Thoracic outlet and pectoralis minor syndromes

Neurogenic Thoracic Outlet Syndrome: A Primer for Hand and Peripheral Nerve Surgeons

Neurogenic thoracic outlet syndrome is a complex condition and is commonly misunderstood. Historically, much of this confusion has been because of its grouping with other diagnoses that have little in common other than anatomic location. Modern understanding emphasizes the role of small unmyelinated C type pain and sympathetic fibers. Diagnosis is primarily clinical, after ruling out other common conditions. Hand therapy is usually the first-line treatment with variable success. Local anesthetic, botulinum toxins, or steroid injections can aid in diagnosis and offer short-term relief. Although surgery can yield reliable results, it is technically challenging, and the preferred surgical approach is a matter of debate. Despite limitations in diagnosis and treatment, recognition and successful treatment of this condition can be highly impactful for the patient.

McCleery Syndrome Caused by Pectoralis Minor Hypertrophy Treated with Multimodal Physical Therapy-A Case Report

We present a case of a healthy young male professional water polo player who presented with swelling and pain in the upper arm and elbow after vigorous exercise. Diagnostic workup included an MRI and dynamic duplex ultrasound, which revealed compression of the axillary vein by a hypertrophic pectoralis minor muscle without thrombosis, constituting McCleery syndrome. This is a rare entity within the multiple thoracic outlet syndrome aetiologies. Taking a detailed history and physical examination complemented with diagnostic imaging are vital to the diagnosis. Afterward, the patient was treated with multimodal physical therapy and fully recovered and even exceeded his previous training and play level.

Upper-limb neurovascular compression, pectoralis minor and quadrilateral space syndromes: A narrative review of current literature

Pectoralis minor syndrome (PMS) and quadrilateral space syndrome (QSS) are uncommon neurovascular compression disorders affecting the upper extremity. PMS involves compression under the pectoralis minor muscle, and QSS results from compression in the quadrilateral space-both are classically observed in overhead-motion athletes. Diagnosing PMS and QSS may be challenging due to variable presentations and similarities with other, more common, upper-limb pathologies. Although there is no gold standard diagnostic, local analgesic muscle-block response in a patient with the appropriate clinical context is often all that is required for an accurate diagnosis after excluding more common etiologies. Treatment ranges from conservative physical therapy to decompressive surgery, which is reserved for refractory cases or severe, acute vascular presentations. Decompression generally yields favorable outcomes, with most patients experiencing significant relief and restored baseline function. In conclusion, PMS and QSS, although rare, can cause debilitating upper-extremity symptoms; accurate diagnosis and appropriate treatment offer excellent outcomes, alleviating pain and disability.

Systematic Review on Botulinum Toxin Injections as Diagnostic or Therapeutic Tool in Thoracic Outlet Syndrome

BACKGROUND

The optimal diagnostic and treatment algorithm for patients with suspected thoracic outlet syndrome (TOS) remains challenging. Botulinum toxin (BTX) muscle injections have been suggested to shrink muscles in the thoracic outlet reducing neurovascular compression. This systematic review evaluates the diagnostic and therapeutic value of BTX injections in TOS.

METHODS

A systematic review of studies reporting BTX as a diagnostic or therapeutic tool in TOS (or pectoralis minor syndrome as TOS subtype) was conducted in PubMed, Embase, and CENTRAL databases on May 26, 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. Primary end point was symptom reduction after primary procedure. Secondary end points were symptom reduction after repeated procedures, the degree of symptom reduction, complications, and duration of clinical effect.

RESULTS

Eight studies (1 randomized controlled trial [RCT], 1 prospective cohort study, and 6 retrospective cohort studies) were included reporting 716 procedures in at least 497 patients (at minimum 350 primary and 25 repeated procedures, residual unclear) diagnosed with presumably only neurogenic TOS. Except for the RCT, the methodological quality was fair to poor. All studies were designed on an intention to treat basis, one also investigated BTX as a diagnostic tool to differentiate pectoralis minor syndrome from costoclavicular compression. Reduction of symptoms was reported in 46-63% of primary procedures; no significant difference was found in the RCT. The effect of repeated procedures could not be determined. Degree of symptom reduction was reported by up to 30-42% on the Short-form McGill Pain scale and up to 40 mm on a visual analog scale. Complication rates varied among studies, no major complications were reported. Symptom relief ranged from 1 to 6 months.

CONCLUSIONS

Based on limited quality evidence, BTX may provide short-lasting symptom relief in some neurogenic TOS patients but remains overall undecided. The role of BTX for treatment of vascular TOS and as a diagnostic tool in TOS is currently unexploited.

Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome is a challenging condition to diagnose and treat, often precipitated by the triad of repetitive overhead activity, pectoralis minor contracture, and scapular dyskinesia. The resultant protracted scapular posture creates gradual repetitive traction injury of the suprascapular nerve via tethering at the suprascapular notch and decreases the volume of the brachial plexus cords and axillary vessels in the retropectoralis minor space. A stepwise and exhaustive diagnostic protocol is essential to exclude alternate pathologies and confirm the diagnosis of this dynamic pathologic process. Ultrasound-guided injections of local anesthetic or botulinum toxin are a key factor in confirming the diagnosis and prognosticating potential response from surgical release. In patients who fail over 6 months of supervised physical therapy aimed at correcting scapular posture and stretching of the pectoralis minor, arthroscopic surgical release is indicated. We present our diagnostic algorithm and technique for arthroscopic suprascapular neurolysis, pectoralis minor release, brachial plexus neurolysis, and infraclavicular thoracic outlet decompression.

Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain

CASE

A 74-year-old male patient presenting with chronic radiating shoulder pain, paresthesias, and weakness had previously undergone reverse shoulder arthroplasty and anterior cervical discectomy and fusion for an irreparable cuff tear and cervical radiculopathy, respectively. After being diagnosed with neurogenic thoracic outlet syndrome and undergoing physiotherapy, the patient's recalcitrant condition was surgically managed with arthroscopic pectoralis minor tenotomy, suprascapular nerve release, and brachial plexus neurolysis.

CONCLUSION

This ultimately led to complete pain relief and improved function. By sharing this case, we aim to shed light on this overlooked pathology and help prevent unnecessary procedures for others suffering from similar conditions.

Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome

The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.

A narrative review of nine commercial point of care influenza tests: an overview of methods, benefits, and drawbacks to rapid influenza diagnostic testing

CONTEXT

Rapid influenza diagnostic tests (RIDTs) are becoming increasingly accurate, available, and reliable as the first line of testing when suspecting influenza infections, although the global burden of influenza infections remains high. Rapid diagnosis of influenza infections has been shown to reduce improper or delayed treatment and to increase access to diagnostic measures in public health, primary care, and hospital-based settings.

OBJECTIVES

As the use of RIDTs continues to expand in all healthcare settings, there is a multitude of molecular techniques being employed by these various testing platforms. With this in mind, we compare the sensitivity, specificity, and time to diagnosis for nine highly utilized commercial RIDTs.

METHODS

Nine commercially available RIDTs were identified from the US Centers for Disease Control and Prevention (CDC) website, which were also referenced on PubMed by name within the title or abstract of peer-reviewed publications examining the sensitivity and specificity of each test against a minimum of three influenza A virus (IAV) strains as well as seasonal influenza B virus (IBV). Data from the peer-reviewed publications and manufacturers' websites were combined to discuss the sensitivity, specify, and time to diagnosis associated with each RIDT.

RESULTS

The sensitivity and specificity across the examined RIDTs were greater than 85.0% for both IAV and IBV across all platforms, with the reverse transcriptase-polymerase chain reaction (RT-PCR) assays maintaining sensitivity and specificity greater than 95.0% for all viruses tested. However, the RT-PCR platforms were the longest in time to diagnosis when compared to the other molecular methods utilized in the examined RIDTs.

CONCLUSIONS

Herein, we discussed the benefits and limitations of nine commercially available RIDTs and the molecular techniques upon which they are based, showing the relative accuracy and speed of each test for IAV and IBV detection as reported by the peer-reviewed literature and commercial manufacturers.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Smart Nanostructured Materials for SARS-CoV-2 and Variants Prevention, Biosensing and Vaccination

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has raised great concerns about human health globally. At the current stage, prevention and vaccination are still the most efficient ways to slow down the pandemic and to treat SARS-CoV-2 in various aspects. In this review, we summarize current progress and research activities in developing smart nanostructured materials for COVID-19 prevention, sensing, and vaccination. A few established concepts to prevent the spreading of SARS-CoV-2 and the variants of concerns (VOCs) are firstly reviewed, which emphasizes the importance of smart nanostructures in cutting the virus spreading chains. In the second part, we focus our discussion on the development of stimuli-responsive nanostructures for high-performance biosensing and detection of SARS-CoV-2 and VOCs. The use of nanostructures in developing effective and reliable vaccines for SARS-CoV-2 and VOCs will be introduced in the following section. In the conclusion, we summarize the current research focus on smart nanostructured materials for SARS-CoV-2 treatment. Some existing challenges are also provided, which need continuous efforts in creating smart nanostructured materials for coronavirus biosensing, treatment, and vaccination.

Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome

Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.

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.

[Please Don't Forget the Neurogenic Thoracic Outlet Syndrome]

Please Don't Forget the Neurogenic Thoracic Outlet Syndrome Abstract. We report the case of a 52-year-old patient who was treated for years for headaches, pain in the neck and arms, and sweating. Despite various therapeutic approaches there was no improvement in the symptoms. Further investigations showed a bilateral thoracic outlet syndrome in the status after multiple bilateral rib fractures after a fall from a window at the age of 18. After the operation of a bilateral thoracic outlet syndrome, the headache disappeared almost completely and there was no more sweating.

Neurogenic thoracic outlet syndrome in the overhead and throwing athlete: A narrative review

Thoracic outlet syndrome is an important cause of shoulder pain and dysfunction due to compression of neurovascular structures as they traverse the thoracic outlet. Symptoms are most commonly due to compression of the brachial plexus called neurogenic thoracic outlet syndrome (nTOS). Throwing athletes are at increased risk of nTOS because of a variety of biomechanical factors. However, because nTOS symptoms are often nonspecific, delayed diagnosis is common. Neurogenic thoracic outlet largely remains a diagnosis of exclusion with advanced imaging ruling out vascular involvement and diagnostic injections gaining favor in helping localize sites of compression. Although rehabilitation alone may improve symptoms in some athletes, many require surgical treatment for long-term relief. This generally entails decompression of the thoracic outlet by some combination of muscle release, brachial plexus neurolysis, and first rib resection. Outcomes tend to be successful in athletes with most achieving resolution of symptoms and return to athletic activity. NTOS is an important cause of shoulder pain and dysfunction in throwing athletes. The history and physical examination should focus on activities that exacerbate symptoms. Treatment of nTOS generally requires surgical intervention and allows throwing athletes to return to sport.

Pectoralis minor syndrome: diagnosis with Botulinum injection and treatment with tenotomy - a prospective case series

BACKGROUND

Pectoralis minor syndrome involves pain, paraesthesia and weakness in the arm due to compression of the brachial plexus passing beneath pectoralis minor; this paper reports the results of a single centre's treatment pathway in affected patients.

METHODS

During a four-year period, patients exhibiting symptoms of pectoralis minor syndrome without significant improvement following physiotherapy proceeded to Botulinum injection. Those with good response to injection but subsequent recurrence of symptoms were offered pectoralis minor tenotomy. Oxford shoulder Scores were collected at baseline and after interventions.

RESULTS

Twenty-one patients received Botulinum injection; at six weeks following injection, mean change in Oxford Shoulder Score was +12.4, with only one patient reporting a worsening of symptoms. Of the 17 patients with clinically significant response to injection, 12 have subsequently undergone tenotomy; three months following tenotomy, mean change in Oxford Shoulder Score from baseline was +22.3. Improvement was maintained in all patients at prolonged follow-up (average 20 months post-tenotomy).

DISCUSSION

This pathway has shown to be extremely effective in patients not responding to first-line treatment for pectoralis minor syndrome, with 85% of patients post-injection and 100% of patients post-tenotomy showing significant (greater than published minimal clinically important difference value of six points) improvements in Oxford Shoulder Score, maintained at follow-up.

Role of botulinum toxin in pectoralis minor syndrome

INTRODUCTION

Thoracic outlet syndrome (TOS) causes neurogenic symptoms in 95% of the cases due to neurovascular bundle compression. The treatment goal is the decompression of the neurovascular structures. In the last decade, non-surgical treatments have been evaluated as a treatment option for spastic syndromes and thoracic outlet syndrome. In this study we report the use of botulinum toxin (BTX-A) injection as a diagnostic tool to identify the pectoral minor syndrome, and as a less aggressive treatment-option.

METHODS

An observational cohort study of patients with neurogenic thoracic outlet syndrome who underwent sonographically guided chemodenervation of pectoral minor muscle with botulinum toxin. Follow-up includes clinical evaluation at one month, 3 months and 6 months after the procedure. Clinical evaluation was made with clinical questionnaire. In case of patients with partial improvement of the symptoms, a second infiltration of BTX-A was performed. The categorical variables were shown as percentages, and the continuous variables as mean and standard deviation (SD). For the comparison of categorical variables, the Fisher's exact test was used. Statistical analysis was performed using the SPSS version 20.0 program. We consider p <0.05 to be statistically significant.

RESULTS

A total of twenty-six patients were diagnosed with thoracic outlet syndrome in this period, and 20 accomplished the inclusion criteria. Seven patients were excluded (1 due to neoplasia, 2 did not sign the informed consent, 1 due to neoplasia, 2 did not sign the informed consent, 1 was lost during the follow-up and 3 due to anomalies of the first rib secondary to fractures and cervical rib and 1 was lost during the follow-up), therefore a sample of 13 patients aged between 24 and 55 years was obtained. The most common type of procedure performed was the single injection of 50 IU of botulinum toxin. Four patients were infiltrated in two occasions due to partial improvement in symptoms at one-month follow-up. Clinical stability was found at three months and at six months follow-up.

CONCLUSION

The ultrasound-guided botulinum injection of the pectoralis minor muscles provides symptoms relief in patients with pectoral minor syndrome, and could be considered a safe tool in the diagnosis of the pectoralis minor syndrome within the spectrum of thoracic operculum syndrome.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Jury verdicts, outcomes, and tort reform features of malpractice cases involving thoracic outlet syndrome

OBJECTIVE/BACKGROUND

Thoracic outlet syndrome (TOS) is most often referred to vascular surgeons. However, there is a lack of understanding of the malpractice cases involving TOS. The goal of this study is to better understand the medicolegal landscape related to the care of TOS.

METHODS

The Westlaw Edge AI-powered proprietary system was retrospectively reviewed for malpractice cases involving TOS. A Boolean search strategy was used to identify target cases under the case category of "Jury Verdicts & Settlements" for all state and federal jurisdictions from 1970 to September 2020. The settled case was described but not included in the statistical analysis. Descriptive statistics were used to report our findings, and when appropriate. The P ≤ .05 decision rule was established a priori as the null hypothesis rejection criterion to determine associations between jury verdicts outcomes and state's tort reform status.

RESULTS

In this study, 39 cases were identified and met the study's inclusion criteria from the entire Westlaw Edge database. Among plaintiffs who disclosed age and/or gender, median age was 35.0 years with a female majority (67.6%). Cases involving TOS were noted to be steadily decreasing since the mid-1990s. The cases were unevenly spread across 18 states, with the highest number of cases (14, 35.9%) from California and the second highest (4, 10.3%) from Pennsylvania. A similar uneven distribution was seen among U.S. census regions, in which the West had the highest cases (39.5%). The study revealed that more cases were brought to trials in tort reform states (26, 68.4%) than in non-tort reform states (12, 31.6%). A total of 24 of 39 (61.5%) plaintiffs had one specific claim, which resulted in their economic and noneconomic damages. Negligent operation and treatment complication represented an overwhelming majority of claims brought by 38 of 39 plaintiffs (97.4%). Misdiagnosis and lack of informed consent were both brought nine times (23.1%) by the group. Intraoperative nerve injury (20 patients, 51.3%) was the most commonly reported complication. Excluding one case with a settlement of $965,000, 30 of 38 (78.9%) cases went to trials and received defense verdicts. Eight cases (20.5%) were found in favor of plaintiffs with a median payout of $725,581.

CONCLUSIONS

This study highlighted higher than average payouts to plaintiffs and risk factors that may result in malpractice lawsuits for surgeons undertaking TOS treatment. Future studies are needed to further clarify the relationships between tort reform and outcomes of malpractice cases involving TOS.

The clinical anatomy of variations of the pectoralis minor

Shoulder pathology is a very common medical presentation and can be due to anatomical variations. Therefore, knowledge of variants is important for the clinician treating patients with such complaints so that misdiagnosis is minimized and iatrogenic injury prevented. A review of the literature was performed of the variant anatomy of the pectoralis minor muscle. The aim of this review is to better inform clinicians who might treat patients with shoulder pathology so that if identified, variants of the pectoralis minor muscle are better appreciated.

Thoracic Outlet Syndrome: A Narrative Review

Thoracic outlet syndrome comprises a group of disorders that result in compression of the brachial plexus and subclavian vessels exiting the thoracic outlet. Symptoms include pain, paresthesia, pallor, and weakness depending upon the compromised structures. While consensus in diagnostic criteria has not yet been established, a thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis. General first-line therapy for thoracic outlet syndrome is a conservative treatment, and may include physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids. Patients who have failed conservative therapy are considered for surgical decompression. This article aims to review the epidemiology, etiology, relevant anatomy, clinical presentations, diagnosis, and management of thoracic outlet syndrome.

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.

Supraclavicular Versus Transaxillary First Rib Resection for Thoracic Outlet Syndrome

Background: Thoracic outlet syndrome (TOS) results from compression of neurovascular structures supplying the upper extremity as they exit the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. Objectives: Transaxillary (TA) and supraclavicular (SC) approaches are both widely utilized and deemed effective. Our objective was to review the outcomes for both approaches at our institution. Methods: A retrospective review was conducted on patients who underwent thoracic outlet decompression between 2010 and 2015. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected. Operative times, length of hospital stay, perioperative complications, and outcomes were also studied. Results: A total of 82 thoracic outlet decompression procedures were performed during the study period: 42% neurogenic TOS, 46% venous TOS, and 12% arterial TOS. In total, 49% underwent TA approach and 51% underwent SC approach. Adjunct procedures were performed in 13% of patients. There were no significant differences in average operative time (151.3 ± 54.1 minutes versus 126.1 ± 36.1 minutes, P = .11) or hospital stay (2.3 ± 1.9 days versus 2.4 ± 1.4 days, P = .23) between both groups, respectively. Minor complications were seen in 6% of patients with no significant difference in both groups, whereas 6% had major complications. No perioperative or 30-day mortalities were observed. In total, 49% of patients had complete resolution of symptoms, 46% had partial improvement, and 5% had no improvement. There was no difference in symptom resolution between either group. Conclusions: TA and SC approaches are equally safe and effective for the treatment of TOS. SC decompression allows for adjunct procedures and vascular reconstructions.

Spasticity-induced Pectoralis minor syndrome: a case-report

Background: Pectoralis minor syndrome (PMS) develops when the neurovascular bundle compression occurs at the retropectoralis minor space. It may occur due to repetitive overhead activities, traumatic incident, structural causes, myofascial pain syndrome in the pectoralis minor muscle, as well as spasticity of the pectoralis minor muscle. In patients with hemiplegia, adductor muscles along with pectoralis minor muscle spasticity may be present in the upper extremity.Objective: We report a 19-year-old male patient with spastic hemiparesis who was diagnosed with PMS due to spasticity of the pectoralis minor muscle.Method: Diagnosis of PMS was confirmed by Ultrasound-guided 4 cc 1% lidocaine injection to the right pectoralis minor muscle and Ultrasound-guided onabotulinum toxin A injection was performed. Stretching exercises to the pectoral muscles were also added to the rehabilitation program.Result: Complaints of the patient were controlled by botulinum toxin injections at 3-month intervals.Conclusion: It should be kept in mind that spasticity in the upper extremity may develop in the pectoralis minor muscle, and may cause pressure on the neurovascular structures. Ultrasound-guided botulinum toxin injections can be a safe and effective treatment for PMS in a patent with post stroke spastic hemiparesis.

Outcomes following operative management of thoracic outlet syndrome in the pediatric patients

Objectives

Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients.

Methods

Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed.

Results

Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients.

Conclusions

Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.

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.

All-Endoscopic Brachial Plexus Complete Neurolysis for Idiopathic Neurogenic Thoracic Outlet Syndrome: A Prospective Case Series

PURPOSE

To describe an all-endoscopic technique for infra- and supraclavicular brachial plexus (BP) neurolysis and to assess its functional outcomes for patients suffering from nonspecific neurogenic thoracic outlet syndrome (NTOS).

METHODS

Between January 2010 and January 2013, 36 patients presenting an idiopathic nonspecific NTOS benefited from an endoscopic decompression in our institution. The inclusion criteria were a typical clinical NTOS and failure of a 6-month well-conducted nonsurgical treatment. Preoperative findings about other shoulder conditions and complementary procedures were exclusion criteria. Interscalene, costoclavicular, and retropectoralis minor spaces were released endoscopically. The primary endpoint was the Disability of the Arm, Shoulder and Hand (DASH) score improvement 6 months after the surgery. Postoperative criteria such as pain relief, paresthesia, upper limb weakness, and provocative tests were also assessed.

RESULTS

Of 36 patients, 10 were excluded and 5 were lost during follow-up. The data of the 21 remaining patients were analyzed after 6 months. Pre- and postoperative mean DASH scores were, respectively, 70 (range 36-98) and 34 (range 2-91). The average improvement was 36 (range -20 to 80), with P = .0002. Pain and paresthesia were relieved in 80% to 90% of the cases. No complication was reported.

CONCLUSIONS

Although requiring arthroscopic skills and expert knowledge of the anatomy, our technique seems to be safe and reproducible, and it provides significant functional improvements in the selected patients with nonspecific NTOS, with an average postoperative DASH score improvement of 36%.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Pectoralis Minor Syndrome: Subclavicular Brachial Plexus Compression

The diagnosis of brachial plexus compression-either neurogenic thoracic outlet syndrome (NTOS) or neurogenic pectoralis minor syndrome (NPMS)-is based on old fashioned history and physical examination. Tests, such as scalene muscle and pectoralis minor muscle blocks are employed to confirm a diagnosis suspected on clinical findings. Electrodiagnostic studies can confirm a diagnosis of nerve compression, but cannot establish it. This is not a diagnosis of exclusion; the differential and associated diagnoses of upper extremity pain are always considered. Also discussed is conservative and surgical treatment options.

All-endoscopic Brachial Plexus Complete Neurolysis for Idiopathic Neurogenic Thoracic Outlet Syndrome: Surgical Technique

Neurogenic thoracic outlet syndrome is caused by a neurologic compression of the brachial plexus before it reaches the arm. Three anatomic areas are common locations for such an entrapment because of their congenital and/or acquired tightness: the interscalene triangle, the costoclavicular space, and the retropectoralis minor space. Because the compression level usually remains unknown, the treatment is still controversial and most teams focus on only one potential site. We propose an all-endoscopic technique of complete brachial plexus neurolysis that can be divided into three parts, one for each entrapment area. First, with a subacromial approach, the suprascapular nerve is released distally from the transverse ligament and then followed up to the upper trunk. Once the upper trunk is located, the middle and lower trunks are dissected in the interscalene triangle. Then, by use of an infraclavicular approach, the brachial plexus is released from the costoclavicular space by detaching the subclavian muscle from the clavicle. Finally, the pectoralis minor is released from the coracoid so that the brachial plexus is distally freed. This technique seems to be safe and reproducible, but expert knowledge of the neurovascular anatomy and advanced endoscopic skills are required.

Osteopathic treatment in a patient with left-ventricular assist device with left brachialgia: a case report

This study deals with an osteopathic approach used for a patient with left-ventricular assist device (L-VAD) affected by left brachialgia. Clinical examination revealed the presence of thoracic outlet syndrome and pectoralis minor syndrome, with compression of the left proximal ulnar nerve, related to the surgical sternotomy performed. The osteopathic techniques used can be classified as indirect and direct, addressed to the pectoralis minor and the first left rib, respectively. To our knowledge, this is the first text in literature with an osteopathic treatment in a patient with L-VAD.