Diagnostic Accuracy of Clinical Tests for Neurogenic and Vascular Thoracic Outlet Syndrome: A Systematic Review

Upper Vascular Thoracic Outlet Syndrome: A Case Study

Thoracic outlet syndrome (TOS) is recognised in approximately 8% of the population. Vascular presentation is rare and diagnosis is often elusive due to its rarity. As episodes of TOS in the upper extremities are rare, proven protocols for rehabilitation management are lacking. The purpose of our article is to present a clinical examination protocol and a treatment protocol for patients after an episode of venous thrombosis in the upper limb (VTOS). We report the case of a middle-aged woman with right venous TOS with pain in the right upper extremity, accompanied by oedema and mild violet discolouration. The results after 10 sessions of physiotherapy were as follows: a reduction in symptoms of approximately 40%, an improvement of approximately 15% in sports performance, and an improvement of approximately 25% in work. There was also an improvement in the results of TOS provocation tests, i.e., a 50-100% improvement in pulse rate and about 30% less discolouration in the extremity. Additionally, there was a significant improvement in posture between the two sides of the upper quadrant. The results after 10 physiotherapy sessions are surprising due to chronic disease after the thrombosis episode. It appears that even after a long period of time since diagnosis, improvement is possible.

Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) involves inconsistent symptoms, presenting a challenge for medical providers to diagnose and treat. Thoracic outlet syndrome is defined as a compression injury to the brachial plexus, subclavian artery or vein, or axillary artery or vein occurring between the cervical spine and upper extremity. Three common subcategories are now used for clinical diagnosis: neurogenic, arterial, and venous. Postural position and repetitive motions such as throwing, weightlifting, and manual labor can lead to symptoms. Generally, TOS is considered a diagnosis of exclusion for athletes due to the poor accuracy of clinical testing, including sensitivity and specificity. Thus, determining a definitive diagnosis and reporting injury is difficult. Current literature suggests there is not a gold standard diagnostic test. Rehabilitation has been shown to be a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations.

Scapular Elevation Sign - A New Sign in Evaluation of Thoracic Outlet Syndrome

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic).

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.

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.

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

BACKGROUND

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

PURPOSE

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

BASIC PROCEDURES

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

MAIN FINDINGS

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

PRINCIPAL CONCLUSIONS

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

Thoracic outlet syndrome (TROTS) registry: A study protocol for the primary upper extremity deep venous thrombosis section

INTRODUCTION

There is a lack of comprehensive and uniform data on primary upper extremity deep venous thrombosis (pUEDVT). pUEDVT includes venous thoracic outlet syndrome related upper extremity deep venous thrombosis (UEDVT) and idiopathic UEDVT. Research on these conditions has been hampered by their rarity, lack of uniform diagnostic criteria, and heterogeneity in therapeutic strategies. To improve current research data collection using input of all various pUEDVT treating medical specialists, we initiated the ThoRacic OuTlet Syndrome (TROTS) registry. The aim of the TROTS registry is to a) collect extensive data on all pUEDVT patients through a predefined protocol, b) give insight in the long term outcome using patient reported outcome measures, c) create guidance in the diagnostic and clinical management of these conditions, and thereby d) help provide content for future research.

METHODS AND ANALYSIS

The TROTS registry was designed as an international prospective longitudinal observational registry for data collection on pUEDVT patients. All pUEDVT patients, regardless of treatment received, can be included in the registry after informed consent is obtained. All relevant data regarding the initial presentation, diagnostics, treatment, and follow-up will be collected prospectively in an electronic case report form. In addition, a survey containing general questions, a Health-related Quality of Life questionnaire (EQ-5D-5L), and Functional Disability questionnaire (Quick-DASH) will be sent periodically (at the time of inclusion, one and two years after inclusion, and every five years after inclusion) to the participant. The registry protocol was approved by the Medical Ethical Review Board and registered in the Netherlands Trial Register under Trial-ID NL9680. The data generated by the registry will be used for future research on pUEDVT and published in peer reviewed journals.

CONCLUSION

TROTS registry data will be used to further establish the optimal management of pUEDVT and lay the foundation for future research and guidelines.

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.

Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome

Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity, specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity, specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%, respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone. The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.

Use of Electroneuromyography in the Diagnosis of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Meta-Analysis

Neurogenic thoracic outlet syndrome (NTOS) is a disabling condition. Its diagnosis remains challenging and is mainly guided by examination. Yet, electrophysiological evaluations are the gold standard for diagnosis of entrapment syndromes. We aimed to assess the interest of electrophysiological evaluation to diagnose NTOS. A systematic literature research was performed using PubMed, ScienceDirect, Embase, Cochrane and Google Scholar databases to collect studies reporting results of electrophysiological assessment of patients with NTOS. Then, a meta-analysis was conducted. Nine studies were eligible and concerned two hundred and thirteen patients. Results were heterogenous among studies and the quality of evidence was very low to moderate. Data could not evaluate sensitivity or specificity of electrophysiological evaluations for NTOS. The meta-analysis found significantly decreased amplitudes of medial antebrachial cutaneous nerve SNAP (sensory nerve action potential), ulnar SNAP, median CMAP (compound motor action potential) and ulnar CMAP. Needle examination found abnormalities for the abductor pollicis brevis, first dorsal interosseous and adductor digiti minimi. Unlike most upper-limb entrapment syndromes, nerve conduction assessment only provided clues in favour of NTOS. Decreased amplitude for ulnar SNAP, medial antebrachial cutaneous SNAP, median CMAP and ulnar CMAP should be assessed, as well as needle examination. Larger studies are needed to evaluate the sensitivity and specificity of electrophysiology in NTOS diagnosis.

Use of hand hydraulic dynamometers as an overall evaluation of the upper-limb weakness in patients with thoracic outlet syndrome

Patients with neurogenic thoracic outlet syndrome report pain and upper-limb weakness. They complain about weakness occurring on the entire upper-limb, especially at the hand and the shoulder levels. Hydraulic dynamometers can reliably assess the strength of the hand, and isokinetic shoulder testing can provide accurate and reliable evaluations of the rotators strength. Yet, isokinetic proximal assessment needs expensive tools, whereas hydraulic hand dynamometers are cheap and easy to use. We aimed to assess the correlation between the isokinetic shoulder strength and the hand grip and the key pinch strength. The grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. Isokinetic rotators strength tests were performed using a Humac Norm® dynamometer at 60 and 180°/s. One-hundred and thirty patients had been included, 72% of women, mean age of 39.8 ± 9.5. Symptomatic hands presented a strength deficit of 12.2% on the grip (p < 0.0001) and 10% on the key pinch (p = 0.01). Isokinetic strength was lower on the symptomatic shoulders at 60 and 180°/s concerning medial rotators [−10.3 and −8.8%, respectively (p = 0.02)] and lateral rotators [−10.8 and −10%, respectively (p = 0.04 and p = 0.03)]. There was a moderate correlation between the grip strength of the symptomatic upper-limbs and the isokinetic rotators strength (p < 0.001). The key pinch strength was moderately correlated to the isokinetic medial and lateral rotators strength at 60°/s (p < 0.001). Hand dynamometers could prove useful during medical consultations or in outpatient management to assess upper-limb overall weakness, but isokinetic measurement remains the gold standard for a precise evaluation.

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.

Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review

Background

Thoracic outlet syndrome (TOS) is a pathological condition caused by a narrowing between the clavicle and first rib leading to a compression of the neurovascular bundle to the upper extremity. The incidence of TOS is probably nowadays underestimated because the diagnosis could be very challenging without a thorough clinical examination along with appropriate clinical testing. Beside traditional supra-, infraclavicular or transaxillary approaches, the robotic assisted first rib resection has been gaining importance in the last few years.

Methods

We conducted a retrospective cohort analysis of all patients who underwent robotic assisted first rib resection due to TOS at Lucerne Cantonal Hospital and then we performed a narrative review of the English literature using PubMed, Cochrane Database of Systematic Reviews and Scopus.

Results

Between June 2020 and November 2021, eleven robotic assisted first rib resections were performed due to TOS at Lucerne Cantonal Hospital. Median length of stay was 2 days (Standard Deviation: +/– 0.67 days). Median surgery time was 180 min (Standard Deviation: +/– 36.5). No intra-operative complications were reported.

Conclusions

Robotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.

Novel Use of Ali Shahab Score as a Diagnostic Tool and Decision of Surgical Management in Scalenus Syndrome: A Case Series

BACKGROUND: Scalenus syndrome is a collection of symptoms as the consequences of nerve and vascular compression within the scalene triangle. However, the entity has long been forgotten in publications and is difficult to recognize. The diagnosis of scalenus syndrome is mainly based on clinical findings. The Ali Shahab score is a new scoring system, generated based on clinical symptoms of scalenus syndrome. AIM: In this study, we presented a case series of scalenus syndrome patients who were diagnosed and decide to be managed surgically based on Ali Shahab score. We also reported post-operative outcomes following scalenectomy in our series. METHODS: This was a case series including patients with scalenus syndrome in Gatot Soebroto Army Hospital, Indonesia, and Siloam Asri Hospital, Indonesia, between 2016 and 2021. The diagnosis of scalenus syndrome was made based on Ali Shahab score with a value of more than 7. All patients were performed scalenectomy to decompress the stenotic subclavian artery and brachial plexus from surrounding fibrotic tissue. Eligible subjects were assessed for sex, side of symptoms, pre-operative and post-operative Ali Shahab score, and post-operative outcome. RESULTS: We included 96 patients with scalenus syndrome in this case series. Most of the included patients were male (59.4%) and experienced scalenus syndrome on the right side (76%). The average pre-operative Ali Shahab score in our series was 7.12 ± 0.48 and the post-operative score was 0.11 ± 0. Regarding post-operative outcomes, more than half of the patients experienced symptoms reduction with 38.5% of patients experiencing complete resolution of symptoms following scalenectomy. CONCLUSION: The application of the Ali Shahab score may be used as a diagnostic tool and decision of surgical management for scalenus syndrome patients. Decompression of the subclavian artery and releasing brachial plexus from surrounding fibrotic tissue can improve clinical symptoms in scalenus syndrome patients.

Update on the thoracic outlet syndrome and plexus brachial syndrome: Specific clinical examination (for all) and rehabilitation protocol

The diagnosis of uncomplicated forms of thoracobrachial outlet syndrome (TOS) and brachial plexus stretching syndrome (BPSS) is imprecise due to the lack of clear differentiation between dynamic vascular or neurological compression and brachial plexus stretching without vascular compression. After a review of literature, we propose and describe a simple way for clinical assessment of TOS, BPSS or association of both comprising 1 clinical sign and 2 manoeuvres. This clinical assessment can be performed by the medical doctor, the physiotherapist and the surgeon. The clinical diagnosis is essential because it will dictate the rehabilitation treatment. We propose and describe also a rehabilitation protocol comprising 10 phases with modulation of exercises according to clinical form (TOS, BPSS or association) and/or severity of symptoms. The physiotherapist has a capital role and is the guarantor of the effectiveness of the medical treatment. In France, a training is now available thanks to personal continuous development for diagnosis and treatment of TOS and BPSS. This is essential in order to propose an optimal care to patients.

A Thoracic Outlet Syndrome That Concealed a Glioblastoma. Findings from a Case Report

Background: Glioblastoma is the most frequent and aggressive malignant brain tumor among adults. Unfortunately, its symptoms can vary considerably depending on the size, location and the anatomic structures of the involved brain. Case report: A 58-year-old male amateur cyclist who suffered from sharp arm pain was examined for a thoracic outlet syndrome due to a previous clavicle fracture. Because of ambiguous results of the neck and nerve plexus imaging, he was referred to a neurosurgeon who properly suspected a brain tumor. The neuroimaging of the brain shown a 3 cm disploriferative mass with a blood enhancement within the left parietal lobe. The mass was urgently removed, and its histologic analysis stated a grade 4 glioblastoma. Conclusion: This case report highlights the differential diagnosis process and the teamwork approach needed to diagnose a rare presentation of a brain glioblastoma, which started its symptoms mimicking a thoracic outlet syndrome caused by a previous bone fracture.

Shoulder Isokinetic Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (NTOS) is an impairing painful condition. Patients usually report upper-limb pain, weakness and paresthesia. Shoulder weakness is frequently reported but has never been described with objective strength evaluation. We aimed to compare isokinetic shoulder strength between patients with NTOS and healthy controls. Patients and controls were prospectively evaluated with an isokinetic strength test at 60 and 180°/s, and an endurance test (30 repetitions at 180°/s) of the shoulder rotators. Patients were functionally assessed with QuickDASH questionnaires. One hundred patients and one hundred healthy subjects were included. Seventy-one percent of patients with NTOS were females with a mean age of 39.4 ± 9.6. They were compared to controls, 73% females and the mean age of 38.8 ± 9.8. Patients' mean QuickDASH was 58.3 ± 13.9. Concerning the peak of strength at 60°/s, the symptomatic limbs of patients with NTOS had significantly 21% and 29% less strength than the control limbs for medial and lateral rotators, respectively (p ≤ 0.001). At 180°/s, the symptomatic limbs had significantly 23% and 20% less strength than the controls for medial and lateral rotators, respectively (p ≤ 0.001). The symptomatic limbs had significantly 45% and 30% less endurance than the controls for medial and lateral rotators, respectively (p ≤ 0.001). These deficits were correlated to the QuickDASH. Patients with NTOS presented a significant deficit of strength and endurance of the shoulder rotators correlated to disability. This highlights the interest in upper-limb strength evaluation in the diagnostic process and the follow-up of NTOS.

Anatomy, Imaging, and Pathologic Conditions of the Brachial Plexus

The brachial plexus is an intricate anatomic structure with an important function: providing innervation to the upper extremity, shoulder, and upper chest. Owing to its complex form and longitudinal course, the brachial plexus can be challenging to conceptualize in three dimensions, which complicates evaluations in standard orthogonal imaging planes. The components of the brachial plexus can be determined by using key anatomic landmarks. Applying this anatomic knowledge, a radiologist should then be able to identify pathologic appearances of the brachial plexus by using imaging modalities such as MRI, CT, and US. Brachial plexopathies can be divided into two broad categories that are based on disease origin: traumatic and nontraumatic. In the traumatic plexopathy group, there are distinct imaging findings and management methods for pre- versus postganglionic injuries. For nontraumatic plexopathies, having access to an accurate patient history is often crucial. Knowledge of the timing of radiation therapy is critical to diagnosing post-radiation therapy brachial plexopathy. In acute brachial neuritis, antecedent stressors occur within a specific time frame. Primary and secondary tumors of the brachial plexus are not uncommon, with the most common primary tumors being peripheral nerve sheath tumors. Direct extension and metastasis from primary malignancies such as breast and lung cancer can occur. Although diagnosing a brachial plexus anomaly is potentially perplexing, it can be straightforward if it is based on foundational knowledge of anatomy, imaging findings, and pathologic features. ^©RSNA, 2020.

Hand Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (NTOS) is a chronic painful and disabling condition. Patients complain about upper-limb paresthesia or weakness. Weakness has been considered one of the diagnostic criteria of NTOS, but objective comparisons to healthy controls are lacking. We compared the grip and the key pinch strengths between NTOS patients and healthy controls. Grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. All the patients with NTOS completed a QuickDASH. We included prospectively 85 patients with NTOS, 73% female and 27% male. The mean age was 40.4 ± 9.6. They were compared to 85 healthy subjects, 77.6% female and 22.4% male. Concerning the grip, symptomatic hands of NTOS patients had significantly 30% less strength compared to control hands (p ≤ 0.001), and 19% less strength compared to asymptomatic hands (p = 0.03). Concerning the key pinch, symptomatic hands of patients with NTOS had significantly 19.5% less strength compared to control hands (p ≤ 0.001). Grip and key pinch strengths had a significant correlation with the QuickDASH (r = −0.515 and r = −0.403, respectively; p ≤ 0.001). Patients with NTOS presented an objective hand strength deficit compared to healthy controls. This deficit was significantly correlated to the upper-limb disability. These findings confirm the interest of hand strength evaluation in the diagnostic process of patients with NTOS.

Doppler waveform analysis during provocative manoeuvres in the assessment for arterial thoracic outlet syndrome results in high false-positive rates; a cross-sectional study

Objectives

There is a high rate of false-positive arterial Thoracic Outlet Syndrome (ATOS) diagnoses due to limited research into the optimal use of ultrasound. To improve future diagnostic efficiency, we aimed to characterise the haemodynamic effects of different provocative positions and estimate the prevalence of compression in the healthy population.

Design

In this cross-sectional, observational study, the effect of varying degrees of arm abduction on discomfort levels and/or changes in subclavian artery Doppler waveform was analysed in the healthy population; the peak systolic velocity (PSV), systolic rise time (SRT), phasicity and extent of turbulence were recorded.

Setting

Department of the Vascular Studies, Royal Free Hospital.

Participants

19 participants (11 females, 27.4 ± 5.2 years) were recruited for bilateral scans.

Main outcome measures

Seven positions were investigated; the primary outcome was an occlusion or monophasic waveform indicating significant compression and this was compared with the secondary outcome; any physiological discomfort.

Results

28.9% experienced significant arterial compression in at least one position; 120° abduction was the position with the greatest level of abduction that did not result in significant waveform changes or symptoms. The PSV and SRT were difficult to accurately measure and bore no correlation to the level of compression.

Conclusion

Ultrasound testing in isolation would result in a false indication of TOS in almost 30% of our normal population. With further research, the 120° abduction position may have a lower false-positive rate. The PSV and SRT must be interpreted with caution due to their variability even within the healthy population.

Subclavian Vessel Compression Assessed by Duplex Scanning in Patients with Neurogenic Thoracic Outlet Syndrome and No Vascular Signs

Neurogenic thoracic outlet syndrome (NTOS) is the most frequent form of TOS. It may affect both sides, but specific complementary exams are lacking. We aimed to evaluate duplex scanning results in a group of patients with unilateral or bilateral NTOS and no clinical vascular signs, referred for rehabilitation. We performed a retrospective observational study in patients with unilateral or bilateral NTOS and no vascular symptoms. Subclavian vessels were assessed by duplex scanning. Compressions were considered in case of >50% of increased or decreased blood flow. A total of 101 patients met NTOS criteria; mean age was 40 +/− 10.2; 79.2% women. Seventy patients had a unilateral NTOS and 31 a bilateral form. Duplex scanning showed that 56.4% of the patients had vessels compression, 55.7% in the unilateral group and 58.1% in the bilateral (p = 0.81). In unilateral NTOS, 21 (30%) patients had bilateral vascular compression, 17 (24.3%) had ipsilateral compression and 1 (1.4%) had contralateral compression. In bilateral NTOS, 15 (48.4%) had bilateral compression and 3 (9.7%) compression on only one side. We found a significant difference of the rate of vascular compressions between symptomatic and non-symptomatic upper-limbs, 54.5% vs. 32.9%, respectively, (p = 0.002) and a significant association between symptomatic upper-limbs and vascular compression (OR = 2.45 [95%IC: 1.33–4.49]; p = 0.002). The sensitivity and the specificity of the duplex scanning were 54.5% and 67%, respectively. The ROC curve area was of 0.608 [95%IC: 0.527–0.690]. Despite a highly significant association between symptomatic upper-limbs and vascular compression, duplex scanning did not help make the diagnosis of NTOS.

Concurrent Validity of Digital Vascular Auscultation for the Assessment of Blood Flow Obliteration on the Radial Artery in Healthy Subjects

This study aimed to determine the validity of digital vascular auscultation for the assessment of changes in the radial pulse in healthy subjects, using Doppler sonography as a validated test referent. Sixty-one non-symptomatic subjects (mean age of 52.5 ± 16.1 years) were assigned and evaluated under one of the following conditions: In condition 1, blood flow of the radial artery was not modified; for condition 2, blood flow of the radial artery was modified using a pressure sleeve around the humerus. The radial pulse was then measured three times with each diagnostic tool by three different blinded evaluators. Both instruments demonstrated a high association between the identification of blood flow modifications or not and the assigned condition (p < 0.001). A strong concordance between the two devices when detecting the “changes” or “no changes” in blood flow was demonstrated (k = 0.936, p < 0.001). Stethoscope sensitivity was 95%, and specificity was 99%. In conclusion, digital vascular auscultation seems to be a valid technique to examine blood flow changes of the radial artery in non-symptomatic subjects, and it could be useful for physical therapists when combined with provocative tests for the screening of possible thoracic outlet syndrome in patients.

Ultrasound for Neurogenic Thoracic Outlet Obstruction Remains Theoretical

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