Feasibility and Outcomes of a Multidisciplinary Care Pathway for Neurogenic Thoracic Outlet Syndrome: A Prospective Observational Cohort Study

Thoracic outlet syndrome in women

Thoracic outlet syndrome (TOS) is observed more frequently in women, although the exact causes of this sex disparity remain unclear. By investigating the three types of TOS-arterial, neurogenic, and venous-regarding symptoms, diagnosis, and treatment, this article aims to shed light on the current understanding of TOS, focusing on its variations in women.

Role of Lifestyle in Thoracic Outlet Syndrome: A Narrative Review

INTRODUCTION

The presence of a positional compression of the neurovascular bundle in the outlet between the thorax and the upper limb during arm movements (mainly abduction) is common but remains asymptomatic in most adults. Nevertheless, a certain number of subjects with thoracic outlet positional compression will develop incapacitating symptoms or clinical complications as a result of this condition. Symptomatic forms of positional neurovascular bundle compression are referred to as "thoracic outlet syndrome" (TOS).

MATERIALS AND METHODS

This paper aims to review the literature and discuss the interactions between aspects of patients' lifestyles in TOS. The manuscript will be organized to report (1) the historical importance of lifestyle evolution on TOS; (2) the evaluation of lifestyle in the clinical routine of TOS-suspected patients, with a description of both the methods for lifestyle evaluation in the clinical routine and the role of lifestyle in the occurrence and characteristics of TOS; and (3) the influence of lifestyle on the treatment options of TOS, with a description of both the treatment of TOS through lifestyle changes and the influence of lifestyle on the invasive treatment options of TOS.

RESULTS

We report that in patients with TOS, lifestyle (1) is closely related to anatomical changes with human evolution; (2) is poorly evaluated by questionnaires and is one of the factors that may induce symptoms; (3) influences the sex ratio in symptomatic athletes and likely explains why so many people with positional compression remain asymptomatic; and (4) can sometimes be modified to improve symptoms and potentially alter the range of interventional treatment options available.

CONCLUSIONS

Detailed descriptions of the lifestyles of patients with suspected TOS should be carefully analysed and reported.

Rapid Functional Recovery After Thoracic Outlet Decompression in a Series of Adolescent Athletes With Chronic Atraumatic Shoulder-Girdle Pain, Scapular Winging/Dyskinesis, and Normal Electrodiagnostic Studies

BACKGROUND

Spontaneous shoulder-girdle pain and scapular winging/dyskinesis can be caused by several neuromuscular disorders identifiable by electrodiagnostic studies (EDX). We describe a group of adolescent athletes with this clinical presentation but normal EDX, followed by later development of neurogenic thoracic outlet syndrome (NTOS).

METHODS

We identified patients referred for evaluation of NTOS that had a history of chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX. Each was refractory to conservative management and underwent supraclavicular decompression and brachial plexus neurolysis for NTOS. Functional disability was quantified by Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores.

RESULTS

There were 5 female patients with a mean age at symptom onset of 14.2 ± 0.4 years, including spontaneous severe pain in the shoulder, scapula, and arm, along with prominent scapular winging/dyskinesis, and normal EDX. Symptoms had persisted for 18.9 ± 4.0 months prior to referral, with pronounced upper extremity disability (mean QuickDASH, 54.6 ± 6.9). By 3 months after surgical treatment for NTOS, all 5 patients experienced near-complete symptom resolution, including scapular winging/dyskinesis, with markedly improved function (mean QuickDASH, 2.2 ± 1.3) and a return to normal activity.

CONCLUSIONS

A subset of patients with chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX may develop dynamic brachial plexus compression characteristic of NTOS, exhibiting an ischemic "Sunderland-zero" nerve conduction block for which surgical decompression can result in rapid and substantial clinical improvement. The presence of surgically treatable NTOS should be considered for selected patients with long-standing scapular winging/dyskinesis who fail conservative management.

General Overview and Diagnostic (Imaging) Techniques for Neurogenic Thoracic Outlet Syndrome

Thoracic outlet syndrome is an uncommon and controversial syndrome. Three different diagnoses can be made based on the compressed structure, arterial TOS, venous TOS, and neurogenic TOS, though combinations do exist as well. Diagnosing NTOS is difficult since no specific objective diagnostic modalities exist. This has resulted in a lot of controversy in recent decades. NTOS remains a clinical diagnosis and is mostly diagnosed based on the exclusion of an extensive list of differential diagnoses. To guide the diagnosis and treatment of TOS, a group of experts published the reporting standards for TOS in 2016. However, a consensus was not reached regarding a blueprint for a daily care pathway in this document. Therefore, we constructed a care pathway based on the reporting standards for both the diagnosis and treatment of NTOS patients. This care pathway includes a multidisciplinary approach in which different diagnostic tests and additional imaging techniques are combined to diagnose NTOS or guide patients in their treatment for differential diagnoses. The aim of the present work is to discuss and explain the diagnostic part of this care pathway.

Considerations for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome: A Meta-Analysis of Patient-Reported Outcomes

PURPOSE

It remains unclear whether the first rib resection, performed via a supraclavicular (SCFRR) or transaxillary (TAFRR) approach, is necessary for patients with neurogenic thoracic outlet syndrome (nTOS). In a systematic review and meta-analysis, we performed a direct comparison of patient-reported functional outcomes following different surgical approaches for nTOS.

METHODS

The authors searched PubMed, Embase, Web of Science, Cochrane Library, PROSPERO, Google Scholar, and the gray literature. Data were extracted based on the procedure type. Well-validated patient-reported outcome measures were analyzed in separate time intervals. Random-effects meta-analysis and descriptive statistics were used where appropriate.

RESULTS

Twenty-two articles were included, with 11 discussing SCFRR (812 patients), 6 discussing TAFRR (478 patients), and 5 discussing rib-sparing scalenectomy (RSS; 720 patients). The mean difference between preoperative and postoperative Disabilities of the Arm, Shoulder and Hand score was significantly different comparing RSS (43.0), TAFRR (26.8), and SCFRR (21.8). The mean difference between preoperative and postoperative visual analog scale scores was significantly higher for TAFRR (5.3) compared to SCFRR (3.0). Derkash scores were significantly worse for TAFRR compared to RSS or SCFRR. RSS had a success rate of 97.4% based on Derkash score, followed by SCFRR and TAFRR at 93.2% and 87.9%, respectively. RSS had a lower complication rate compared to SCFRR and TAFRR. There was a difference in complication rates: 8.7%, 14.5%, and 3.6% for SCFRR, TAFRR, and RSS, respectively.

CONCLUSIONS

Mean differences in Disabilities of the Arm, Shoulder and Hand scores and Derkash scores were significantly better for RSS. Higher complication rates were reported after the first rib resection. Our findings suggest that RSS is an effective option for the treatment of nTOS.

TYPE OF STUDY/ LEVEL OF EVIDENCE

Therapeutic IV.

Pedro M, Kretschmer T, Heinen C, Rosahl SK, Antoniadis G. Neurogenic Thoracic Outlet Syndrome

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleep Problems and Disabilities of the Arm, Shoulder, and Hand in Persons with Thoracic Outlet Syndrome-A Cross-Sectional Study

Thoracic outlet syndrome (TOS) arises as a result of a specific relationship among the anatomical structures that may cause compression in the muscles, nerves, and/or blood vessels in the neck, thereby compromising the local circulation. The aim of the current study was to establish the presence of sleep disturbance and disability in the shoulder, arm, and hand in individuals affected by TOS, as well as to ascertain if there are any differences in these findings relative to TOS-free individuals. The study sample comprised 82 TOS patients and 81 TOS-free individuals aged 19-66 years. Data were gathered by administering the Disabilities of the Arm, Shoulder, and Hand (DASH) and Pittsburgh Sleep Quality Index (PSQI) instruments. The results showed that both the DASH (t = -13.21, p < 0.001) and PSQI (t = -7.27, p < 0.001) scores obtained by the TOS group were higher relative to the controls and were strongly and positively correlated (ρ = 0.58, p < 0.01). As positive DASH scores may be indicative of TOS, they signal the need for further diagnostic evaluations. In individuals in whom TOS is already diagnosed, high DASH scores imply that further sleep quality assessments are required, as compromised sleep patterns may undermine quality of life.

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.

Interpectoral-pectoserratus plane (PECS II) block in patients undergoing trans-axillary thoracic outlet decompression surgery; A prospective double-blind, randomized, placebo-controlled clinical trial

STUDY OBJECTIVE

To investigate if an interpectoral-pectoserratus plane (PECS II) block decreases postoperative pain, postoperative nausea and vomiting and improves quality of recovery in patients with neurogenic thoracic outlet syndrome (NTOS) undergoing trans-axillary thoracic outlet decompression surgery.

DESIGN

A prospective single center double blinded randomized placebo-controlled trial.

SETTING

Perioperative period; operating room, post anesthesia care unit (PACU) and hospital ward.

PATIENTS

Seventy patients with NTOS, undergoing trans-axillary thoracic outlet decompression surgery.

INTERVENTIONS

Patients were randomized to an interventional arm, receiving the block with 40 ml ropivacaine 0.5% (concentration was adjusted if the patient's weight was <66 kg), and a placebo group, receiving a sham block with 40 ml NaCl 0.9%. The interpectoral-pectoserratus plane block was performed ultrasound guided; the first injection below the pectoral minor muscle and the second below the pectoral major muscle. The hospitals' pharmacist prepared the study medication and was the only person able to see the randomization result. The study was blinded for patients, researchers and medical personnel.

MEASUREMENTS

Primary outcome parameters were postoperative pain, measured by numeric rating scale on the PACU (start and end) and on the ward on postoperative day (POD) 0 and 1, and postoperative morphine consumption, measured on the PACU and on the ward during the first 24 h. Secondary outcome parameters were postoperative nausea and vomiting, and quality of recovery.

MAIN RESULTS

There was no statistically significant difference in NRS on the PACU at the start (ropivacaine 4.9 ± 3.2 vs placebo 6.2 ± 3.0, p = .07), at the end (ropivacaine 4.0 ± 1.7 vs placebo 3.9 ± 1.7, p = .77), on the ward on POD 0 (ropivacaine 4.6 ± 2.0 vs placebo 4.6 ± 2.0, p = 1.00) or POD 1 (ropivacaine 3.9 ± 1.8 vs placebo 3.6 ± 2.0, p = .53). There was no difference in postoperative morphine consumption at the PACU (ropivacaine 11.0 mg ± 6.5 vs placebo 10.8 mg ± 4.8, p = .91) or on the ward (ropivacaine 11.6 mg ± 8.5 vs placebo 9.6 mg ± 9.4, p = .39).

CONCLUSIONS

The interpectoral-pectoserratus plane block is not effective for postoperative analgesia in patients with NTOS undergoing trans-axillary thoracic outlet decompression surgery.

Derkash's Classification and Vas Visual Analog Scale to Access the Long-Term Outcome of Neurothoracic Outlet Syndrome: A Meta-Analysis and Systematic Review

Objective

Many publications report outcomes of surgical treatment for neurothoracic outlet syndrome (NTOS); however, high-quality meta-analyses regarding objective evaluation system accessing the long-term outcome of NTOS are lacking. This meta-analysis summarizes and compares the outcomes of Derkosh's classification and vas visual analog scale of the supraclavicular neuroplastic of brachial plexus (SNBP) and trams auxiliary first rib resection (TFRR).

Methods

The Cochrane Library, PubMed, EMBASE, Allied and Complementary Medicine (AMED) were searched for papers published between January 1980 and February 2021, using the keywords “thoracic outlet syndrome,” “treatment, surgical.” Articles were eligible for inclusion if the following criteria were met studies describing outcomes of surgery for NTOS, published in English, human studies, and available in full text. The exclusion criteria were case reports (n < 10), reviews, abstracts, and studies lacking a control group or without evaluation for two types of surgery.

Results

We included 10 studies with 1,255 cases, out of which 622 were in the SNBP group; and 633 were in the TFRR group. After surgery (≥12 months), Derkash's classification was improved in 425 cases with SNBP and 364 cases with TFRR. OR = 1.34 (95% CI: 0.94, 1.92), P = 0.03; vas visual analog scale was improved in 282 cases in the SNBP group and 214 cases in the TFRR group. OR = 1.08 (95% CI: 0.63, 1.85), P = 0.78.

Conclusion

This meta-analysis shows that both SNBP and TFRR are effective for NTOS, but that SNBP is better than TFRR in improving Derkash's classification in the long term. Although patients treated with SNBP are more satisfactory, there is no significant difference in vas visual analog scale from TFRR.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021254203, PROSPERO CRD42021254203.

Reliability and Validity of the Standardized Elevated Arm Stress Test in the diagnosis of Neurogenic Thoracic Outlet Syndrome

OBJECTIVES

We developed a standardized elevated arm stress test (EAST)-meter to standardize posture and measure additional grip and fatigue parameters. This study aims to determine the reliability and validity of the standardized EAST (sEAST) in the diagnosis of neurogenic thoracic outlet syndrome (NTOS).

DESIGN

Prospective cohort study METHODS: Patients evaluated for NTOS between October 2018 and February 2020 were included and performed the sEAST. Patients were classified into a proven NTOS group or a symptomatic control group using the Reporting Standards for NTOS and outcome of thoracic outlet decompression (TOD) surgery. Healthy subjects were recruited as asymptomatic control group. Test-retest reliability, the area under the curve (AUC), and positive and negative predictive values were calculated for each valuable sEAST-parameter.

RESULTS

A total of 426 suspected NTOS patients and 147 healthy controls performed the sEAST measurement. The validity analysis was performed with 111 proven NTOS patients, 94 symptomatic controls and 147 asymptomatic controls. The reporting standards were inconclusive in 116 patients, 77 patients were excluded because TOD surgery was not performed or unsuccessful, and 28 patients were excluded with arterial or venous TOS. The AUC of proven NTOS compared to asymptomatic controls ranged between 0.59 and 0.77, and between 0.54 and 0.63 when compared to symptomatic controls. The positive predictive value ranged between 46% and 65%, and the negative predictive value between 51% and 66%. Test-retest reliability analysis in 80 patients with multiple sEAST measurements showed moderate to good (0.52-0.87) ICC values for duration and grip strength parameters. Grip fatigue parameters demonstrated poor (0.46-0.16) ICC values.

CONCLUSION

The sEAST showed good test-retest reliability for duration and grip strength parameters. However, the discriminative value of all sEAST-parameters is low in NTOS diagnostics. The good test-retest reliability of the sEAST parameters make them valuable outcome measures for comparison in a diagnostic care pathway.

Reliability and Validity of the Elevated Arm Stress Test in the Diagnosis of Neurogenic Thoracic Outlet Syndrome

OBJECTIVES

To assess the test-retest reliability and validity of the elevated arm stress test (EAST) as measured by the duration in a cohort of patients with suspected neurogenic thoracic outlet syndrome (NTOS).

DESIGN

Retrospective analysis of prospectively collected data METHODS: Patients evaluated for NTOS between January 2017 and September 2018 were identified. Test-retest reliability by the intraclass correlation coefficient (ICC) was determined for duration of the EAST. For the validity analysis, patients were classified in a proven NTOS group or a symptomatic control group without NTOS using the SVS-reporting standards and the outcome of thoracic outlet decompression (TOD) surgery. A receiver operating characteristic (ROC) curve was made for the duration of EAST. The area under the curve (AUC), and positive and negative predictive values were calculated for the EAST.

RESULTS

In total, 428 patients with suspected NTOS retrospectively analysed. Of these patients, 61 were excluded because no EAST data was available. Another 101 patients were excluded because of inconclusive reporting standards, arterial or venous TOS, or because TOD surgery was not performed or had a negative result. The validity analysis in the remaining 266 patients showed an AUC for the duration of the EAST of 0.62 (95% confidence interval (CI): 0.55-0.69). The positive predictive value of the duration ranged between 65% and 66%, and the negative predictive value between 53% and 58%. For the test-retest reliability analysis, 118 patients were excluded because they performed only one measurement in a 100-day time period. Analysis in the remaining 148 patients showed an ICC value of 0.65 (95% CI: 0.55-0.74) for duration.

CONCLUSION

The EAST measured by the duration showed a moderate test-retest reliability, but the discriminative value was low in the diagnosis of NTOS. The outcome of the EAST measured by the duration should be used with caution.

Redo surgery for neurogenic thoracic outlet syndrome is useful

INTRODUCTION

Surgery for Neurogenic Thoracic Outlet Syndrome (NTOS) has shown good outcome in numerous case series. However, 5-30% of patients will have persistent or recurrent symptoms, caused by incomplete first rib resection, reattachment of residual scalene muscle, fibrous scarring around the brachial plexus or a wrong NTOS diagnosis. In patients with a sound diagnosis of recurrent or persisting NTOS, not responding to conservative measures, a secondary procedure can be considered. We report the results of redo thoracic outlet decompression surgery through the supraclavicular approach (SC-REDO-TOD) for persistent or recurrent NTOS.

METHODS

A retrospective review of a prospective database was performed. Every patient referred from September 2016 until January 2020 was eligible for inclusion. In a SC-REDO-TOD we perform complete (cartilage-cartilage) resection of the first rib, any bony and fibrous anomalies, complete anterior and middle scalenectomy and complete neurolysis of the brachial plexus (= complete anatomical decompression of the brachial plexus). Clinical outcomes were assessed by questionnaires including the DASH (Disability of Arm, Shoulder and Hand), CBSQ (Cervico-Brachial Symptoms Questionnaire) and TOS disability scale.

RESULTS

In total, 45 patients had a SC-REDO-TOD. The median duration of hospital admission after SC-REDO-TOD was 1.41 days (IQR 1.00). In total 30/45 (66.66%) patients had recurrent NTOS and 15/45 (33.33%) patients had persisting NTOS. Postoperative complications were seen in 8 (18.18%) patients. 1 Patient had postoperative complications with permanent impairment (Horner syndrome). 7 Patients had postoperative complications with full recovery (3 patients had a chylous leakage which was treated with a median-chain triglycerides diet for 6 weeks, 3 patients had transient phrenic nerve palsy with full recovery < 6 weeks, 1 patient had a discrete Horner syndrome which resolved in 6 weeks). The median time of follow-up was 19.50 months (interquartile range (IQR) 14.00) and the response rate to the questionnaires was 91.11% at 6 months and 64.44% at 12 months. We found a positive and statistically significant difference for DASH score, CBSQ score and TOS Disability Scale score comparing scores for all patients. (DASH score: p<0.001; CBSQ score: p<0.001; TOS Disability Scale: p<0.001). Patients with first rib remnants showed a significant better response (lower DASH, CBSQ and TOS Disability Scale scores) compared to patients without first rib remnants (DASH score: p=0.004; CBSQ score: p<=0.014; TOS Disability Scale: p=0.009).

CONCLUSION

SC-REDO-TOD after a previous NTOS surgery shows good results with a low risk of permanent impairment. NTOS patients with first rib remnants after primary surgery seem to benefit the most from REDO surgery.

Thoracic Outlet decompression Surgery for Gilliatt-Sumner Hand as presentation of neurogenic thoracic outlet syndrome

INTRODUCTION

Chronic compression of the inferior trunk of the brachial plexus can result in severe pain and progressive atrophy and weakness of the musculature of the forearm and hand, known as Gilliatt-Sumner Hand (GSH). The objective of treatment in these patients is to stop further atrophy and pain. Restoration of motor function is thought to be seldom achieved. The aim of this contemporary case series is to describe diagnosis, treatment and outcomes of surgery in GSH.

METHODS

All patients referred between January 2017 and May 2021 with visible signs of a GSH were included. Visible GSH signs were defined as muscle atrophy of the abductor digiti minimi (ADM), abductor pollicis brevis (APB), and/or interosseous musculature. Additional electrodiagnostic assessment (EDx) and high-resolution ultrasound (HRUS) were performed in all patients. All diagnosed GSH patients underwent thoracic outlet decompression (TOD) surgery by transaxillary (TA) or supraclavicular (SC) approach. Outcomes were measured with the TOS disability scale, Cervical Brachial Score Questionnaire (CBSQ), Disability of the Arm, Shoulder, and Hand (DASH) score and patient reported outcome of motor function, measured with a numerated rating scale score (NRS). The standardized Elevated Arm Stress Test (sEAST) was used to assess motor function before and after TOD.

RESULTS

Twenty patients were referred to our center with visible signs of a GSH. Clinical examination showed atrophy of the ADM, APB and interosseous musculature in all patients. EDx showed plexopathy of the lower brachial plexus in all patients. HRUS showed an indented inferior trunc of the brachial plexus (so called "wedge sickle sign" WSS) in 18 (90%) patients. Surgical treatment was performed in 17 patients (15 TA-TOD, 2 SC TOD). Three patients refrained from surgical treatment. The median follow-up interval was 15.0 (IQR 14.0) months. The TOS disability scale improved significant (Preoperative: mean 6.31, CI [5.49 - 7.13]; postoperative: mean 4.25, CI [2.80 - 5.70], p=0.026). The same was seen for the CBSQ scores (preoperative mean 77.75, CI [66.63 - 88.87]; postoperative mean 42.65, CI [24.77 - 60.77], p= 0.001) and DASH scores (preoperative mean 59.13, CI [51.49 - 66.77]; postoperative mean 40.96, CI [24.41 - 57.51]; p= 0.032. The NRS for muscle weakness and sEAST showed no statistical difference before and after TOD comparing the whole group (NRS muscle weakness preoperative mean: 6.22, CI [4.31 - 8.14]; postoperative mean: 5.11, CI [3.25 - 6.97]; p= 0.269). However, 4 (23.52%) patients had a 50% or more decrease in NRS for muscle weakness and a minimum increase of 20% in total and average force on the sEAST measurement. The NRS for numbness showed a statistically significant decrease for the whole group (preoperative mean: 5.67, CI [4.18 - 7.16]; postoperative mean: 3.33 [1.37-5.29]; p=0.029).

CONCLUSION

A combination of physical examination, EDx and HRUS studies can differentiate GSH from differential diagnoses. HRUS appears has the advantage over EDx studies in confirming GSH by visualization of compression of the brachial plexus. TOD surgery will stop the progressive muscle atrophy and significantly reduce NTOS complaints and in some patients, motor function will recover.