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Jiang D, Weiss R, Lind B, Morcos O, Lee CJ. Predisposing Anatomy for Thoracic Outlet Syndrome and Functional Outcomes after Supraclavicular Thoracic Outlet Decompression in Athletes. Vasc Specialist Int 2024; 40:19. [PMID: 38858178 PMCID: PMC11165173 DOI: 10.5758/vsi.240011] [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: 01/15/2024] [Revised: 03/06/2024] [Accepted: 03/16/2024] [Indexed: 06/12/2024] Open
Abstract
Purpose This study aims to examine predisposing anatomic factors and subsequent post-decompression functional outcomes among high-intensity athletes with thoracic outlet syndrome (TOS). Materials and Methods A single-institution retrospective review was performed on a prospective database of patients with TOS from 2018 to 2023 who had undergone operative decompression for TOS. Demographics, TOS characteristics, predisposing anatomy, operative details, and postoperative outcomes were examined. The primary outcome was postoperative return to sport. Secondary outcomes included vascular patency. Results A total of 13 patients who were engaged in high-demand athletic activity at the time of their diagnosis were included. Diagnoses included 8 (62%) patients with venous TOS, 4 (31%) patients with neurogenic TOS, and 1 (8%) patient with arterial TOS. Mixed vascular and neurogenic TOS was observed in 3 (23%) patients. The mean age of the cohort was 30 years. Abnormal scalene structure was observed in 12 (92%) patients, and abnormal bone structures were noted in 4 (27%) patients; 2 (15%) with cervical ribs and 3 (23%) patients with clavicular abnormalities. Prior ipsilateral upper extremity trauma was reported in 4 (27%) patients. Significant joint hypermobility was observed in 8 (62%) patients with a median Beighton score of 6. Supraclavicular cervical and/or first rib resection with scalenectomy was performed in all patients. One case of postoperative pneumothorax was treated non-operatively. Ten (77%) patients returned to sport. Duplex ultrasonography showed subclavian vein patency in all 8 patients with venous TOS and wide patency with no drop in perfusion indices in the patient with arterial TOS. Conclusion Athletes with TOS who required operative intervention had a high incidence of musculoskeletal aberrations and joint hypermobility. Supraclavicular decompression was associated with a high success rate, with overall good functional outcomes and good likelihood of patients returning to preoperative high-intensity athletics.
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Affiliation(s)
- David Jiang
- Section of Vascular Surgery and Endovascular Therapy, University of Chicago Medicine, Chicago, USA
| | - Robert Weiss
- Section of Vascular Surgery and Endovascular Therapy, University of Chicago Medicine, Chicago, USA
| | - Benjamin Lind
- Division of Vascular Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Omar Morcos
- Division of Vascular Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Cheong Jun Lee
- Division of Vascular Surgery, NorthShore University Health System, Evanston, IL, USA
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Potluri VK, Li RD, Crisostomo P, Bechara CF. A review of arterial thoracic outlet syndrome. Semin Vasc Surg 2024; 37:12-19. [PMID: 38704178 DOI: 10.1053/j.semvascsurg.2024.02.001] [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: 12/04/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 05/06/2024]
Abstract
Arterial thoracic outlet syndrome (TOS) is a condition in which anatomic abnormalities in the thoracic outlet cause compression of the subclavian or, less commonly, axillary artery. Patients are usually younger and typically have an anatomic abnormality causing the compression. The condition usually goes undiagnosed until patients present with signs of acute or chronic hand or arm ischemia. Workup of this condition includes a thorough history and physical examination; chest x-ray to identify potential anatomic abnormalities; and arterial imaging, such as computed tomographic angiography or duplex to identify arterial abnormalities. Patients will usually require operative intervention, given their symptomatic presentation. Intervention should always include decompression of the thoracic outlet with at least a first-rib resection and any other structures causing external compression. If the artery is identified to have intimal damage, mural thrombus, or is aneurysmal, then arterial reconstruction is warranted. Stenting should be avoided due to external compression. In patients with symptoms of embolization, a combination of embolectomy, lytic catheter placement, and/or therapeutic anticoagulation should be done. Typically, patients have excellent outcomes, with resolution of symptoms and high patency of the bypass graft, although patients with distal embolization may require finger amputation.
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Affiliation(s)
- Vamsi K Potluri
- Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153
| | - Ruojia D Li
- Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153
| | - Paul Crisostomo
- Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153
| | - Carlos F Bechara
- Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL, 60153.
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3
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Pfnür A, Antoniadis G, Wirtz CR, Pedro MT. [Long-Term Outcomes after Surgery of the Neurogenic Thoracic-Outlet Syndrome in Adolescents]. HANDCHIR MIKROCHIR P 2024; 56:32-39. [PMID: 38316411 DOI: 10.1055/a-2234-5066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Neurogenic Thoracic Outlet Syndrome (nTOS) describes a complex of symptoms caused by the compression of neural structures at the upper thoracic outlet. Typical symptoms include pain, numbness and motor weakness of the affected extremity. The incidence of nTOS is 2-3 per 100,000 and is highest between the ages of 25 and 40. There are only a few studies evaluating the surgical outcomes of nTOS in adolescent patients. In particular, there is a lack of long-term data. MATERIALS AND METHODS In a retrospective study of nTOS cases receiving surgical treatment in our clinic between 2002 and 2021, eight patients between 15 and 18 years of age were included. Demographic data, risk factors, clinical symptoms, clinical functional tests, neurophysiological, radiological and intraoperative findings were evaluated. Postoperative data were recorded using a standardised questionnaire. Decompression of the inferior truncus and the C8 and Th1 nerve roots was performed via a supraclavicular approach. RESULTS The average duration of symptoms before surgery was two years. Of the eight patients who underwent surgery, six answered the written questionnaire and could be analysed for the study. The average follow-up was nine years (1-18 years). After surgery, all patients experienced pain reduction; three were pain-free in the long run and five no longer required pain medication. Strength improved in all patients, but two patients still had mild motor deficits. Sensory disturbances were reduced in all patients, but residual hypoesthesia persisted in five. With regard to overhead work, half of the patients had no impairment after surgery. All patients were able to work at the time of the survey. Half of the patients pursued their sports activities without impairment, while mild impairment was reported by the other half. CONCLUSION nTOS in adolescents is a rare compression syndrome. Decompression of the lower parts of the brachial plexus using a supraclavicular approach without resection of the first rib is an adequate treatment. This retrospective study showed that a reduction in pain was achieved in all patients. In some patients, slight sensory and motor disturbances as well as a certain restriction in overhead work persisted. Patients were able to return to sports.
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Affiliation(s)
- Andreas Pfnür
- Neurochirurgie, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Tolga G, Nilay YÇ, Umut MO, Çağrı TC. Surgical Management of Neurogenic Thoracic Outlet Syndrome: Exploring the Efficacy of the Posterior Intermuscular Approach in Cases Involving Bone Anomalies. Oper Neurosurg (Hagerstown) 2024; 26:133-140. [PMID: 37747340 DOI: 10.1227/ons.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/28/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES This article presents a cohort study focusing on neurogenic thoracic outlet syndrome (NTOS) caused by bone anomalies in the cervicothoracic region, specifically the extraforaminal area and the scalene triangle. Our aim was to contribute to understanding NTOS diagnosis and management, particularly in patients with bone anomalies, and to highlight the potential benefits of the posterior intermuscular approach as a surgical option in this particular patient group. METHODS We retrospectively evaluated the patients who underwent surgery for NTOS with accessory ribs or an elongated cervical vertebrae 7 (C7) transverse process (n = 9). Patients' clinical data, preoperative neurophysiological tests, cervical computed tomography (CT) scans, CT angiography, and postoperative cervical CT scans were reviewed. A single experienced surgeon used the posterior intermuscular approach on all patients. The accessory rib and/or elongated C7 transverse process and fibrous bands were removed; C7, C8, and T1 branches of the plexus were decompressed; and neurolysis was performed. Quality of life, a functional outcome, was measured by using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and pain was measured using visual analog scale scores. RESULTS The mean follow-up time after surgery was 7 months (range: 4-10 months). Before surgery, the mean DASH score was 55.8 ± 5.6. At the 3- and 6-month postoperative evaluations, the mean DASH scores decreased to 15.7 ± 5.8 and 15.4 ± 5.7, respectively. The mean visual analog scale score was 8.2/10 before surgery and decreased to 2.4/10 and 2.1/10 at the 3- and 6-month postoperative evaluations, respectively. All patients experienced good or excellent recovery at the 3- and 6-month postoperative evaluations. CONCLUSION Cervicothoracic extraforaminal area may be the primary site of nerve compression in NTOS, and posterior decompression using the posterior intermuscular approach can provide efficient access to extraforaminal nerve roots.
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Affiliation(s)
- Gediz Tolga
- Department of Neurosurgery, Antalya Training and Research Hospital, Antalya , Turkey
| | - Yalçın Çavuşoğlu Nilay
- Department of Thoracic and Vascular Surgery, Antalya Training and Research Hospital, Antalya , Turkey
| | - Mutlucan Ogün Umut
- Department of Neurosurgery, Antalya Training and Research Hospital, Antalya , Turkey
| | - Türk Cezmi Çağrı
- Department of Neurosurgery, University of Health Sciences, Hamidiye School of Medicine, İstanbul , Turkey
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Maślanka K, Zielinska N, Karauda P, Balcerzak A, Georgiev G, Borowski A, Drobniewski M, Olewnik Ł. Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature. J Clin Med 2023; 12:6811. [PMID: 37959276 PMCID: PMC10648912 DOI: 10.3390/jcm12216811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.
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Affiliation(s)
- Krystian Maślanka
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Piotr Karauda
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Adrian Balcerzak
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Georgi Georgiev
- Department of Orthopaedics and Traumatology, University Hospital Queen Giovanna—ISUL, Medical University of Sofia, 1527 Sofia, Bulgaria;
| | - Andrzej Borowski
- Orthopaedics and Paediatric Orthopaedics Department, Medical University of Lodz, 90-419 Lodz, Poland; (A.B.); (M.D.)
| | - Marek Drobniewski
- Orthopaedics and Paediatric Orthopaedics Department, Medical University of Lodz, 90-419 Lodz, Poland; (A.B.); (M.D.)
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
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6
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Faber LL, Wiley AP, Geary RL, Chang KZ, Goldman MP, Freischlag J, Velazquez G. Boney abnormalities cause arterial, venous, and/or neurogenic thoracic outlet syndrome. J Vasc Surg Cases Innov Tech 2022; 9:101080. [PMID: 36747607 PMCID: PMC9898748 DOI: 10.1016/j.jvscit.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
Background Thoracic outlet syndrome (TOS) is a rare condition caused by compression of the neurovascular structures within the thoracic outlet. Different classifications of TOS exist depending on the neurovascular structure being compressed: neurogenic, venous, or arterial. Any of these forms can present independently or coexist with one other. TOS symptoms are sometimes precipitated by the presence of boney abnormalities that often require surgical intervention for ultimate resolution. This retrospective review will examine the presentations and outcomes of patients with TOS whose cause was a boney abnormality. Methods A total of 73 patients who underwent thoracic outlet surgery between 2016 and 2021 were retrospectively reviewed via electronic medical records. Twelve (16%) patients demonstrated boney abnormalities on presentation causing their symptoms. The patients with boney abnormalities were analyzed based on venous, arterial, or neurogenic TOS diagnosis. Results Of the 12 patients with boney abnormalities, 5 were classified as venous TOS, 6 patients as neurogenic TOS, and 1 as arterial TOS. The boney abnormalities were as follows: venous TOS: three clavicular fractures, one nonfused congenital clavicle, and one residual rib; neurogenic TOS: three fractured first ribs, one fractured clavicle, and two cervical ribs; and arterial TOS: fused first and second rib with bilateral cervical ribs and arterial compression. Postoperatively, there were no artery, vein, or nerve injuries. Five patients had a pneumothorax treated over night with a chest tube, and one patient had a superficial wound infection. The median hospital stay was 1 day. All patients completed physical therapy after surgery. All patients have symptom resolution at follow-up. Conclusions Patients with boney abnormalities constitute about one-fifth of patients who can present with all three forms of TOS: neurogenic, arterial, and venous, and some will have more than one of these presentations. Results in patients undergoing surgery with boney abnormalities causing thoracic outlet syndrome are excellent with symptom resolution and without substantial complications.
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Affiliation(s)
- Lydia L. Faber
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC,Correspondence: Lydia L. Faber, BS, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Aidan P. Wiley
- University of Maryland School of Medicine, Baltimore, MD
| | - Randolph L. Geary
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Kevin Z. Chang
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Matthew P. Goldman
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Julie Freischlag
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Gabriela Velazquez
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
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7
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Troyer W, Gardner JE, Bowers RL. Neurogenic thoracic outlet syndrome in the overhead and throwing athlete: A narrative review. PM R 2022; 15:629-639. [PMID: 35403345 DOI: 10.1002/pmrj.12816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 03/09/2022] [Accepted: 03/25/2022] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Wesley Troyer
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - James E Gardner
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Onode E, Takamatsu K, Kazuki K, Nakamura H. Thoracic Outlet Syndrome with Subclavian Artery Thrombosis Caused by Synostosis of the First and Second Ribs: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00001. [PMID: 35385410 DOI: 10.2106/jbjs.cc.21.00751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 43-year-old woman presented with pain, paresthesia, and coldness of the right upper extremity suggestive of the diagnosis of thoracic outlet syndrome. Three-dimensional computed tomography angiography revealed that the right subclavian artery was constricted because it traveled over an abnormal first rib. After anticoagulation and antithrombotic therapy, the patient underwent resection of the abnormal first rib. Postoperative angiography documented improvement over time of the poststenotic dilatation and recanalization of the subclavian artery capable of delivering almost normal distal flow. CONCLUSION Arterial reconstruction is not always necessary for the treatment of arterial thoracic outlet syndrome associated with poststenotic dilatation of the subclavian artery.
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Affiliation(s)
- Ema Onode
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kiyohito Takamatsu
- Department of Orthopaedic Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Kenichi Kazuki
- Department of Orthopaedic Surgery, Gakuen Minami Clinic, Nara, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Camporese G, Bernardi E, Venturin A, Pellizzaro A, Schiavon A, Caneva F, Strullato A, Toninato D, Forcato B, Zuin A, Squizzato F, Piazza M, Stramare R, Tonello C, Di Micco P, Masiero S, Rea F, Grego F, Simioni P. Diagnostic and Therapeutic Management of the Thoracic Outlet Syndrome. Review of the Literature and Report of an Italian Experience. Front Cardiovasc Med 2022; 9:802183. [PMID: 35391849 PMCID: PMC8983020 DOI: 10.3389/fcvm.2022.802183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
The Thoracic Outlet Syndrome is a clinical potentially disabling condition characterized by a group of upper extremity signs and symptoms due to the compression of the neurovascular bundle passing through the thoracic outlet region. Because of the non-specific nature of signs and symptoms, to the lack of a consensus for the objective diagnosis, and to the wide range of etiologies, the actual figure is still a matter of debate among experts. We aimed to summarize the current evidence about the pathophysiology, the diagnosis and the treatment of the thoracic outlet syndrome, and to report a retrospective analysis on 324 patients followed for 5 years at the Padua University Hospital and at the Naples Fatebenefratelli Hospital in Italy, to verify the effectiveness of a specific rehabilitation program for the syndrome and to evaluate if physical therapy could relieve symptoms in these patients.
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Affiliation(s)
- Giuseppe Camporese
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Enrico Bernardi
- Department of Emergency and Accident Medicine, Hospital of Treviso, Treviso, Italy
| | - Andrea Venturin
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alice Pellizzaro
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alessandra Schiavon
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Francesca Caneva
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alessandro Strullato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Daniele Toninato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Beatrice Forcato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Andrea Zuin
- Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Francesco Squizzato
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Michele Piazza
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Roberto Stramare
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Chiara Tonello
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Naples Buon Consiglio Fatebenefratelli Hospital, Naples, Italy
| | - Stefano Masiero
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Federico Rea
- Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Franco Grego
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Department of Internal Medicine, General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, University Hospital of Padua, Padua, Italy
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Ajalat MJ, Pantoja JL, Ulloa JG, Cheng MJ, Patel RP, Chun TT, Gelabert HA. A Single Institution 30-Year Review of Abnormal First Rib Resection For Thoracic Outlet Syndrome. Ann Vasc Surg 2022; 83:53-61. [PMID: 34998937 DOI: 10.1016/j.avsg.2021.12.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/05/2021] [Accepted: 12/22/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Congenital abnormalities of the first rib (ABNFR) are a rare cause of thoracic outlet syndrome (TOS). The range of abnormalities have not been clearly documented in the literature. Surgical decompression in these patients presents with increased complexity secondary to anomalous anatomy. Our goal is to review an institutional experience of first rib resection (FRR) performed for ABNFRs, to present a novel classification system, and to analyze outcomes according to clinical presentation. METHODS A prospectively collected database was used to identify individuals with ABNFRs who underwent FRR for TOS between 1990-2021. These individuals were identified both by preoperative imaging and intraoperative descriptions of the first rib after resection. Demographic, clinical, perioperative and pathological data were reviewed. ABNFRs were classified into three categories according to anatomical criteria: (I) Hypoplastic, (II) Fused, and (III) Hyperplastic. Outcomes were rated using the standardized Quick Disability of Arm Shoulder and Hand Scores (QDS), Somatic Pain Scores (SPS) and Derkash Scores (DkS). RESULTS Among the 2200 cases of TOS, there were 19 patients (0.8%) with ABNFR who underwent FRR. Average age at surgery was 30.5 (range 11-74), including 13 men and 6 women. Presentations included 9 arterial (ATOS), 6 neurogenic (NTOS), and 4 venous (VTOS) cases. There were 6 class I, 6 class II, and 7 class III ABNFRs. Among 6 NTOS patients there were 4 abnormal nerve conduction tests and 5 positive anterior scalene muscle blocks. Among the 9 patients with ATOS, thrombolysis was attempted in 5 patients, and of these, 3 ultimately required surgical thrombectomy. Of 4 VTOS cases, 2 were managed with thrombolysis, and 2 with anticoagulation alone. The approach for FRR was transaxillary in all patients. Secondary procedures included 1 pectoralis minor tenotomy, 1 scalenectomy, and 1 contralateral rib resection. No major neurological or vascular complications occurred. There was 1 patient who required surgical evacuation of a hematoma. Intraoperative chest tube placement was required in 5 patients secondary to pleural entry during dissection. There was an overall improvement in symptoms over an average follow-up of 7.4 months. QDS reduced from 49.7 pre-op to 22.1 (p<.05). SPS improved from 3.4 pre-op to 1.8. DkS scores were good to excellent in 79% of patients. Residual symptoms were noted in 7, and ATOS accounted for 5 (70%) of these. All patients were able to return to work. CONCLUSIONS Despite increased complexity, ABNFRs may be safely resected via transaxillary approach with low incidence of complications, very good symptom relief, and excellent outcomes. Congenital ABNFRs may by classified into three categories (hypoplastic, fused, and hyperplastic) with a variety of presentations, including ATOS, NTOS, and VTOS. Classification of ABNFRs allows concise description of abnormal anatomy which facilitates comparison between series and provides direction for surgical management to ultimately optimize patient outcomes.
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Affiliation(s)
- Mark J Ajalat
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles.
| | - Joe L Pantoja
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles
| | - Jesus G Ulloa
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles
| | - Michael J Cheng
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles
| | - Rhusheet P Patel
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles
| | - Tristen T Chun
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, University of California, Los Angeles
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11
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Habibollahi P, Zhang D, Kolber MK, Pillai AK. Venous thoracic outlet syndrome. Cardiovasc Diagn Ther 2021; 11:1150-1158. [PMID: 34815966 DOI: 10.21037/cdt-20-168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
Venous thoracic outlet syndrome (vTOS) is a spectrum of disease caused by external compression of the subclavian vein as it passes through the costoclavicular space. Paget-Schroetter's Syndrome (PSS) or effort thrombosis is a subtype of vTOS where compression and microtrauma to subclavian vein from repetitive arm movements results in venous thrombosis. PSS or effort thrombosis mostly affects young otherwise healthy active individuals, and this further highlights the importance of this condition. Early diagnosis and aggressive early intervention aimed at complete resolution of acute symptoms and minimizing the risk of recurrence is ultimately important and increases the likelihood of the full restoration of limb function. Several noninvasive imaging techniques are currently available to confirm the initial diagnosis including Doppler ultrasound, contrast-enhanced computed tomography, and magnetic resonance imaging. Following diagnosis, multiple algorithms exist for the management of PSS and almost all require a multidisciplinary approach. Like any other condition involving the thrombosis of deep venous system, initial step in the management is anticoagulation. Catheter-directed therapies (CDT) have also a pivotal role as the initial treatment to resolve the acute thrombosis and establish venous patency. CDT combined with medical anticoagulation and surgical decompression are the components of most treatment algorithms for the management of patients suffering from PSS.
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Affiliation(s)
- Peiman Habibollahi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dianbo Zhang
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcin K Kolber
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anil K Pillai
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Li W, Dissanaike S. Jury verdicts, outcomes, and tort reform features of malpractice cases involving thoracic outlet syndrome. J Vasc Surg 2021; 75:962-967. [PMID: 34601048 DOI: 10.1016/j.jvs.2021.08.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/22/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/BACKGROUND Thoracic outlet syndrome (TOS) is most often referred to vascular surgeons. However, there is a lack of understanding of the malpractice cases involving TOS. The goal of this study is to better understand the medicolegal landscape related to the care of TOS. METHODS The Westlaw Edge AI-powered proprietary system was retrospectively reviewed for malpractice cases involving TOS. A Boolean search strategy was used to identify target cases under the case category of "Jury Verdicts & Settlements" for all state and federal jurisdictions from 1970 to September 2020. The settled case was described but not included in the statistical analysis. Descriptive statistics were used to report our findings, and when appropriate. The P ≤ .05 decision rule was established a priori as the null hypothesis rejection criterion to determine associations between jury verdicts outcomes and state's tort reform status. RESULTS In this study, 39 cases were identified and met the study's inclusion criteria from the entire Westlaw Edge database. Among plaintiffs who disclosed age and/or gender, median age was 35.0 years with a female majority (67.6%). Cases involving TOS were noted to be steadily decreasing since the mid-1990s. The cases were unevenly spread across 18 states, with the highest number of cases (14, 35.9%) from California and the second highest (4, 10.3%) from Pennsylvania. A similar uneven distribution was seen among U.S. census regions, in which the West had the highest cases (39.5%). The study revealed that more cases were brought to trials in tort reform states (26, 68.4%) than in non-tort reform states (12, 31.6%). A total of 24 of 39 (61.5%) plaintiffs had one specific claim, which resulted in their economic and noneconomic damages. Negligent operation and treatment complication represented an overwhelming majority of claims brought by 38 of 39 plaintiffs (97.4%). Misdiagnosis and lack of informed consent were both brought nine times (23.1%) by the group. Intraoperative nerve injury (20 patients, 51.3%) was the most commonly reported complication. Excluding one case with a settlement of $965,000, 30 of 38 (78.9%) cases went to trials and received defense verdicts. Eight cases (20.5%) were found in favor of plaintiffs with a median payout of $725,581. CONCLUSIONS This study highlighted higher than average payouts to plaintiffs and risk factors that may result in malpractice lawsuits for surgeons undertaking TOS treatment. Future studies are needed to further clarify the relationships between tort reform and outcomes of malpractice cases involving TOS.
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Affiliation(s)
- Wei Li
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Tex; Loyola University Chicago School of Law, Chicago, Ill.
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Tex
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13
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Hoexum F, Jongkind V, Coveliers HM, Yeung KK, Wisselink W. Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome. Vascular 2021; 30:217-224. [PMID: 33832359 DOI: 10.1177/1708538121997332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars. METHODS We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire. RESULTS Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population. CONCLUSION Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.
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Affiliation(s)
- Frank Hoexum
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Vincent Jongkind
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | | | - Kak K Yeung
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Willem Wisselink
- Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
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14
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Abstract
Arterial thoracic outlet syndrome is rare and may be associated with a bony anomaly. Patient presentation can range from mild arm discoloration and claudication to severe limb-threatening ischemia. For patients with subclavian artery dilation without secondary complications, thoracic outlet decompression and arterial surveillance is sufficient. Patients with subclavian artery aneurysms or distal embolization require decompression with reconstruction or thromboembolectomy and distal bypass respectively.
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Affiliation(s)
- Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Andrew J Soo Hoo
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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15
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Schut PC, Brosens E, Van Dooren TJM, Galis F, Ten Broek CMA, Baijens IMM, Dremmen MHG, Tibboel D, Schol MP, de Klein A, Eggink AJ, Cohen-Overbeek TE. Exploring copy number variants in deceased fetuses and neonates with abnormal vertebral patterns and cervical ribs. Birth Defects Res 2020; 112:1513-1525. [PMID: 32755042 PMCID: PMC7689732 DOI: 10.1002/bdr2.1786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/03/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
Background Cervical patterning abnormalities are rare in the general population, but one variant, cervical ribs, is particularly common in deceased fetuses and neonates. The discrepancy between the incidence in the general population and early mortality is likely due to indirect selection against cervical ribs. The cause for the co‐occurrence of cervical ribs and adverse outcome remains unidentified. Copy number variations resulting in gain or loss of specific genes involved in development and patterning could play a causative role. Methods Radiographs of 374 deceased fetuses and infants, including terminations of pregnancies, stillbirths and neonatal deaths, were assessed. Copy number profiles of 265 patients were determined using single nucleotide polymorphism array. Results 274/374 patients (73.3%) had an abnormal vertebral pattern, which was associated with congenital abnormalities. Cervical ribs were present in 188/374 (50.3%) and were more common in stillbirths (69/128 [53.9%]) and terminations of pregnancies (101/188 [53.7%]), compared to live births (18/58, 31.0%). Large (likely) deleterious copy number variants and aneuploidies were prevalent in these patients. None of the rare copy number variants were recurrent or overlapped with candidate genes for vertebral patterning. Conclusions The large variety of copy number variants in deceased fetuses and neonates with similar abnormalities of the vertebral pattern probably reflects the etiological heterogeneity of vertebral patterning abnormalities. This genetic heterogeneity corresponds with the hypothesis that cervical ribs can be regarded as a sign of disruption of critical, highly interactive stages of embryogenesis. The vertebral pattern can probably provide valuable information regarding fetal and neonatal outcome.
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Affiliation(s)
- Pauline C Schut
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erwin Brosens
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tom J M Van Dooren
- Naturalis Biodiversity Center, Leiden, The Netherlands.,CNRS, Institute of Ecology and Environmental Sciences iEES Paris, Sorbonne University, Paris, France
| | | | | | - Inge M M Baijens
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marjolein H G Dremmen
- Department of Radiology, Division of Paediatric Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Paediatric Surgery, Erasmus MC, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martin P Schol
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Titia E Cohen-Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Rached R, Hsing W, Rached C. Evaluation of the efficacy of ropivacaine injection in the anterior and middle scalene muscles guided by ultrasonography in the treatment of Thoracic Outlet Syndrome. ACTA ACUST UNITED AC 2019; 65:982-987. [PMID: 31389509 DOI: 10.1590/1806-9282.65.7.982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/20/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A clinical, placebo-controlled, randomized, double-blind trial with two parallel groups. OBJECTIVE to evaluate the efficacy of ropivacaine injection in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome (TOS) compared to cutaneous pressure. METHODS 38 patients, 19 in the control group (skin pressure in each belly of the anterior and middle scalene muscles) and 19 in the intervention group (ropivacaine). Subjects with a diagnosis of Nonspecific Thoracic Outlet Syndrome, pain in upper limbs and/or neck, with no radiculopathy or neurological involvement of the limb affected due to compressive or encephalic root causes were included. The primary endpoint was functionality, evaluated by the Disabilities of the Arm, Shoulder, and Hand - DASH scale validated for use in Brasil. The time of the evaluations were T0 = before the intervention; T1 = immediately after; T2 = 1 week; T3 = 4 weeks; T4 = 12 weeks; for T1, the DASH scale was not applied. RESULTS Concerning the DASH scale, it is possible to affirm with statistical significance (p> 0.05) that the intervention group presented an improvement of functionality at four weeks, which was maintained by the 12th week. CONCLUSION In practical terms, we concluded that a 0.375% injection of ropivacaine at doses of 2.5 ml in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome helps to improve function.
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Affiliation(s)
- Roberto Rached
- Departamento de Fisiatria, Instituto de Medicina Física e Reabilitação - IMREA - HC-FMUSP, São Paulo, Brasil
| | - WuT Hsing
- Departamento de Patologia da Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - Chennyfer Rached
- Programa de Mestrado Profissional de Gestão em Saúde, Universidade Nove de Julho, São Paulo, Brasil
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17
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Matos JM, Gonzalez L, Kfoury E, Echeverria A, Bechara CF, Lin PH. Outcomes following operative management of thoracic outlet syndrome in the pediatric patients. Vascular 2018; 26:410-417. [DOI: 10.1177/1708538117747628] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.
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Affiliation(s)
- Jesus M Matos
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houstan, TX, USA
| | - Lorena Gonzalez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houstan, TX, USA
| | - Elias Kfoury
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houstan, TX, USA
| | - Angela Echeverria
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houstan, TX, USA
| | - Carlos F Bechara
- Department of Cardiothoracic and Vascular Surgery, Houston Methodist Hospital, Houstan, TX, USA
| | - Peter H Lin
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houstan, TX, USA
- University Vascular Associates, Los Angeles, CA, USA
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18
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Kuwayama DP, Lund JR, Brantigan CO, Glebova NO. Choosing Surgery for Neurogenic TOS: The Roles of Physical Exam, Physical Therapy, and Imaging. Diagnostics (Basel) 2017. [PMID: 28644402 PMCID: PMC5489957 DOI: 10.3390/diagnostics7020037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Neurogenic thoracic outlet syndrome (nTOS) is characterized by arm and hand pain, paresthesias, and sometimes weakness resulting from compression of the brachial plexus within the thoracic outlet. While it is the most common subtype of TOS, nTOS can be difficult to diagnose. Furthermore, patient selection for surgical treatment can be challenging as symptoms may be vague and ambiguous, and diagnostic studies may be equivocal. Herein, we describe some approaches to aid in identifying patients who would be expected to benefit from surgical intervention for nTOS. We describe the role of physical examination, physical therapy, and imaging in the evaluation and diagnosis of nTOS.
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Affiliation(s)
- David P Kuwayama
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Denver, CO 80045 USA.
| | - Jason R Lund
- Ashbaugh Center for Physical Therapy, Denver, CO 80222, USA.
| | - Charles O Brantigan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Denver, CO 80045 USA.
| | - Natalia O Glebova
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Denver, CO 80045 USA.
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Ave, Room 5409, Mail Stop C 312, Aurora, CO 80045, USA.
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19
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Mirza AK, Duncan AA. Thoracic outlet syndrome as a consequence of isolated atraumatic first rib fracture. J Surg Case Rep 2017; 2017:rjx100. [PMID: 28616159 PMCID: PMC5461470 DOI: 10.1093/jscr/rjx100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/22/2017] [Indexed: 11/14/2022] Open
Abstract
Neurogenic thoracic outlet syndrome (nTOS) resulting from an isolated first rib fracture is extremely infrequent. We report a case of performance limiting nTOS in a college athlete who was initially evaluated and treated for upper extremity ligamentous injury with only transient improvement. Subsequent noninvasive studies were consistent with TOS physiology and MRA showed a large hypertrophic callus on the first rib adjacent to the brachial plexus. With continued athletic limitations and radiographic findings consistent with TOS, surgical decompression was performed resulting in resolution of symptoms. Although apparent atraumatic isolated first rib fractures are infrequently reported etiologies for TOS in athletes, they are a reasonable consideration in this population with corresponding presentations.
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Affiliation(s)
- Aleem K Mirza
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Audra A Duncan
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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20
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Janák D, Novotný K, Roček M, Rohn V. Thoracic Outlet Syndrome: A Significant Family Genetic Phenotypic Presentation. Prague Med Rep 2017; 117:117-123. [PMID: 27668528 DOI: 10.14712/23362936.2016.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We report on a very rare case of diagnosis and successful surgical treatment of three young family members with a four-fold presentation of thoracic outlet syndrome. In the relevant family case, we are considering and discussing the population incidence, a possible HOX genes disorder, and a significant phenotypic presentation.
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Affiliation(s)
- David Janák
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic. .,Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Karel Novotný
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Miloslav Roček
- Department of Radiology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Vilém Rohn
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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21
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Ahmed S, Lewis J, Abidia A, Partridge W, Hamady M, Aldin Z. Thoracic outlet syndrome arising from an extrapleural lipoma. J Vasc Surg Cases Innov Tech 2016. [DOI: 10.1016/j.jvsc.2015.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Puttmann KT, Satiani B, Vaccaro P. Thoracic Outlet Syndrome in a Volleyball Player Due to Nonunion of the First Rib Fracture. Vasc Endovascular Surg 2016; 50:563-565. [DOI: 10.1177/1538574416674642] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fracture of the first rib with ensuing callus formation is a rare cause of thoracic outlet syndrome. We report a case of a 17-year-old female volleyball player who presented with months of chronic arm pain. Radiographic imaging demonstrated nonunion fracture of the first rib. Physical therapy had been unsuccessful in relieving the pain, and surgical management was performed with resection of the first rib through a transaxillary approach with complete resolution of symptoms. Inflammation surrounding such fractures may destroy tissue planes, making dissection more technically difficult.
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Affiliation(s)
- Kathleen T. Puttmann
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University College of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bhagwan Satiani
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University College of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick Vaccaro
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University College of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
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Arányi Z, Csillik A, Böhm J, Schelle T. Ultrasonographic Identification of Fibromuscular Bands Associated with Neurogenic Thoracic Outlet Syndrome: The "Wedge-Sickle" Sign. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2357-2366. [PMID: 27444863 DOI: 10.1016/j.ultrasmedbio.2016.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 06/06/2023]
Abstract
Thoracic outlet syndrome (TOS) is a disorder characterized by compression of the lower trunk of the brachial plexus, most often in association with anomalous congenital fibromuscular bands in the scalenic region. Early diagnosis is important, because the neurologic deficit associated with TOS may be irreversible. Using high-resolution ultrasound, we investigated 20 consecutive patients with clinical signs suggestive of TOS (all females, average age: 40.4 ± 14.9 y) and 25 control patients. In 19 patients, we identified a hyper-echoic fibromuscular structure at the medial edge of the middle scalene muscle, which indented the lower trunk of the brachial plexus ("wedge-sickle sign"). It was associated with the significant enlargement (p < 0.0001) and hypo-echogenicity of the lower trunk. This novel and distinctive ultrasonographic sign allows pre-surgical identification of anomalous fibromuscular bands causing TOS. It is especially useful in patients without neurologic deficit, in whom the diagnosis may not be as straightforward.
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Affiliation(s)
- Zsuzsanna Arányi
- MTA-SE NAP B Peripheral Nervous System Research Group, Department of Neurology, Semmelweis University, Budapest, Hungary.
| | - Anita Csillik
- MTA-SE NAP B Peripheral Nervous System Research Group, Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Josef Böhm
- Neurologische Praxis, Dr. Friedrich Behse/Dr. Josef Böhm, Berlin, Germany
| | - Thomas Schelle
- Department of Neurology, Städtisches Klinikum Dessau, Dessau-Rosslau, Germany
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Veraa S, Bergmann W, van den Belt AJ, Wijnberg I, Back W. EX VIVO COMPUTED TOMOGRAPHIC EVALUATION OF MORPHOLOGY VARIATIONS IN EQUINE CERVICAL VERTEBRAE. Vet Radiol Ultrasound 2016; 57:482-8. [DOI: 10.1111/vru.12393] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 05/25/2016] [Accepted: 05/27/2016] [Indexed: 11/27/2022] Open
Affiliation(s)
- Stefanie Veraa
- Division of Diagnostic Imaging, Faculty of Veterinary Medicine; Utrecht University; Yalelaan 110, 3584 CM (Veraa, van den Belt)
| | - Wilhelmina Bergmann
- Department of Pathobiology, Faculty of Veterinary Medicine; Utrecht University; Yalelaan 1, 3584 CL (Bergmann)
| | - Antoon-Jan van den Belt
- Division of Diagnostic Imaging, Faculty of Veterinary Medicine; Utrecht University; Yalelaan 110, 3584 CM (Veraa, van den Belt)
| | - Inge Wijnberg
- Department of Equine Sciences, Faculty of Veterinary Medicine; Utrecht University; Yalelaan 114, 3584 CM (Wijnberg, Back) Utrecht The Netherlands
| | - Willem Back
- Department of Equine Sciences, Faculty of Veterinary Medicine; Utrecht University; Yalelaan 114, 3584 CM (Wijnberg, Back) Utrecht The Netherlands
- Department of Surgery and Anaesthesiology of Domestic Animals, Faculty of Veterinary Medicine; Ghent University; Salisburylaan 133, B-9820 Merelbeke Belgium (Back)
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25
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Thoracoscopic Resection of a Symptomatic, Congenital Rib Synostosis. Ann Thorac Surg 2016; 101:1596-8. [DOI: 10.1016/j.athoracsur.2015.06.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 05/12/2015] [Accepted: 06/01/2015] [Indexed: 11/23/2022]
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Abstract
Venous thoracic outlet syndrome is a complex but rare disease that often can have excellent outcomes if quickly recognized and treated. The syndrome results from compression of the subclavian vein along its exit from the thoracic cavity and frequently affects young otherwise healthy patients. Modern diagnosis is made with a combination of clinical exam, appropriate non-invasive imaging, and, finally, contrast venography, which can be both diagnostic and therapeutic. Treatments have evolved over time to the point where patients can undergo less extensive procedures than previously performed and still maintain excellent outcomes. One of the most important predictors of outcome is the initiation of treatment within 14 days of symptoms. Hence, the importance of the accurate and prompt diagnosis of this syndrome in patients with an upper-extremity deep vein thrombotic episode cannot be further underscored. This review is a concise summary of the background and treatment algorithm for this patient population.
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Affiliation(s)
- Robert Moore
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD, USA General Surgery Resident, Walter-Reed National Military Medical Center, Bethesda, MD, USA
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Stella M, Santolini E, Briano S, Santolini F. Late recurrent peripheral upper limb ischemia after non-union of a clavicle fracture. Injury 2015; 46 Suppl 7:S3-7. [PMID: 26738457 DOI: 10.1016/s0020-1383(15)30035-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A 74-year-old woman was referred to our hospital due to recurrent episodes of upper limb ischemia. Her past medical history included a clavicle non-union developed after a clavicle midshaft fracture that had occurred 30 years previously. After a long asymptomatic period, she started showing symptoms of chronic ischemia to the left arm that were misdiagnosed. Thoracic outlet syndrome (TOS) is a rare but possible complication of mal-union and non-union of clavicle fractures; symptoms related to arterial involvement (ATOS) amount to less than 1% of all existing forms of thoracic outlet syndrome. In case of clavicle non-union, local instability plays a key role in determining the initial injury to the vessels and the recurrence of symptoms. Restoration of local bone stability and anatomy, obtained by compression plating and autologous bone grafting, combined with an appropriate vascular surgery, is essential to achieve a clinical resolution of symptoms and to avoid the recurrence of symptomatology as seen in the herein case.
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Affiliation(s)
- Marco Stella
- Orthopaedic and Trauma Unit, Department of Emergency, IRCCS AOU San Martino - IST, Largo Rosanna Benzi 10, 16132 Genoa, Italy.
| | - Emmanuele Santolini
- Orthopaedic and Trauma Unit, Department of Emergency, IRCCS AOU San Martino - IST, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Stefania Briano
- Orthopaedic and Trauma Unit, Department of Emergency, IRCCS AOU San Martino - IST, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Federico Santolini
- Orthopaedic and Trauma Unit, Department of Emergency, IRCCS AOU San Martino - IST, Largo Rosanna Benzi 10, 16132 Genoa, Italy
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Thoracic outlet syndrome caused by synostosis of the first and second thoracic ribs: 2 case reports and review of the literature. J Hand Surg Am 2014; 39:2444-7. [PMID: 25307506 DOI: 10.1016/j.jhsa.2014.08.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 02/02/2023]
Abstract
We present 2 cases of combined arterial and neurogenic thoracic outlet syndrome triggered by trauma in patients with congenital synostoses of the first and second ribs. These patients were successfully treated with supraclavicular resection of the first and second ribs and scalenectomy. We review these cases and the associated literature on thoracic outlet syndrome and rib synostosis.
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29
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Freischlag J, Orion K. Understanding thoracic outlet syndrome. SCIENTIFICA 2014; 2014:248163. [PMID: 25140278 PMCID: PMC4129179 DOI: 10.1155/2014/248163] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 06/28/2014] [Indexed: 06/03/2023]
Abstract
The diagnosis of thoracic outlet syndrome was once debated in the world of vascular surgery. Today, it is more understood and surprisingly less infrequent than once thought. Thoracic outlet syndrome (TOS) is composed of three types: neurogenic, venous, and arterial. Each type is in distinction to the others when considering patient presentation and diagnosis. Remarkable advances have been made in surgical approach, physical therapy, and rehabilitation of these patients. Dedicated centers of excellence with multidisciplinary teams have been developed and continue to lead the way in future research.
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Affiliation(s)
- Julie Freischlag
- Division of Vascular Surgery, Department of Surgery, The Johns Hopkins Hospital, 720 Rutland Avenue, Ross 759, Baltimore, MD 21205, USA
| | - Kristine Orion
- Division of Vascular Surgery, Department of Surgery, The Johns Hopkins Hospital, 600 N. Wolfe Street, Halsted 668, Baltimore, MD 21287, USA
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