS

Images were sub-optimal in 53% 2D TOF and 10% 3DCE MRA examinations. 3DCE MRA offered vessel coverage from the aortic arch to the distal axilliary arteries, whereas, 2D TOF sequences gave more limited coverage. Eight patients were found to have significant impingement (n=7) or stenosis (n=1) of the subclavian artery attributable to TOS. 3DCE MRA also demonstrated other relevant significant stenoses not attributable to TOS (n=5). All cases of impingement were either seen only, or more prominently, on sequences with the arms abducted. Reformatting the 3DCE MRA studies demonstrated the cause of impingement.

CONCLUSIONS

Both 2D TOF and 3DCE MRA may demonstrate TOS with significant arterial impingement. In comparison with 2D TOF sequences, 3DCE MRA offers extensive vessel coverage, is less prone to artefact and frequently demonstrates the underlying cause of TOS when studies are reformatted. Evidence of impingement should be sought from sequences performed with the arms abducted and venous phase sequences may show corroborative venous impingement.

Recurrent neurogenic thoracic outlet syndrome

BACKGROUND

Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience "excellent" or "good" results after thoracic outlet decompression, recurrent symptoms may develop in certain patients.

METHODS

This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed.

RESULTS

Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had "excellent" or "good" results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these).

CONCLUSIONS

Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.

Conservative treatment for thoracic outlet syndrome

Conservative treatment of thoracic outlet syndrome consists initially of pain control and medicinal and physical measures. Therapy then addresses tight muscles, with strengthening of weakened neck and shoulder girdle muscles. Range of motion and nerve gliding exercises are instituted simultaneously, and the patient is educated in proper posture and ergonomics at home and in the work setting.

Thoracic outlet syndrome

Success in conservative management depends upon an accurate assessment and development of a treatment plan relative to the irritability of the patient's condition. Postural correction and avoidance of irritating positions must begin early in the rehabilitation phase to retrain the patient in symptom-reducing postures. Treatment addressing only the neurovascular structures may produce temporary relief of symptoms, but postural correction cannot be maintained without correction of the associated muscle imbalance in the cervicoscapular region. Long-term success of conservative management depends on patient compliance to a home exercise program and behavior modification at home and at work. Surgical decompression should be reserved for patients who fail to improve with conservative management.