Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations

Pediatric thoracic outlet syndrome: a systematic review with metadata

INTRODUCTION

Thoracic outlet syndrome (TOS) typically considered a condition of the adult population; it is often disregarded in children and adolescents due to its limited recognition within the pediatrics. The current study aims to systematically review and provide insights into TOS among pediatric patients.

METHODS

PubMed, Scopus, Web of Science, and Google Scholar databases were thoroughly searched for English language studies published until March 15th, 2024. The study included those articles focusing on pediatric or adolescent individuals diagnosed with TOS. Data collected from studies encompassed date of publication, number of participants or reported cases, age (years), gender of participants, type of TOS, affected side, type of treatment, surgical approach, bony abnormality, duration of symptoms (months), outcome, and follow-up time duration (months).

RESULTS

The current study comprised 33 articles, 21 of which were case reports, 10 of which were case series, and the remaining were cohort studies. In this study, 356 patients were included. Females constituted 234 (65.73%) of the patient population. Among TOS types, neurogenic TOS was found among 201 (56.5%) patients. Sporting-related activity or physical activity was present in 193 (54%) patients, followed by a history of trauma in 27 (7%) patients.

CONCLUSIONS

Pediatric patients exhibited a higher percentage of vascular TOS than their adult counterparts, with the supraclavicular approach emerging as the preferred treatment method. Sports-related activities were identified as the primary risk factor associated with pediatric TOS.

Thoracic Outlet Syndrome in the Pediatric and Young Adult Population

PURPOSE

This study aimed to assess both nonsurgical and operative treatment outcomes of pediatric and young adult patients with thoracic outlet syndrome (TOS) at a tertiary care pediatric hospital.

METHODS

A retrospective chart review of patients diagnosed with TOS, who were seen between January 2010 and August 2022 at a tertiary care pediatric hospital, was conducted. Collected pre- and postoperative data included symptoms, provocative testing (ie, Roo's, Wright's, and Adson's tests), participation in sports or upper-extremity activities, additional operations, and surgical complications. Assessment of operative treatment efficacy was based on pre- and post-provocative testing, pain, venogram results, alleviation of symptoms, and return to previous activity level 6 months after surgery.

RESULTS

Ninety-six patients, (70 females and 26 males) with an average age at onset of 15 ± 4 (4-25) years, met the inclusion criteria for TOS. Among them, 27 had neurogenic TOS, 29 had neurogenic and vasculogenic TOS, 20 had vasculogenic TOS, 19 had Paget-Schroetter Syndrome, and one was asymptomatic. Twenty-six patients were excluded because of less than 6 months of follow-up. Of the remaining 70, 6 (8.6%) patients (4 bilateral and 2 unilateral) underwent nonoperative management with activity modification and physical therapy only, and one was fully discharged because of complete relief of symptoms. Sixty-four (90.1%) patients (45 bilateral and 19 unilateral) underwent surgery. A total of 102 operations were performed. Substantial improvements were observed in provocative maneuvers after surgery. Before surgery, 79.7% were involved in sports or playing musical instruments with repetitive overhead activity, and after surgery, 86.2% of these patients returned to their previous activity level.

CONCLUSIONS

Few patients were successfully managed with nonoperative activity modification and physical therapy. In those requiring surgical intervention, first or cervical rib resection with scalenectomy using a supraclavicular approach provided resolution of symptoms with 86.2% of patients being able to return to presymptom sport or activity level.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Neurogenic thoracic outlet syndrome and controversies in diagnosis and management

Compression of the neurovascular structures at the level of the scalene triangle and pectoralis minor space is rare, but increasing awareness and understanding is allowing for the treatment of more individuals than in the past. We outlined the recognition, preoperative evaluation, and treatment of patients with neurogenic thoracic outlet syndrome. Recent work has illustrated the role of imaging and centrality of the physical examination on the diagnosis. However, a fuller understanding of the spatial biomechanics of the shoulder, scalene triangle, and pectoralis minor musculotendinous complex has shown that, although physical therapy is a mainstay of treatment, a poor response to physical therapy with a sound diagnosis should not preclude decompression. Modes of failure of surgical decompression stress the importance of full resection of the anterior scalene muscle and all posterior rib impinging elements to minimize the risk of recurrence of symptoms. Neurogenic thoracic outlet syndrome is a rare but critical cause of disability of the upper extremity. Modern understanding of the pathophysiology and evaluation have led to a sounder diagnosis. Although physical therapy is a mainstay, surgical decompression remains the gold standard to preserve and recover function of the upper extremity. Understanding these principles will be central to further developments in the treatment of this patient population.

Trans-axillary thoracic outlet decompression

Thoracic outlet syndrome (TOS) is a group of conditions thought to be caused by the compression of neurovascular structures going to the upper extremity. TOS is a difficult disease to diagnose, and surgical treatment remains challenging. Many different surgical techniques for the treatment of TOS have been described in the literature and many reasonable to good outcomes have been reported, which makes it hard for surgeons to determine which techniques should be used. Our aim was to describe the rationale, techniques, and outcomes associated with the surgical treatment of TOS. Most patients in our center are treated primarily through a trans-axillary approach. We will elaborate on the technical details of performing trans-axillary thoracic outlet decompression. The essential steps during surgery are illustrated with videos. We focused on the idea behind performing a trans-axillary thoracic outlet decompression in primary cases. Institutional data on the outcomes of this surgical approach are described briefly.

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.

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review

Thoracic outlet syndrome is a constellation of signs and symptoms due to compression of the neurovascular bundle of the upper limb. In particular, neurogenic thoracic outlet syndrome can present with a wide constellation of clinical manifestations ranging from pain to paresthesia of the upper extremity, resulting in a challenge to correctly diagnose this syndrome. Treatment options range from nonoperative treatment, such as rehabilitation and physical therapy, to surgical correction, such as decompression of the neurovascular bundle.

Methods

Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome.

Results

Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS.

Conclusions

In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

Development and validation of a prediction model for outcomes after transaxillary first rib resection for neurogenic thoracic outlet syndrome following strict Society for Vascular Surgery diagnostic criteria

OBJECTIVE

Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS.

METHODS

We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation.

RESULTS

A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88).

CONCLUSIONS

Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.

Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes

BACKGROUND

The clinical outcomes of reoperations for recurrent neurogenic thoracic outlet syndrome (NTOS) remain undefined.

METHODS

From 2009 to 2019, 90 patients with recurrent NTOS underwent anatomically complete supraclavicular reoperation after previous operation(s) performed at other institutions using either supraclavicular (Prev-SC = 48), transaxillary (Prev-TA = 31), or multiple/combination (Prev-MC = 11) approaches. Prospectively maintained data were analyzed retrospectively.

RESULTS

The mean patient age was 39.9 ± 1.4 years, 72% were female, and the mean interval after previous operation was 4.1 ± 0.6 years. The mean Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 62 ± 2, reflecting substantial preoperative disability. Residual scalene muscle was present in 100% Prev-TA, 79% Prev-SC, and 55% Prev-MC (P < .05). Retained/residual first rib was present in 90% Prev-TA, 75% Prev-SC, and 55% Prev-MC (P < .05). There were no differences in operative time (overall 210 ± 5 minutes), length of hospital stay (4.7 ± 0.2 days), or 30-day readmissions (7%). During follow-up of 5.6 ± 0.3 years, the improvement in QuickDASH scores was 21 ± 2 (36% ± 3%) (P < .01) and patient-rated outcomes were excellent in 10%, good in 36%, fair in 43%, and poor in 11%.

CONCLUSIONS

Anatomically complete decompression for recurrent NTOS can be safely and effectively accomplished by supraclavicular reoperation, regardless of the type of previous operation. Residual scalene muscle and retained/residual first rib are more frequently encountered after transaxillary operations than after supraclavicular or multiple/combined operations. Supraclavicular reoperation can achieve significant symptom reduction and functional improvement for approximately 90% of patients with recurrent NTOS.

Thoracic outlet syndrome: a review

Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.

Thoracic outlet syndrome: a review for the primary care provider

CONTEXT

Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS.

OBJECTIVES

This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options.

METHODS

The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS.

RESULTS

The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS.

CONCLUSIONS

The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.

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.

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.

Targeted Muscle Reinnervation of the Supraclavicular Nerve to the Motor Branch of the Omohyoid Muscle in Patients Undergoing Thoracic Outlet Syndrome Procedures

Transection of the supraclavicular nerve (SCN) through supraclavicular incisions can lead to debilitating neuroma formation. Targeted muscle reinnervation (TMR) proved to be an effective technique for the prevention and treatment of neuroma. In this case series, we propose the TMR of the SCN to the motor branch of the omohyoid muscle (OM) to prevent the formation of neuroma and avoid chronic pain at the supraclavicular area after thoracic outlet syndrome (TOS) procedures. A total of 10 patients underwent the procedure. Dissection of the SCN and its branches was performed through a supraclavicular incision. The branches were transected close to the clavicle. The inferior belly of the OM was identified and its motor branch isolated. Coaptation of the SCN branches with the motor branch of the OM was performed under the microscope and the wound was closed in layers. All the patients denied pain or hypersensitivity at the supraclavicular area on follow-up. In summary, the motor branch of the OM is a viable recipient for the TMR of the SCN and can prevent and treat painful neuromas at the supraclavicular area with minimal morbidity.

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.

Intermediate and Long-term Outcomes Following Surgical Decompression of Neurogenic Thoracic Outlet Syndrome in an Adolescent Patient Population

Background: Although the diagnosis of thoracic outlet syndrome (TOS) is often missed, outcomes from surgical intervention significantly improve patient satisfaction. This article seeks to highlight patient characteristics, intraoperative findings, and both short and long-term outcomes of thoracic outlet decompression in the adolescent population. Methods: A retrospective chart review of patients between the ages of 13 and 21 years with a clinical diagnosis of neurogenic thoracic outlet syndrome (NTOS) who were treated surgically between 2000 and 2015 was performed. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient-reported outcome scores, including Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Cervical Brachial Symptom Questionnaire (CBSQ), and NTOS index, were obtained for a cohort of patients with follow-up ranging from 2 to 15 years. Results: The study population consisted of 54 patients involving 61 extremities. The most common procedures included neurolysis of the supraclavicular brachial plexus (60, 98.4%), anterior scalenectomy (59, 96.7%), and middle scalenectomy (54, 88.5%). First rib resection (FRR) was performed in 28 patients (45.9%). Long-term outcomes were collected for 24 (44%) of 54 patients with an average follow-up of 69.5 months (range, 24-180 months). The average VAS improved from 7.5 preoperatively to 1.8 postoperatively. The average SANE increased from 28.9 preoperatively to 85.4 postoperatively. The average postoperative scores were 11.4 for the QuickDASH, 27.4 for the CBSQ, and 17.2 for the NTOS index. Subgroup analysis of patients having FRR (28, 45.9%) demonstrated no difference in clinical outcome measures compared with patients who did not have FRR. Conclusion: Surgical treatment of NTOS in adolescent patients has favorable intermediate and long-term outcomes.

Digital Biomarkers for the Objective Assessment of Disability in Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (nTOS) is a musculoskeletal disorder in which compression of the brachial plexus between the scalene muscles of the neck and the first rib results in disabling upper extremity pain and paresthesia. Currently there are no objective metrics for assessing the disability of nTOS or for monitoring response to its therapy. We aimed to develop digital biomarkers of upper extremity motor capacity that could objectively measure the disability of nTOS using an upper arm inertial sensor and a 20-s upper extremity task that provokes nTOS symptoms. We found that digital biomarkers of slowness, power, and rigidity statistically differentiated the affected extremities of patients with nTOS from their contralateral extremities (n = 16) and from the extremities of healthy controls (n = 13); speed and power had the highest effect sizes. Digital biomarkers representing slowness, power, and rigidity correlated with patient-reported outcomes collected with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the visual analog scale of pain (VAS); speed had the highest correlation. Digital biomarkers of exhaustion correlated with failure of physical therapy in treating nTOS; and digital biomarkers of slowness, power, and exhaustion correlated with favorable response to nTOS surgery. In conclusion, sensor-derived digital biomarkers can objectively assess the impairment of motor capacity resultant from nTOS, and correlate with patient-reported symptoms and response to therapy.

Current status of patient-reported outcome measures in vascular surgery

A previously published review focused on generic and disease-specific patient-reported outcome measures (PROMs) relevant to vascular surgery but limited to arterial conditions. The objective of this project was to identify all available PROMs relevant to diseases treated by vascular surgeons and to evaluate vascular surgeon perceptions, barriers to widespread implementation, and concerns regarding PROMs. We provide an overview of what a PROM is and how they are developed, and summarize currently available PROMs specific to vascular surgeons. We also report results from a survey of 78 Society for Vascular Surgery members serving on committees within the Policy and Advocacy Council addressing the barriers and facilitators to using PROMs in clinical practice. Finally, we report the qualitative results of two focus groups conducted to assess granular perceptions of PROMS and preparedness of vascular surgeons for widespread implementation of PROMs. These focus groups identified a lack of awareness of existing PROMs, knowledge of how PROMs are developed and validated, and clarity around how PROMs should be used by the clinician as main subthemes for barriers to PROM implementation in clinical practice.

Erector Spinae Plane Block versus Continuous Perineural Local Anesthetic Infusion for Postoperative Pain Control After Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A Matched Case-Control Comparison

OBJECTIVE

The purpose of this study was to determine if single injection erector spinae plane blocks are associated with improved pain control, opioid use, numbness, length of stay, or patient satisfaction compared to intraoperatively placed continuous perineural infusion of local anesthetic after decompression of neurogenic thoracic outlet syndrome.

METHODS

This is a retrospective cohort study at a tertiary academic center of eighty patients that underwent supraclavicular decompression for thoracic outlet syndrome between May 2019 and January 2020. Forty consecutive patients treated with single-injection preoperative erector spinae plane blocks were retrospectively compared to 40 age- and gender-matched controls treated with continuous perineural infusion.

RESULTS

The primary outcome of mean pain scores was not significantly different between the erector spinae and perineural infusion groups over the three-day study period (4.2-5.3 vs 3.0-5.1 P=0.08). On post-operative day 0, mean pain scores were significantly higher in the erector spinae group (4.2 vs 3.0, P=0.02). While statistically significant, the score was still lower in the erector spinae group on day 0 than on day 1,2, or 3 in either group. Opioid use, nausea, length of stay and patient satisfaction were also similar. Upper extremity numbness was significantly less severe in the erector spinae group (36% vs 73% moderate-extreme, P=0.03) at 6-month follow-up.

CONCLUSIONS

Seventy-two-hour perineural local anesthetic infusion did not provide superior analgesia compared to preoperative single-injection erector spinae blocks. Furthermore, there was significantly less long-term postoperative numbness associated with erector spinae blocks compared to perineural local anesthetic infusion.

Improvement of disability in neurogenic thoracic outlet syndrome by robotic first rib resection

BACKGROUND

Robotic transthoracic first rib resection (R-FRR) has advantages over traditional approaches however its impact on post-operative nTOS outcomes is unknown. Our primary objective was to determine improvement of patient-reported outcome measures (PROMs) of pain and disability following R-FRR in neurogenic thoracic outlet syndrome (nTOS). Our secondary objective was to compare improvement of patient-reported pain between R-FRR and supraclavicular FRR (SC-FRR) in nTOS.

METHODS

We queried a prospectively-maintained, single surgeon, single institution database for nTOS patients undergoing R-FRR or SC-FRR with available pre-operative and post-operative PROMs. PROMs included the Disability of the Arm, Hand, and Shoulder (DASH) questionnaire and Visual Analog Scale (VAS) for pain.

RESULTS

Cohort 1 included 37 patients undergoing 40 R-FRRs and was comprised of 32 females, aged 36 years on average. Pre-operative VAS and DASH (6.0 and 64.2, respectively) improved significantly at the first (2.8 and 35.0, P<0.001 for both) and second post-operative visits (1.4 and 30.2, P<0.01 for both) which occurred at 2.6 and 15.3 weeks, respectively. Cohort 2 included 57 R-FRR performed in 53 patients, and 35 SC-FRRs performed in 34 patients. R-FRR and SC-FRR groups did not significantly differ in sex, age, hand dominance, TOS laterality, or pre-operative VAS. At first post-operative visit (2.4 weeks), R-FRR was associated with lower VAS scores (P=0.023) and greater VAS improvement than SC-FRR (53% and 27% decrease, respectively, P=0.008).

CONCLUSIONS

R-FRR results in significant improvement in disability and pain in nTOS and may have a greater impact on patient-reported pain than SC-FRR in the early postoperative period.

Rare Case of Dynamic Thoracic Outlet Syndrome Resolved by an Isolated Subclavius Posticus Muscle Resection: A Case Report

CASE

We reported a dynamic neurogenic left thoracic outlet syndrome (TOS) with a permanent abduction of the fifth left finger. Preoperative magnetic resonance imaging (MRI) assessed the presence of subclavius posticus muscle (SPM). Because of a nonoperative treatment failure, we performed a brachial plexus neurolysis and SPM resection. Immediate postoperative assessment showed an immediate disappearance of the Wartenberg sign.

CONCLUSION

SPM constitutes an underestimated cause of TOS. A careful MRI reading is necessary to make correct diagnosis. Nonoperative treatment includes physiotherapy and can be proposed in first instance. When nonoperative treatment fails, brachial plexus exploration with release of the SPM may result in resolution of symptoms.

Essentials of thoracic outlet syndrome: A narrative review

Thoracic outlet syndrome (TOS) is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region. TOS results in pain, numbness, paresthesia, and motor weakness in the affected upper limb. We reviewed the pathophysiology, clinical evaluation, differential diagnoses, and treatment of TOS. TOS is usually classified into three types, neurogenic, venous, and arterial, according to the primarily affected structure. Both true neurogenic and disputed TOS are considered neurogenic TOS. Since identifying the causative lesions is complex, detailed history taking and thorough clinical investigation are needed. Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS. The existence of a disputed TOS remains controversial. Neuromuscular physicians tend to be skeptical about the existence of disputed TOS, but thoracic surgeons argue that disputed TOS is under-diagnosed. Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.

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

OBJECTIVE

The North American Society for Vascular Surgery (SVS) reporting standards for neurogenic thoracic outlet syndrome (NTOS) were published in 2016 to produce consistency in the diagnosis and treatment of NTOS, but outcomes resulting from following these standards are not yet available. The results of a standardised multidisciplinary care pathway for NTOS based on the North American SVS reporting standards for NTOS are reported.

METHODS

Patients referred between August 2016 and December 2019 with suspected NTOS were evaluated in this single center prospective cohort study. Diagnosis and treatment were performed according to a care pathway based on the North American SVS reporting standards. The outcome of surgically treated patients was determined by the Derkash score, thoracic outlet syndrome disability scale (TDS), Cervical Brachial Score Questionnaire (CBSQ), Disability of the Arm Shoulder and Hands Dutch language version (DASH-DLV) and Short Form-12 (SF-12) at three, six, 12, and 24 months.

RESULTS

Of 856 referred patients, 476 (55.6%) patients were diagnosed with NTOS. Dedicated physiotherapy was successful in 186 patients (39.1%). Surgical treatment was performed in 290 (60.9%) patients of whom 274 were included in the follow up. At a mean follow up of 16.9 ± 9.2 months, significant improvement (p < .001) in TDS, CBSQ, DASH-DLV, and SF-12 scores was seen in the surgical group between baseline and all follow up intervals. Derkash outcome after surgical intervention was excellent in 83 (30.3%), good in 114 (41.6%), fair in 43 (15.7%), and poor in 34 (12.4%) of the patients. Complications occurred in 16 (5.8%) patients, and 32 (10.4%) patients experienced recurrent or persistent NTOS complaints.

CONCLUSION

A multidisciplinary care pathway based on the North American SVS reporting standards for NTOS helped to confirm the diagnosis in 56% of patients referred, and guided the selection of patients who might benefit from thoracic outlet decompression surgery after unsuccessful dedicated physiotherapy. Intermediate follow up showed good outcomes in the majority of surgically treated patients.

Neurogenic Thoracic Outlet Syndrome with Supraclavicular Release: Long-Term Outcome without Rib Resection

Our aim was to define clinical long-term outcome of surgery for neurogenic thoracic outlet syndrome without rib resection, and to find factors predicting long-term results. For the 94 patients, the main outcomes were pain, numbness, weakness, and upper-extremity function. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a numerical rating system served as functional outcome measures. Mean follow-up was 12.9 years. Preoperative pain diminished from 7.8 to 2.2, numbness from 7.4 to 4.0, and weakness from 7.3 to 3.8. Grip strength increased from 25.7 to 31.8 kg. QuickDASH averaged at follow-up 37.1 and CBSQ 51.5. No correlation appeared between smoking and long-term results regarding pain, numbness, weakness, or functioning. Positive TOS provocative tests or intraoperative anatomical findings like consistency of the scaleni muscles showed no correlation with outcome. 82% of female and 57% of male patients reported that aid from this surgery had been excellent or good; 69% reported that surgery helped considerably for at least a mean 9.9 years. The risk for worse self-reported long-term outcome was higher among men, but neither BMI nor age at surgery associated with self-reported outcome. Pain, numbness, and weakness significantly decreased and function improved after supraclavicular release without rib resection. We found no significant preoperative nor per-operative factors predicting long-term results.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety of robotic first rib resection for thoracic outlet syndrome

OBJECTIVES

Robotic first rib resection (R-FRR) is an emerging approach in the field of thoracic outlet syndrome (TOS) that has technical advantages over traditional open approaches, including superior exposure of the first rib and freedom from retracting neurovascular structures. We set out to define the safety of R-FRR and compare it with that of the conventional supraclavicular approach (SC-FRR).

METHODS

We queried a prospectively maintained, single-surgeon, single-institution database for all FRR operations performed for neurogenic TOS and venous TOS. Preoperative, intraoperative, and complications were compared between approaches.

RESULTS

Seventy-two R-FRRs and 51 SC-FRRs were performed in 66 and 50 patients, respectively. These groups were not significantly different in age, body mass index, sex, type of TOS, or preoperative use of opioids. Length of procedure and hospital stay were not different between groups. Postoperative inpatient self-reported pain (visual analog scale score 4.7 vs 5.2; P = .049) and administered morphine milligram equivalents (37.5 vs 81.1 MME, P < .001) were significantly lower in R-FRR than SC-FRR. Brachial plexus palsy was less frequent after R-FRR than SC-FRR (1% vs 18%, P = .002) and resolved by 4 months in call cases. All cases were sensory palsies with the exception of 2 motor palsies, which were both in the SC-FRR group. In multivariable analyses, R-FRR was independently associated with less frequent total complications than SC-FRR (P = .002; odds ratio, 0.08; 95% confidence interval, 0.02-0.39).

CONCLUSIONS

R-FRR provides outstanding exposure of the first rib and eliminates retraction of the brachial plexus and its consequences.

Thoracic Outlet Syndrome in the Overhead Athlete: Diagnosis and Treatment Recommendations

PURPOSE OF REVIEW

Neurovascular compression in the upper extremity is rare but can affect even those participating in high-level competitive athletics. To assess optimal approaches to treatment, in this review, we evaluate the current literature on neurovascular compressive syndromes affecting the upper extremity, with a special focus on the thoracic outlet syndrome (TOS).

RECENT FINDINGS

Neurovascular compression at the thoracic outlet can involve the brachial plexus, subclavian artery, or subclavian vein, each with distinct clinical manifestations. Neurogenic TOS is best treated with surgical decompression, if physical therapy has not improved symptoms. Venous TOS results in acute thrombosis superimposed on chronic venous compression. Treatment is best directed at early anticoagulation, catheter-directed thrombolysis, and surgical decompression, with most patients able to discontinue anticoagulation and return to high-level athletic activity. Arterial TOS is related to aneurysmal degeneration of the subclavian artery with distal embolization, leading to limb-threatening ischemia. This should be aggressively treated with surgery. Similar degenerative changes can occur in the axillary artery and its branches, leading to distal embolization. Prompt recognition of these potential sources of limb-threatening ischemia is critical to limb preservation. TOS includes rare but important conditions in the overhead athlete. Recent advances in physical therapy and image-guided diagnostic techniques have facilitated more accurate diagnosis. Surgical treatment remains the gold standard to maximize function or for limb preservation, and future research is needed to clarify optimal pain and physiotherapy regimens, as well as to examine novel approaches to neurovascular decompression.

Sonographically guided botulinum toxin injections in patients with neurogenic thoracic outlet syndrome: correlation with surgical outcomes

OBJECTIVE

We examined the role of botulinum toxin (BTX) injections of anterior scalene (AS) and pectoralis minor (PM) muscles in patients undergoing surgery for neurogenic thoracic outlet syndrome (NTOS). We hypothesized that symptomatic improvement from BTX injections correlates with favorable long-term response to surgery for NTOS.

MATERIALS AND METHODS

This Health Insurance Portability and Accountability Act compliant study was approved by the institutional review board and prior informed consent requirement was waived. We retrospectively analyzed prospectively acquired data in NTOS patients who underwent sonographically guided chemodenervation of AS and PM using BTX type A followed by scalenectomy and first rib resection. Overall responses to BTX injections and surgery were recorded after each procedure. Statistical analyses were performed to determine correlation between responses to BTX injections and surgery.

RESULTS

In 157 patients, 178 BTX injections followed by surgery were identified (114 females; mean age 38 ± 13 years). Responders and non-responders to BTX injections and surgery had similar preoperative symptom duration and age (P > 0.14). Better response to BTX injections correlated positively with better response to surgery (P = 0.003), persisting after adjustment for age, gender, and symptom duration (P = 0.03). A high proportion of responders to BTX injections also responded to surgery (positive predictive value of 99%), and BTX injections showed high specificity (90%). BTX injections were moderately sensitive (66%) and accurate (67%) to determine surgical response and had low negative predictive value (14%).

CONCLUSION

Response to BTX injections correlates positively with long-term surgical outcome in subjects with NTOS, potentially playing an important role in patient management.

Interfascial Plane Blocks Reduce Postoperative Pain and Morphine Consumption in Thoracic Outlet Decompression

BACKGROUND

Postoperative analgesia in patients undergoing transaxillary thoracic outlet decompression (TATOD) is challenging because of the invasive surgery, the complex innervation of the axillary region, and the preoperative use of opioids by many patients. Commonly, postoperative pain is managed with additional opioids that introduce well-known sideeffects. To investigate the analgesic efficacy of 2 novel regional anesthesia techniques, we performed a retrospective study comparing the combined pectoral block type 1 and erector spinae block (PECS 1 + ESB) and the pectoral block type 2 (PECS 2) and systemic intravenous opioids regimen (no block) in patients undergoing TATOD.

MATERIALS AND METHODS

We performed 10 PECS 1 + ESB and 10 PECS 2 blocks in patients undergoing TATOD. Twenty patients were randomly selected as controls. The primary endpoint was pain. Secondary endpoints were opioid use, nausea, and vomiting.

RESULTS

Postoperative maximal numeric rating scale scores on recovery were significantly lower in patients receiving either a PECS 1 + ESB or a PECS 2 block compared with controls without block (no block: median 6.00, interquartile range [IQR] 3.00; PECS 1 + ESB: median 4.50, IQR 4.00; PECS 2: median 4.00, IQR 5.00; P = 0.031). Postoperative intravenous morphine consumption was 43% lower in the PECS 1 + ESB group and 56% lower in the PECS 2 group compared with the group with no block (oral morphine equivalents; no block: mean 16.05 ± SD 6.79 mg; PECS 1 + ESB mean 9.05 ± SD 6.24 mg; PECS 2: mean 7.00 ± SD 6.16; P = 0.03 and P = 0.003, respectively). There was no statistical difference in both nausea and vomitus (no block 45% nausea and 30% vomitus, PECS 1 + ESB 40% nausea and 20% vomitus, PECS 2 10% nausea and 0% vomitus, P = 0.17 and P = 0.14, respectively).

CONCLUSIONS

There was a significant reduction in postoperative pain and opioid consumption for patients treated with either the PECS 1 + ESB block or PECS 2.

A pilot study of forearm microvascular impairment and pain while using a telephone

OBJECTIVE

To determine if using a telephone can induce forearm pain and ischemia.

DESIGN

Prospective case-control trial.

SETTING

Vascular laboratory in the university hospital in Angers between September 2018 and March 2019.

PARTICIPANTS

Fifteen apparently healthy subjects (controls) and 32 patients with suspected thoracic outlet syndrome (TOS) of vascular or non-vascular origin.

INTERVENTION

Hand-holding a cellular phone to answer a call from investigators.

MAIN OUTCOME MEASURES

Presence of forearm fatigue or pain (primary outcome), ability to hold the phone with each hand for 1 min (secondary outcome 1) and decrease in forearm transcutaneous oxygen pressure DROP index indicating forearm ischemia (secondary outcome 2). A DROP < -15 mm Hg defined ischemia.

RESULTS

Answering a phone call resulted in 25(78%) patients with forearm fatigue or pain and in 18 (56%) cases in the inability to hold the phone for 1 min, on one or both arms in patients with suspected TOS, but never occurred in healthy volunteers (p < .05 and p < .001). The presence of ischemia was observed in one or both arms in 10 (31%) patients with proved TOS and was always associated to phone-induced pain. Three (20%) of the controls had phone-induced ischemia. All had asymptomatic TOS and remained asymptomatic during the phone test (p = .42 from suspected-TOS patients).

CONCLUSION

The phone conversation resulted in pain in many patients with suspected TOS. Transcutaneous oximetry can document the underlying ischemia. Forearm phone-call-induced pain may be indicative of TOS provided that no earplug or headset is used. Trial registrationClinicalTrials.govNCT03355274.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Comparison of Athletes and Nonathletes Undergoing Thoracic Outlet Decompression for Neurogenic Thoracic Outlet Syndrome

BACKGROUND

Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome (TOS) and may occur from injury, occupational stress, or athletic endeavors. Although most patients with NTOS will improve after first-rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than nonathletes. We hypothesized that athletes would do better after FRRS than nonathletes despite the added physical stress that sporting activity imposes.

METHODS

We reviewed our office records for all patients treated for TOS from July 2009 to May 2014 and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS and compared athlete versus nonathlete survey responses.

RESULTS

Five hundred sixty-four patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were nonathletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. nonathletes 80%, P = 0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs. nonathletes 79%, P = 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. nonathletes 65%, P = 0.02), and 86% could perform activities of daily living without limitation (athletes 95% vs. nonathletes 77%, P = 0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. nonathletes 22%, P = 0.6), 89% felt that they had made the right decision (athletes 93% vs. nonathletes 80%, P = 0.09). Multivariable analysis of age, race, gender, previous surgery, preoperative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living.

CONCLUSIONS

Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. Although being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction after FRRS was similar to that in nonathletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors.

Influence of Body Weight on Surgical Treatment for Neurogenic Thoracic Outlet Syndrome

BACKGROUND

Body weight affects outcomes of surgical treatment for various conditions, but its effects on the treatment of neurogenic thoracic outlet syndrome (NTOS) are unknown. The purpose of this study was to evaluate the influence of body weight on technical and functional outcomes of surgical treatment for NTOS.

METHODS

A retrospective review of prospectively collected data was conducted for 265 patients who underwent supraclavicular decompression for NTOS between January 1, 2014 and March 31, 2016. Patients were grouped according to 6 standard body mass index (BMI) categories. The influence of BMI on measures of surgical outcome was analyzed using Pearson correlation statistics, analysis of variance (ANOVA), and multivariate logistic regression.

RESULTS

Mean patient age was 33.3 ± 0.7 years (range, 12-70), and 208 (78%) patients were women. Mean BMI was 27.2 ± 0.4 (range 16.8-49.9), with 7 underweight (3%), 95 normal (36%), 84 overweight (32%), 47 obese-I (18%), 15 obese-II (6%), and 17 obese-III (6%). There was a slight but significant association between BMI and age (Pearson P < 0.0001, r = 0.264; ANOVA P = 0.0002), but no correlations between BMI and other preoperative variables. There were no differences between BMI groups for intraoperative, immediate postoperative, or 3-month outcomes. Multivariate logistic regression demonstrated that BMI had no significant effect on functional outcome as measured by the extent of improvement in Disability of the Arm, Shoulder, and Hand score at 3 months (P = 0.429).

CONCLUSIONS

There was no substantive influence of BMI on preoperative characteristics or intraoperative, postoperative, or 3-month outcomes for patients with NTOS, and no indication of an "obesity paradox" for this condition. Supraclavicular decompression for NTOS achieves similar outcomes across the BMI spectrum.

A user's survey of the clinical application and content validity of the DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure

STUDY DESIGN

Survey.

PURPOSE OF THE STUDY

To elicit feedback on the clinical use and content validity of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure from frontline users of the instrument.

METHODS

A cross-sectional survey was administered to registered DASH users and inquired about how the DASH was being used and to identify the informational value of items of the DASH (content validity).

RESULTS

About 172 completed the survey. One or both of the DASH and/or QuickDASH were consistently (89.5%) being used. About 90% were using it in adults (21-65 years), and at least 70% were using it across the entire extremity, and to a lesser extent, 10% reported using it in isolated neck injuries. Most respondents (66.9%-75.8%) were using the DASH in musculoskeletal (MSK) disorders, with some applying it for other more unique or non-MSK conditions (2.5%-16.6%). All but 1 of the 30 DASH items had at least 10% endorsement as being informative, and 4 items were identified as being problematic by greater than 20%.

CONCLUSIONS

The DASH is being used as intended (whole extremity and MSK conditions), and in addition, it is being used in different body regions and diverse conditions.

LEVEL OF EVIDENCE

Not applicable (descriptive survey).

Cervical Rib Prevalence and its Association with Thoracic Outlet Syndrome: A Meta-Analysis of 141 Studies with Surgical Considerations

BACKGROUND

Cervical ribs (CR) are supernumerary ribs that arise from the seventh cervical vertebra. In the presence of CR, the boundaries of the interscalene triangle can be further constricted and result in neurovascular compression and thoracic outlet syndrome (TOS). The aim of our study was to provide a comprehensive evidence-based assessment of CR prevalence and their association with TOS as well as surgical approach to excision of CR and surgical patients' characteristics.

METHODS

A thorough search of major electronic databases was conducted to identify any relevant studies. Data on the prevalence, laterality, and side of CR were extracted from the eligible studies for both healthy individuals and patients with TOS. Data on the type of TOS and surgical approach to excision of CR were extracted as well.

RESULTS

A total of 141 studies (n = 77,924 participants) were included into the meta-analysis. CR was significantly more prevalent in patients with TOS than in healthy individuals, with pooled prevalence estimates of 29.5% and 1.1%, respectively. More than half of the patients had unilateral CR in both the healthy and the TOS group. The analysis showed that 51.3% of the symptomatic patients with CR had vascular TOS, and 48.7% had neurogenic TOS. Most CR were surgically excised in women using a supraclavicular approach.

CONCLUSIONS

CR ribs are frequent findings in patients with TOS. We recommended counseling asymptomatic patients with incidentally discovered CR on the symptoms of TOS, so that if symptoms develop, the patients can undergo prompt and appropriate workup and treatment.

Frequency of the Pectoralis Minor Compression Syndrome in Patients Treated for Thoracic Outlet Syndrome

BACKGROUND

Pectoralis minor compression syndrome (PMCS) is a compression of the neurovascular structures in the subpectoral tunnel and remains underestimated in the management of patients with thoracic outlet syndrome (TOS). Its underdiagnosis may be responsible for incomplete or failed treatment. The aim of the study was to evaluate the frequency of PMCS in our experience.

METHODS

We retrospectively reviewed all patients treated for TOS in our department. We selected those in whom PMCS was diagnosed with a systematic dynamic arteriography. Surgery was performed using the Roos axillary approach when a first rib resection was associated or an elective approach when a first rib resection was not associated.

RESULTS

From January 2004 to December 2014, 374 surgeries for TOS were performed in 279 patients, which included 90 men (sex ratio = 0.48) with a mean age of 40.1 ± 10 years old. Among these patients, 63 (22.5%) underwent 82 interventions (21.9%) for PMCS, including 26 men (sex ratio = 0.70, P < 0.05) with a mean age of 37.9 ± 9.4 years old. Tenotomy of the pectoralis minor muscle was performed using axillary approach if it was associated with a first rib resection in 74 cases (90.2%) or through an elective approach in 8 cases (9.8%) if it was isolated. Four (4.9%) postoperative complications were found (1 hematoma [1.2%], 1 hemothorax [1.2%], 1 scapula alata [1.2%], and 1 subclavian vein thrombosis [1.2%]), all after an axillary approach. In 63 cases (79.7%), preoperative symptoms were resolved. In 14 cases (17.7%), symptom resolution was incomplete, and 2 patients (2.6%) had recurrent symptoms.

CONCLUSIONS

Evaluation of PMCS in TOS is justified by its frequency and the simplicity and low morbidity of the surgical procedure.

Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome

BACKGROUND

Neurogenic thoracic outlet syndrome (NTOS) results from compression of the brachial plexus by the clavicle, first rib, and scalene muscles and may develop secondary to repetitive motion of the upper extremity. Athletes routinely perform repetitive motions, and sports requiring significant arm and shoulder use may put the participant at increased risk for NTOS. Competitive athletes who develop NTOS may require first rib resection and scalenectomy (FRRS) for symptomatic relief. However, the effectiveness of FRRS has not previously been studied in this vulnerable population.

METHODS

This is a cross-sectional study of competitive athletes with NTOS who received FRRS by the senior author between 2009 and 2014. Eligible patients were contacted by phone and invited to complete a nine-item survey assessing the long-term effects of FRRS on pain medication use, postoperative physical therapy duration, patient satisfaction, symptom relief, activities of daily living, athletic performance, time to return of athletic performance, and need for other operations. Multivariate analyses of the following risk factors were performed: age, pectoralis minor release, preoperative narcotic use, athletic shutdown, and involvement in a throwing sport.

RESULTS

There were 232 competitive athletes who met the inclusion criteria, and 67 of these (age, 14-48 years; 35 male; 99% white) responded to the survey. The average time between surgery and survey completion was 3.9 years (range, 2.2-7.0 years). The most frequent sports conducted by this group were baseball and softball (n = 44 [66%]), volleyball (n = 7 [10%]), and cheerleading and gymnastics (n = 5 [7%]), ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%. Multivariate regression analysis identified younger age as a predictor of the length of physical therapy and preoperative narcotics use as a predictor of symptom resolution.

CONCLUSIONS

At our center, >40% of patients requiring FRRS for NTOS are competitive athletes. The results of this study show that the majority of them are able to return to their precompetitive state after FRRS, and few experience limitations in their daily living activities. Half can return to competition at or exceeding their premorbid ability level within 6 months of surgery. The majority are pleased with their decision to undergo FRRS. Further investigation is needed to identify predictive factors for successful return to competitive athletics.

Video-assisted thoracoscopic surgery for intrathoracic first rib resection in thoracic outlet syndrome

BACKGROUND

First rib resection is a surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, extrathoracic approaches have used a posterior, supraclavicular, or transaxillary incision to remove the first rib. In this report, we demonstrate video-assisted thoracoscopic surgery for intrathoracic first rib resection (VATS-IFRR).

METHODS

Between 2009 and 2014, eight patients underwent VATS-IFRR for TOS. Surgery was performed through two 5-mm ports and one 10-mm port. Endoscopic graspers, a hook-type electrocautery probe, a long peapod intervertebral disc rongeur, and Kerrison punches were used. The types of disease, operative times, chest tube indwelling days, lengths of hospital stay after operation, perioperative complications, postoperative pain scale ratings, and postoperative symptom recurrence rates at provocation tests were reviewed. The surgical outcomes were compared to published outcomes of extrathoracic approaches and other VATS approaches.

RESULTS

The eight patients (3 right ribs, 5 left ribs) exhibited neurogenic (1 patient), combined type (2 patients), arterial (4 patients), and venous type (1 patient) TOS. The mean operative time was 190 (range 155-310) minutes. No mortalities or major complications occurred. The mean chest tube indwelling duration was 6 (range 3-10) days, and the mean postoperative hospital stay was 9 (range 4-21) days. The mean immediate postoperative pain numeric rating scale (NRS) score was 2.7/10 (range 2-4). No recurrence was observed during follow-up (median 25.5 months, range 10-64 months) in any patient.

CONCLUSIONS

VATS-IFRR was safe and had several advantages. Thus, VATS-IFRR is a minimally invasive surgical option suitable for treating selective cases of TOS.

Postoperative Pain Management following Thoracic Outlet Decompression

BACKGROUND

Thoracic outlet decompression (TOD) is associated with significant postoperative pain often leading to hospital length of stay out of proportion to the risk profile of the operation. We seek to describe the improvement in hospital length of stay and patient pain control with an improved multiagent pain management regimen.

METHODS

We retrospectively reviewed the hospital length of stay, medication regimen/usage, operative details, and operative indications for all patients undergoing TOD from January 2012 through June 2015. During early experience, single-agent narcotic therapy was the mainstay of postoperatively pain control. Since 2014, we have adopted a regimen consisting of narcotic patient controlled analgesia, oral narcotics, and scheduled ibuprofen and valium, which is transitioned to oral narcotics/valium upon discharge. Operative approach (supraclavicular, infraclavicular, transaxial, or paraclavicular) was determined by patient anatomy and indication for procedure (neurogenic/arterial thoracic outlet syndrome or arteriovenous access dysfunction).

RESULTS

Seventy-four patients were treated with TOD over the study period: 36 (49.3%) for neurogenic thoracic outlet syndrome, 23 (31.5%) for venous thoracic outlet syndrome, and 15 (19.2%) for arteriovenous access dysfunction. Prior to 2014, the mean length of stay was 4 days with a median pain score of 6. Since 2014, the mean length of stay was 2.6 (P = 0.04) with a median pain score of 4 (P = 0.005). There was no statistically significant difference in the indication for operation or operative approach between the two periods.

CONCLUSIONS

Since adoption of a multiagent pain management regimen to include scheduled NSAIDs and benzodiazepines, we have reduced the mean pain score experienced by our patients as well as the hospital length of stay.

Clinical presentation and management of arterial thoracic outlet syndrome

OBJECTIVE

Arterial thoracic outlet syndrome (TOS) is a rare condition characterized by subclavian artery pathology associated with a bony abnormality. This study assessed contemporary clinical management of arterial TOS at a high-volume referral center.

METHODS

A prospectively maintained database was used to conduct a retrospective review of patients undergoing primary or reoperative treatment for arterial TOS during an 8-year period (2008 to 2016). Presenting characteristics, operative findings, and clinical and functional outcomes were evaluated.

RESULTS

Forty patients underwent surgical treatment for arterial TOS, representing 3% of 1401 patients undergoing operations for all forms of TOS during the same interval. Patients were a mean age of 40.3 ± 2.2 years (range, 13-68 years), and 72% were women. More than half presented with upper extremity ischemia/emboli (n = 21) or posterior stroke (n = 2), including eight that had required urgent brachial artery thromboembolectomy. The presentation in 17 (42%) was nonvascular, with 11 having symptoms of neurogenic TOS and six having an asymptomatic neck mass or incidentally discovered subclavian artery dilatation. All patients underwent thoracic outlet decompression (25 supraclavicular, 15 paraclavicular), of which there were 30 (75%) with a cervical rib (24 complete, 6 partial), 5 with a first rib abnormality, 4 with a clavicle fracture, and 1 (reoperation) with no remaining bone abnormality. Subclavian artery reconstruction was performed in 70% (26 bypass grafts, 1 patch, 1 suture repair), and 30% had mild subclavian artery dilatation (<100%) requiring no arterial reconstruction. Mean postoperative length of stay was 5.4 ± 0.6 days. During a mean follow-up of 4.5 ± 0.4 years (range, 0.9-8.1 years), subclavian artery patency was 92%, none had further dilatation or embolism, and chronic symptoms were present in six (4 postischemic/vasospasm, 2 neurogenic). Functional outcomes measured by scores on the 11-item version of the Disability of the Arm, Shoulder and Hand Outcome Measure improved from 39.1 ± 3.8 to 19.2 ± 2.7 (P < .0001).

CONCLUSIONS

This relatively large single-institution series demonstrates the diverse clinical presentation of arterial TOS coincident with a spectrum of bony and arterial pathology. Current surgical protocols can achieve excellent outcomes for this rare and often complicated condition.

Perioperative Outcomes of Thoracic Outlet Syndrome Surgical Repair in a Nationally Validated Database

We evaluated the occurrence of thoracic outlet syndrome (TOS) and 30-day postoperative outcomes. Patients undergoing cervical/first rib resection surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Thoracic outlet syndrome types were then examined. Propensity score matching was performed to account for potential confounders; 1180 patients were explored during the study period, 1007 (85.3%) were of the neurogenic TOS (NTOS), 32 (2.7%) patients had arterial TOS (ATOS), and 141 (12.0%) patients had venous TOS (VTOS). Patients with ATOS were significantly older (median age [interquartile range, IQR]—NTOS: 34 [25-44], ATOS: 49.5 [42.5-57], VTOS: 34 [23-43]; P < .001). Median operating time was significantly longer for patients with ATOS. Median in-hospital stay was also longer for patients with ATOS (median length of in-hospital stay [LOS; IQR]—NTOS: 2 [1-4]; ATOS: 6 [3-7]; and VTOS: 5 [2-7] days; P < .001). Patients with VTOS showed twice longer LOS when compared to NTOS after matching. Presentation and treatment of TOS have been studied extensively at highly experienced centers.