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Satake H, Nito T, Naganuma Y, Maruyama M, Hanaka N, Uno T, Takagi M. Endoscopically assisted transaxillary release of the scalene muscles for thoracic outlet syndromes: a comparison with or without first rib resection. Gen Thorac Cardiovasc Surg 2024; 72:487-494. [PMID: 38700608 DOI: 10.1007/s11748-024-02031-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/02/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES There are several surgical techniques for thoracic outlet syndrome (TOS). However, there have been no reports of endoscopically assisted transaxillary release of the anterior and middle scalene muscles (EATRS), leaving the first rib intact for TOS. We hypothesized that EATRS would achieve a good Quick Disability of the Arm, Shoulder and Hand score. This study aims to present our experience with a new technique for TOS using endoscopy. METHODS We chose two surgeries depending on the patient's TOS condition. If the costoclavicular space was under 12 mm, we selected endoscopically assisted transaxillary first rib resection (EAFRR). If the costoclavicular space was over 12 mm, we selected EATRS. Between January 2021 and December 2022, 31 consecutive surgeries for TOS were performed in our institution. Twenty-five patients underwent EAFRR, and six (19%) underwent EATRS. Since July 2022, EAFRR has been performed under differential lung ventilation. RESULTS Complete and almost complete relief was achieved in 24 patients (77%), and partial relief was conducted in seven patients (23%) at a mean of 19.7 months after surgery. The symptoms improved in all cases. Intraoperative pneumothorax did not occur, and no other complications were observed. Both EAFRR and EATRS were effective and safe surgeries for TOS. Operative time was significantly shorter in EATRS than in EAFRR. CONCLUSIONS We first report EATRS surgery for TOS. EATRS is indicated for patients whose costoclavicular space is preserved before surgery. Good surgical results were obtained after surgery for this indication.
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Affiliation(s)
- Hiroshi Satake
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan.
| | - Toshiya Nito
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Yasushi Naganuma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Masahiro Maruyama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Naomi Hanaka
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
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Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023. [PMID: 37521545 PMCID: PMC10382898 DOI: 10.1016/j.jhsg.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.
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Ahmed AS, Graf AR, Karzon AL, Graulich BL, Egger AC, Taub SM, Gottschalk MB, Bowers RL, Wagner ER. Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:469-488. [PMID: 37588453 PMCID: PMC10426640 DOI: 10.1016/j.xrrt.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.
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Affiliation(s)
- Adil S. Ahmed
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexander R. Graf
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Anthony L. Karzon
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Anthony C. Egger
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah M. Taub
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael B. Gottschalk
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert L. Bowers
- Department of Orthopaedic Surgery, Sports Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric R. Wagner
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Satake H, Honma R, Nito T, Naganuma Y, Shibuya J, Maruyama M, Uno T, Takagi M. Midterm results of endoscopically assisted first rib resection in the zero position for thoracic outlet syndrome. Interact Cardiovasc Thorac Surg 2022; 35:6696242. [PMID: 36094365 PMCID: PMC9536291 DOI: 10.1093/icvts/ivac239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hiroshi Satake
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Ryusuke Honma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Toshiya Nito
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Yasushi Naganuma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Junichiro Shibuya
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Masahiro Maruyama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
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Dengler NF, Ferraresi S, Rochkind S, Denisova N, Garozzo D, Heinen C, Alimehmeti R, Capone C, Barone DG, Zdunczyk A, Pedro MT, Antoniadis G, Kaiser R, Dubuisson A, Kretschmer T, Rasulic L. Thoracic Outlet Syndrome Part I: Systematic Review of the Literature and Consensus on Anatomy, Diagnosis, and Classification of Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery. Neurosurgery 2022; 90:653-667. [PMID: 35319532 PMCID: PMC9514726 DOI: 10.1227/neu.0000000000001908] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although numerous articles have been published not only on the classification of thoracic outlet syndrome (TOS) but also on diagnostic standards, timing, and type of surgical intervention, there still remains some controversy because of the lack of level 1 evidence. So far, attempts to generate uniform reporting standards have not yielded conclusive results. OBJECTIVE To systematically review the body of evidence and reach a consensus among neurosurgeons experienced in TOS regarding anatomy, diagnosis, and classification. METHODS A systematic literature search on PubMed/MEDLINE was performed on February 13, 2021, yielding 2853 results. Abstracts were screened and classified. Recommendations were developed in a meeting held online on February 10, 2021, and refined according to the Delphi consensus method. RESULTS Six randomized controlled trials (on surgical, conservative, and injection therapies), 4 "guideline" articles (on imaging and reporting standards), 5 observational studies (on diagnostics, hierarchic designs of physiotherapy vs surgery, and quality of life outcomes), and 6 meta-analyses were identified. The European Association of Neurosurgical Societies' section of peripheral nerve surgery established 18 statements regarding anatomy, diagnosis, and classification of TOS with agreement levels of 98.4 % (±3.0). CONCLUSION Because of the lack of level 1 evidence, consensus statements on anatomy, diagnosis, and classification of TOS from experts of the section of peripheral nerve surgery of the European Association of Neurosurgical Societies were developed with the Delphi method. Further work on reporting standards, prospective data collections, therapy, and long-term outcome is necessary.
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Affiliation(s)
- Nora Franziska Dengler
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany;
| | - Stefano Ferraresi
- Department of Neurosurgery, Ospedale Santa Maria della Misericordia, Rovigo, Italy;
| | - Shimon Rochkind
- Division of Peripheral Nerve Reconstruction, Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv-Yafo, Israel;
| | - Natalia Denisova
- Department of Functional Neurosurgery, Federal Neurosurgical Center, Novosibirsk, Russia
| | - Debora Garozzo
- Department of Neurosurgery, Mediclinic Parkview Hospital, Dubai, United Arab Emirates
| | - Christian Heinen
- Peripheral Nerve Unit Nord, Christliches Krankenhaus Quakenbrück GmbH, Quakenbrück, Germany;
| | - Ridvan Alimehmeti
- Department of Neurosurgery at University Hospital Center “Mother Theresa”, Tirana, Albania;
| | - Crescenzo Capone
- Department of Peripheral Nerve Surgery, Ospedale Civile di Faenza, Local Health Authority of Romagna, Faenza, Italy;
| | | | - Anna Zdunczyk
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany;
| | - Maria Teresa Pedro
- Peripheral Nerve Unit, Department of Neurosurgery, BKH Günzburg at Ulm University, Günzburg, Germany
| | - Gregor Antoniadis
- Peripheral Nerve Unit, Department of Neurosurgery, BKH Günzburg at Ulm University, Günzburg, Germany
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Praha, Czech Republic;
| | - Annie Dubuisson
- Department of Neurosurgery, CHU Liège, Avenue de L’Hôpital 1, Liège, Belgium;
| | - Thomas Kretschmer
- Department of Neurosurgery & Neurorestoration, Klinikum Klagenfurt, Klagenfurt am Wörthersee, Austria;
| | - Lukas Rasulic
- Faculty of Medicine, University of Belgrade, Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
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