Observations on the use of seprafilm on the brachial plexus in 249 operations for neurogenic thoracic outlet syndrome

Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series

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.

Rib-sparing scalenectomy for neurogenic thoracic outlet syndrome: Early results

OBJECTIVE

Neurogenic thoracic outlet syndrome (NTOS) is no longer either "controversial" or "disputed"; however, its optimal surgical management remains unclear. Many thoracic outlet decompression procedures are performed by first rib resection, usually via a transaxillary route.

METHODS

A retrospective review of a prospectively maintained NTOS database was performed. Patients with NTOS associated with a cervical rib and those with recurrent NTOS were excluded from the present analysis. All study patients had satisfied a 5-point clinical diagnostic protocol and had experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis via a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All the patients had completed QuickDASH (11-item version of the Disability of the Arm, Shoulder, and Hand questionnaire) preoperatively and at 3 or 6 months postoperatively.

RESULTS

From 2011 to 2019, 504 thoracic outlet decompression procedures had been performed in 442 patients. The average operative time was 1.15 hours, and the average hospital length of stay was 1.05 days. Major complications, including intraoperative arterial injury, postoperative wound hematoma requiring reoperation, and chylothorax, occurred in 7 patients (1.4%). All but 2 patients (99.6%) had symptomatic improvement. Using a more rigorous definition of operative success of ≥50% improvement in the 3- or 6-month QuickDASH score, 458 rib-sparing NTOS operations (90.9%) were successful. In contrast to the mean preoperative QuickDASH score of 62.6, the average postoperative QuickDASH score was 25.2 (P = .001).

CONCLUSIONS

These results suggest that (1) adherence to a rigorous preoperative diagnostic regimen, including performance of a scalene block, ensures, at the least, that surgery for NTOS can be successfully restricted to patients actually with the condition; (2) fibrotic, contracted scalene muscles are the cause of NTOS; (3) the first rib does not require removal for successful surgical treatment of NTOS; and (4) 90% of the patients so treated can expect significant early symptomatic and functional improvement.

Preventive Effect of Alginate Gel Formulation on Perineural Adhesion

Background: Perineural adhesion is a potential complication of manipulating peripheral nerves. Using a model of median nerve manipulation in the carpal tunnel, perineural adhesion preventive effects of an alginate gel formulation were examined. Methods: After exposing carpal tunnels of Japanese white rabbits and dissecting the median nerve, the gliding floor was excised as much as possible and the transverse carpal ligament was repaired to induce a perineural tissue reaction. Prior to wound closure, 0.5 ml of alginate gel formulation was administered into the right carpal tunnel (formulation group) and 0.5 ml of physiological saline was administered into the left carpal tunnel (control group). At 1, 2, 3, and 6 weeks after treatment, electrophysiological evaluation of thenar distal latency, macroscopic evaluation with adhesion score, and pathological evaluation of carpal tunnel cross sections were performed (N = 4-5 at each time point). Results: Although distal latency tended to be low in the formulation group, there was no significant difference between the groups according to electrophysiological evaluation. Macroscopic evaluation revealed that the adhesion score was always lower in the formulation group than in the control group; over the course of treatment, it remained unchanged in the formulation group, but peaked at 3 weeks after treatment in the control group. In pathological evaluation, neural perfusion peaked at 2-3 weeks after treatment in both groups; neural perfusion tended to be lower in the formulation group than in the control group. Conclusions: Results suggested that the peak tissue response associated with nerve dissection occurred 2-3 weeks after treatment and that the repair process started subsequently. The alginate gel formulation modified the surrounding environment of the nerve and promoted repair by acting as a physical barrier against perineural fibrosis. The preventive effect of alginate gel on perineural adhesion may improve treatment outcomes of constrictive neuropathy.

Outcomes of Surgical Management of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Bayesian Perspective

PURPOSE

To provide a summary of the relevant evidence on outcomes of transaxillary first rib excision (TAFRE), supraclavicular first rib excision with scalenectomy (SCFRE), and supraclavicular release leaving the first rib intact (SCR) for patients with neurogenic thoracic outlet syndrome (TOS), and interpret the treatment effects from a Bayesian perspective.

METHODS

A systematic literature search and review were performed. Random-effects meta-analyses were conducted to estimate success rate and complete relief rate of each procedure. The probabilities of specified success rates and complete relief rates were calculated using a Bayesian method. Sensitivity analyses for TOS type, neck trauma, and cervical rib were performed. Complications of each procedure were also reviewed.

RESULTS

Data were extracted from 17 studies of TAFRE, 9 of SCFRE, and 14 of SCR to conduct the meta-analyses. The pooled success rate and complete relief rate were 0.76 (95% confidence interval [95% CI)], 0.65-0.85) and 0.53 (95% CI, 0.38-0.68) for TAFRE, 0.77 (95% CI, 0.68-0.85) and 0.57 (95% CI, 0.41-0.72) for SCFRE, and 0.85 (95% CI, 0.76-0.92) and 0.61 (95% CI, 0.35-0.84) for SCR, respectively. The probabilities of success rate greater than 70% were 90%, 87%, and 99% for TAFRE, SCFRE, and SCR, respectively. If the success rate of 80% or greater was considered, the probabilities were 34%, 31%, and 91%, respectively. The probabilities of complete relief rate of 50% or greater were 67%, 71%, and 69% for TAFRE, SCFRE, and SCR, respectively. Sensitivity analyses showed similar results. The complication rates for TAFRE, SCFRE, and SCR were, respectively, 22.5%, 25.9%, and 12.6%.

CONCLUSIONS

The SCR has a high probability of success rate greater than 80%; both TAFRE and SCFRE have high probabilities of a success rate greater than 70% but only low probabilities of success rate greater than 80%. The TAFRE and SCFRE have more complications than SCR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Amnion membrane improves results in treating neurogenic thoracic outlet syndrome

A patient with neurogenic thoracic outlet syndrome was initially treated with scalenectomy, first rib resection, and wrapping of the brachial plexus (BP) with amnion membrane (AM) to prevent postoperative adhesions. Twelve months later, at reoperation for recurrent symptoms, the AM was observed to be intact. The BP had no scar tissue around it. Recurrence was due to scarring around the nerve roots superior to the portion of the plexus that had been wrapped with AM. It was concluded that the AM had successfully protected the portion of the BP that had been wrapped. Longer term studies are in progress.

NEW TECHNIQUE FOR REDUCING FIBROSIS IN RECURRENT CASES OF CARPAL TUNNEL SYNDROME

Purpose: Synthetic bio-degradable materials have been used as an artificial barrier in prophylaxis of adhesions. We report on the use of lactid caprolacton film (Mesofol®) in recurrent carpal tunnel syndrome. We hypothesise that its use will give favourable results regarding the functional outcome and the recurrence rate.

Patients and methods: Fourteen patients were prospectively reviewed following neurolysis and application of Mesofol® film. Average age was 48 years. Outcome assessment measures included; two-point discrimination, verbal rating scale, and Boston Questionnaire.

Results: Follow-up period averaged 25.5 months. Post-operative two-point discrimination improved to an average of 4.57 mm. The post-operative average verbal rating scale was 1.5. The mean symptom severity score improved to 1.88 and the mean functional score improved to 1.69 post-operatively.

Conclusion: In cases of recurrent carpal tunnel syndrome, the use of mesofol barrier yields good functional results at the short term follow-up. The technique is simple. No patients needed further surgeries.

Seprafilm® adhesion barrier: (1) a review of preclinical, animal, and human investigational studies

The aim of this study was to provide a single site resource for investigators, clinicians, and others seeking preclinical, animal, and human investigational studies concerning the postsurgical, anti-adhesion barrier Seprafilm™ (Genzyme Corporation, Cambridge, MA). All published preclinical, animal, human extra-abdominal research as of July 2011 have been summarized and included in this document. Searches of Medline and EMBASE Drugs and Pharmaceuticals databases were conducted for original preclinical, animal, and human extra-abdominal studies involving Seprafilm. Preclinical, animal, and extra-abdominal human investigational studies are the study selection for this manuscript. Intraabdominal use is discussed in the accompanying manuscript. Data extraction includes systematic manuscript review. Summary of preclinical, animal, and extra-abdominal human investigational use of Seprafilm by surgical discipline were gathered for data synthesis. The clinical use of Seprafilm, which was approved by the FDA for intra-abdominal procedures, is supported by preclinical and animal studies relating to general surgical and obstetrical/gynecological applications. Findings from preclinical, animal, and human investigational studies at other sites throughout the body raises the potential for additional human clinical trials to assess efficacy and safety following surgical procedures at non-abdominal locations.

Updated perspectives on neurogenic thoracic outlet syndrome

Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Similar to other persistent pain conditions, the physical discomfort associated with NTOS can cause severe and often debilitating symptoms. In fact, those suffering from the syndrome report a quality of life impacted as significantly as those with chronic heart failure. This evidence-based literature review focuses on the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS, with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and more contemporary minimally invasive intramuscular treatments with botulinum toxin.

CT-guided injection of the anterior and middle scalene muscles: technique and complications

BACKGROUND AND PURPOSE

Anterior scalene block is a helpful diagnostic test for NTOS and a good predictor of surgical outcome. The purpose of this study was to describe the technique, success rate, and complications associated with CT-guided anesthetic and botulinum toxin injection of the ASM/MSM in patients with NTOS symptoms.

MATERIALS AND METHODS

One hundred six participants (mean age, 41.5 ± 10 years; 80 women) were identified via a retrospective review of medical records for CT-guided scalene blocks. The procedure was evaluated regarding the technical success, defined as satisfactory detection of the ASM/MSM; intramuscular needle placement; intramuscular injection of contrast; appropriate delivery of medication; and frequency of unintended BP block or other complications. We also determined the outcome of patients who underwent surgery following the block.

RESULTS

Study participants underwent 146 scalene injections, 83 blocks, and 63 chemodenervations, which were included in this investigation. In all cases, detection of the ASM/MSM and intramuscular needle placement was satisfactory. Postprocedural complications included 5 (3.4%) temporary BP blocks, 1 patient with (0.7%) Horner sign, 7 (4.8%) needle-induced pain reports, 1 (0.7%) case of dysphagia, and 2 (1.4%) instances of muscle weakness. There were no major complications reported. The rate of good outcome following surgery was the same in patients with positive versus negative blocks, 30/43 (70%) versus 5/7 (71%), respectively.

CONCLUSIONS

CT guidance is a useful adjunct in performing accurate ASM/MSM blocks with a low rate of minor complications.