Thoracic outlet syndrome

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.

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.

Thoracic Outlet Syndrome Part II: Consensus on the Management of Neurogenic Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery

BACKGROUND

In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons.

OBJECTIVE

To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community.

METHODS

The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method.

RESULTS

Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%.

CONCLUSION

Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center.

Elasticity of the Scalene Muscles in Collegiate Baseball Pitchers Using Shear Wave Elastography

Background:

Thoracic outlet syndrome is more common in overhead athletes. The anterior and middle scalene muscles have been associated with thoracic outlet syndrome; however, the relationship between the elastic moduli of the scalene muscles and the overhead-throwing position has not been evaluated.

Purpose:

To investigate the elastic moduli of the anterior and middle scalene muscles in simulated throwing positions using shear wave elastography.

Study Design:

Descriptive laboratory study.

Methods:

We enrolled collegiate baseball players who underwent preseason medical checkups in January and February 2020. The anterior and middle scalene muscles were visualized in the short-axis view using ultrasound. In this view, the elastic moduli of the anterior and middle scalene muscles were measured using shear wave elastography in the following arm and neck positions: (1) adduction and neutral rotation of the shoulder (neutral), (2) 90° of abduction and external rotation of the shoulder (ABER), and (3) ABER with neck rotation toward the nonthrowing side (ABER+NR). Repeated-measures analysis of variance and a paired t test were used to compare the elastic modulus values among the 3 positions and between the 2 muscles, respectively.

Results:

Overall, 30 baseball players were included. In both scalene muscles, the elastic moduli were significantly greater in the ABER versus neutral position (anterior scalene: 14.4 ± 3.8 vs 9.4 ± 2.0 kPa, respectively [P < .001]; middle scalene: 15.8 ± 5.0 vs 10.9 ± 3.4 kPa, respectively [P < .001]). In the neutral position, the elastic modulus was significantly greater in the middle scalene than the anterior scalene (10.9 ± 3.4 vs 9.4 ± 2.0 kPa, respectively; P = .03). In the ABER+NR position, the elastic modulus was significantly greater in the anterior scalene than the middle scalene (18.1 ± 4.6 vs 15.8 ± 2.6 kPa, respectively; P = .03).

Conclusion:

Because the ABER position was a simulation of the throwing position, these results indicate that this position could be associated with high elastic moduli of the scalene muscles, and both the anterior and middle scalene muscles may be involved.

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.

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.

Cerebral Embolic Stroke and Arm Ischemia in a Teenager With Arterial Thoracic Outlet Syndrome: A Case Report

A rare presentation of arterial thoracic outlet syndrome (TOS) is described in a young woman. Arterial TOS caused by a cervical rib produced acute upper extremity ischemia due to subclavian artery aneurysm formation. Clinical presentation also included left hemiparesis caused by right subclavian artery thrombosis and retrograde embolization of thrombus via the common carotid artery to the right middle cerebral artery distribution. Surgical repair of the subclavian artery was performed, but permanent neurologic deficit remained. Acute thrombosis of the right subclavian artery can produce cerebrovascular complication. The assessment of such risk in patients with arterial TOS is warranted and the arterial lesion corrected surgically.

Thirty-Day Outcomes Following Surgical Decompression of Thoracic Outlet Syndrome

BACKGROUND

Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013.

RESULTS

There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays ( P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9).

CONCLUSIONS

Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.

Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations

Thoracic outlet syndrome (TOS) describes a group of disorders that are due to a dynamic compression of blood vessels or nerves, between the clavicle and first rib or cervical vertebral nerve roots. Individuals with TOS typically experience upper limb pain, numbness, tingling, or weakness that is exacerbated by shoulder or neck movement. The causes of TOS vary, and can include abrupt movements, hypertrophy of the neck musculature, and anatomical variations in which the brachial plexus roots pass through this musculature, edema, pregnancy, repeated overhead motions, the blockage of an artery or vein, or abnormal posture. To understand the complexity of this condition, an analysis of shoulder anatomy and mechanics are needed to help describe limitations and the subsequent pathophysiology of TOS. Several treatment options are available, including surgery, medications, and exercise. A comprehensive study of shoulder anatomy and biomechanics, and knowledge of the benefits of exercise, may help clinicians and healthcare practitioners determine the most appropriate treatment plan for an individual with TOS.

A case of large deep fibrolipoma in the left subclavicular region that compromised the branchial plexus and thoracic duct: A case report

INTRODUCTION

A fibrolipoma of the left subclavicular region, a neoplasm rarely encountered in this region, was compromising the branchial plexus and thoracic duct, causing thoracic outlet syndrome in a symptomatic patient.

CASE PRESENTATION

A 41-year-old Asian woman was brought to our ENT (ear-nose-throat) clinic because of slowly progressive swelling of the left subclavicular region since 10 years before, which became painful with time, associated with increasing subpectoral and shoulder pains, left arm swelling, and left forearm paresthesias.

DISCUSSION

The exact etiology of fibrolipomas remains disputed, and endocrine, dysmetabolic, genetic, and traumatic factors have been often considered. A fibrolipoma characteristically grows by simple expansion in a well-encapsulated fashion without the tissue infiltration that is more characteristic of liposarcomas.

CONCLUSION

The purpose of this case report is to highlight an unusually large tumor of this type in a dangerous area that caused thoracic outlet syndrome-like symptoms.

Secondary Chondrosarcoma Presenting with Symptoms Similar to Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is caused by heterogeneous factors that compress the brachial plexus and subclavian artery; tumor is rarely a cause of TOS. Here, we present the case of a 26-year-old man with secondary chondrosarcoma arising from osteochondroma of the left clavicle causing TOS, with a direct compression of the brachial plexus and subclavian artery. Immediately after surgery, the symptoms of TOS reduced. To our knowledge, this is the first case of a secondary chondrosarcoma of the clavicle causing TOS, which is possibly the key symptom for diagnosing malignant transformation of osteochondroma of the clavicle.

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.

Arterial Thoracic Outlet Syndrome Treated Successfully with Totally Endoscopic First Rib Resection

Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. TOS may be classified as either neurogenic TOS (NTOS) or vascular TOS: venous TOS (VTOS) or arterial TOS (ATOS), depending on the specific structure being affected. The basis for the surgical treatment of TOS is resection of the first rib, and it may be combined with scalenectomy or cervical rib resection. Herein, we describe a case of arterial thoracic outlet syndrome which was successfully treated with totally endoscopic video-assisted thoracoscopic surgery (VATS) first rib resection.

Venous Thoracic Outlet Syndrome as a Cause of Intractable Migraines

Thoracic outlet syndrome (TOS) refers to the compression of the neurovascular bundle within the thoracic outlet. Cases are classified by primary etiology-arterial, neurogenic, or venous. In addition to the typical symptoms of arm swelling and paresthesias, headaches have been reported as a potential symptom of TOS. In this report, we describe a patient with debilitating migraines, which were consistently preceded by unilateral arm swelling. Resolution of symptoms occurred only after thoracic outlet decompression. Patients with migraines and concomitant swelling and/or paresthesias, especially related to provocative arm maneuvers, should be considered a possible atypical presentation of TOS and evaluated in more detail.

Infraclavicular subpectoral lipoma causing thoracic outlet syndrome

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Thoracic outlet syndrome (TOS) is caused by compression of neurovascular structures.

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Diagnosis of TOS is a difficult challenge and its treatment is controversial.

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TOS has been reported as caused by several diseases but never by a subpectoral mass.

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We report a case of TOS caused by a subpectoral infraclavicular multilobar lipoma.

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The surgical outcome was uneventful and the patient symptom-free at 6 month follow up.

Introduction

Thoracic outlet syndrome (TOS) includes a group of disorders caused by extrinsic compression of neurovascular structures between the 1st rib and clavicle. It usually presents as an enlarging neck mass, with shoulder or upper limb pain, weakness, paresthesias and impalpable radial pulse (Raynaud’s phenomenon).

Presentation of case

We report a rare case of TOS caused by an infraclavicular subpectoral lipoma that, although challenging because of limited access and proximity of vital neurovascular structures, was successfully removed through a simple transaxillary incision with an excellent esthetic result. The patients is symptom-free 6 months after surgery.

Discussion

Multiplicity of symptoms makes causes, diagnosis, and treatment of TOS controversial. Accurate diagnosis of TOS can be a substantial challenge in practice, because of a lack of physician awareness, overlapping of clinical features, and an absence of clearly defined diagnostic criteria. TOS may be associated with the presence of a benign subpectoral mass like lipomas, that seldom have an irregular distribution that involve neurovascular structures.

Conclusion

Although benign soft tissue tumors infraclavicular subpectoral lipomas may exert pressure on neurovascular surrounding structures during their progressive expansion and cause TOS. Therefore, a thorough preoperative study by radiological imaging such as MRI or neurophysiological test should always be performed in order to prevent unintentional lesions of the involved axillo-subclavicular plexus and plan correct surgical procedure.

Thoracic outlet syndrome in 3T MR neurography-fibrous bands causing discernible lesions of the lower brachial plexus

OBJECTIVES

To investigate whether targeted magnetic resonance neurography (MRN) of the brachial plexus can visualise fibrous bands compressing the brachial plexus and directly detect injury in plexus nerve fascicles.

METHODS

High-resolution MRN was employed in 30 patients with clinical suspicion of either true neurogenic thoracic outlet syndrome (TOS) or non-specific TOS. The protocol for the brachial plexus included a SPACE (3D turbo spin echo with variable flip angle) STIR (short tau inversion recovery), a sagittal-oblique T2-weighted (T2W) SPAIR (spectral adiabatic inversion recovery) and a 3D PDW (proton density weighted) SPACE. Images were evaluated for anatomical anomalies compressing the brachial plexus and for abnormal T2W signal within plexus elements. Patients with abnormal MR imaging findings underwent surgical exploration.

RESULTS

Seven out of 30 patients were identified with unambiguous morphological correlates of TOS. These were verified by surgical exploration. Correlates included fibrous bands (n = 5) and pseudarthrosis or synostosis of ribs (n = 2). Increased T2W signal was detected within compressed plexus portion (C8 spinal nerve, inferior trunk, or medial cord) and confirmed the diagnosis.

CONCLUSIONS

The clinical suspicion of TOS can be diagnostically confirmed by MRN. Entrapment of plexus structures by subtle anatomical anomalies such as fibrous bands can be visualised and relevant compression can be confirmed by increased T2W signal of compromised plexus elements.

KEY POINTS

• MR neurography (MRN) can aid the diagnosis of thoracic outlet syndrome (TOS). • Identifiable causes of TOS in MRN include fibrous bands and bony anomalies. • Increased T2W signal within brachial plexus elements indicate relevant nerve compression. • High positive predictive value allows confident and targeted indication for surgery.

NTOS symptoms and mobility: a case study on neurogenic thoracic outlet syndrome involving massage therapy

Neurogenic thoracic outlet syndrome (NTOS) is a neuromuscular condition affecting brachial plexus functionality. NTOS is characterized by paresthesia, pain, muscle fatigue, and restricted mobility in the upper extremity. This study quantified massage therapy's possible contribution to treatment of NTOS. A 24-year-old female with NTOS received eight treatments over 35 days. Treatment included myofascial release, trigger point therapy, cross fiber friction, muscle stripping, and gentle passive stretching. Abduction and lateral rotation at the glenohumeral (GH joint) assessments measured range of motion (ROM). A resisted muscle test evaluated upper extremity strength. The client rated symptoms daily via a visual analog scale (VAS). Findings showed improvement in ROM at the GH joint. VAS ratings revealed a reduction in muscle weakness, pain, numbness, and 'paresthesia'. Results suggest massage may be useful as part of a broad approach to managing NTOS symptoms and improving mobility.

Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome

OBJECTIVE

This study evaluated the early effectiveness of isolated pectoralis minor tenotomy (PMT) in the surgical treatment of selected patients with neurogenic thoracic outlet syndrome (NTOS) compared with supraclavicular decompression (SCD; as scalenectomy, neurolysis, and first rib resection) plus PMT (SCD+PMT).

METHODS

Data were obtained for 200 patients undergoing operative treatment for disabling NTOS between 2008 and 2011. Isolated PMT was offered to 57 patients with physical examination findings limited to the subcoracoid space, and SCD+PMT was offered to 143 with scalene triangle and subcoracoid findings. Functional outcomes were assessed before and 3 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) survey and related instruments.

RESULTS

There were no significant differences (P > .05) between PMT and SCD+PMT patients with respect to age (overall, 37 ± 1 years), sex (73% women), side affected (52% right, 14% bilateral), or the frequency of various NTOS symptoms, but fewer PMT patients had a bony anomaly (0% vs 18%; P < .01) or a history of injury (35% vs 61%; P < .01). Mean preoperative DASH scores were similar between PMT and SCD+PMT groups (49.9 ± 3.6 vs 50.8 ± 1.6), but previous use of opiate pain medications was higher in PMT patients (47% vs 20%; P = .0004). PMT was conducted as an outpatient procedure, whereas the mean hospital stay after SCD+PMT was 4.8 ± 0.1 days, with two patients (1%) requiring early reoperations for persistent lymph leaks. Mean DASH scores 3 months after surgery were significantly improved after isolated PMT (29.6 ± 4.2; P < .01) and SCD+PMT (41.5 ± 2.2; P < .01), but the mean extent of improvement in DASH scores was not significantly different in PMT (32% ± 9%) vs SCD+PMT (19% ± 5%). There were also no significant differences in the proportion of PMT vs SCD+PMT patients demonstrating improvement in functional outcome measures (75% vs 72%) or in overall use of opiate medications (35% vs 27%).

CONCLUSIONS

Isolated PMT is a low-risk outpatient procedure that is effective for the treatment of selected patients with disabling NTOS, with early outcomes similar to SCD+PMT. These findings emphasize the importance of recognizing subcoracoid brachial plexus compression as part of the spectrum of NTOS and support the role of PMT in surgical management.

A 12-year-old girl with absent radial pulse: arterial thoracic outlet syndrome with subclavian artery aneurysm and thrombosis of the brachial artery

Brachial arterial occlusion is rare in children and adolescents. Once a traumatic cause is excluded, the differential diagnosis consists of a variety of rare conditions. We report the case of a 12-year-old girl whose presenting symptoms--an absent radial pulse and Raynaud's phenomenon of the right hand--could be easily mistaken for a vasculitis. She was found to have arterial thoracic outlet syndrome with right subclavian artery compression and aneurysm formation caused by an anomalous first rib and consecutive thromboembolic occlusion of the brachial artery. The diagnosis and differential diagnosis of this condition are reviewed.

Síndrome do desfiladeiro torácico - ressecção de costela cervical por videotoracoscopia

A base do tratamento cirúrgico da Síndrome do Desfiladeiro Torácico (SDT) é a ressecção da primeira costela, podendo associar-se à escalenectomia ou ainda à ressecção de costela cervical. Esta última é feita tradicionalmente por meio de um acesso supraclavicular ou mesmo axilar, o qual é tecnicamente mais trabalhoso. Pode ser realizada também por meio de acesso paraescapular. Embora tecnicamente atrativa e associada à menor invasividade e maior segurança, com ótimo resultado estético, a ressecção da primeira costela torácica, por intermédio de cirurgia videoassistida transaxilar ou pela técnica videotoracoscópica, é pouco relatada na literatura, e nenhuma referência foi encontrada sobre ressecção de costela cervical mediante essa técnica. Neste artigo, apresentamos essa inovação cirúrgica realizada com sucesso para ressecção de costela cervical em duas pacientes.

Thoracic outlet syndrome

Of the many clinical entities involving the neck region, one of the most intriguing is thoracic outlet syndrome (TOS). TOS is an array of disorders that involves injury to the neurovascular structures in the cervicobrachial region. A classification system based on etiology, symptoms, clinical presentation, and anatomy is supported by most physicians. The first type of TOS is vascular, involving compression of either the subclavian artery or vein. The second type is true neurogenic TOS, which involves injury to the brachial plexus. Finally, the third and most controversial type is referred to as disputed neurogenic TOS. This article aims to provide the reader some understanding of the pathophysiology, workup, and treatment of this fascinating clinical entity.

Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management

BACKGROUND

Proper management of thoracic outlet syndrome (TOS) requires an understanding of the underlying causes of the disorder. A comprehensive examination process, as described in Part 1 of this review, can reveal the bony and soft tissue abnormalities and mechanical dysfunctions contributing to an individual's TOS symptoms.

OBJECTIVE

Part 2 of this review focuses on management of TOS.

CONCLUSION

The clinician uses clinical examination results to design a rehabilitation program that focuses on correcting specific problems that were previously identified. Disputed neurogenic TOS is best managed with a trial of conservative therapy before surgical treatment options are considered. Cases that are resistant to conservative treatment may require surgical intervention. True neurogenic TOS may require surgical intervention to relieve compression of the neural structures in the thoracic outlet. Surgical management is required for cases of vascular TOS because of the potentially serious complications that may arise from venous or arterial compromise. Post-operative rehabilitation is recommended after surgical decompression to address factors that could lead to a reoccurrence of the patient's symptoms.

Thoracic outlet syndrome part 2: conservative management of thoracic outlet

Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement. Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques. The rehabilitation outlined in this paper also serves as a model for the management of any shoulder condition where scapula dysfunction is a major contributing factor.

Neurogenic thoracic outlet syndrome: A case report and review of the literature

Neurogenic thoracic outlet syndrome (NTOS) is an oft-overlooked and obscure cause of shoulder pain, which regularly presents to the office of shoulder surgeons and pain specialist. With this paper we present an otherwise healthy young female patient with typical NTOS. She first received repeated conservative treatments with 60 units of botulinium toxin injected into the anterior scalene muscle at three-month intervals, which providing excellent results of symptom-free periods. Later a trans-axillary first rib resection provided semi-permanent relief. The patient was followed for 10 years after which time the symptoms reappeared. We review the literature and elaborate on the anatomy, sonoanatomy, etiology and characteristics, symptoms, diagnostic criteria and treatment modalities of NTOS. Patients with NTOS often get operated upon - even if just a diagnostic arthroscopy, and an interscalene or other brachial plexus block may be performed. This might put the patient in jeopardy of permanent nerve injury, and the purpose of this review is to minimize or prevent this.

Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome

OBJECTIVE

To examine pain relief in patients with neurogenic thoracic outlet syndrome (NTOS) after a single, low dose injection of botulinum toxin A (Botox) into the anterior scalene muscle (ASM) under computed tomographic (CT) guidance.

DESIGN

Prospective longitudinal study.

SETTING

Academic medical institution.

PATIENTS

Patients 18 years of age and older were evaluated for potential scalenectomy and first rib resection using the transaxillary approach at the study institution between 2005 and 2008. All patients had failed physical therapy. A total of 29 procedures on 27 participants were studied.

INTERVENTIONS

A single, 20-unit injection of Botox into the ASM under CT-guidance.

OUTCOME MEASURES

Short-form McGill Pain Questionnaire (SF-MPQ) prior to and at 1, 2, and 3 months post-Botox toxin injection.

RESULTS

There was a decline in pain during the 3 months subsequent to Botox injection as noted by the following components of the SF-MPQ: sensory (P = 0.02), total (P = 0.05), visual analog scale (VAS [P = 0.04]), and present pain intensity (PPI) score (P = 0.06). The proportion of patients reporting more intense pain scores did not return to the pre-intervention level at 3 months post-Botox injection.

CONCLUSION

Patients experienced substantial pain relief in months 1 and 2 following a single Botox injection into the ASM under CT guidance. Significant pain reduction was noted for 3 months after Botox injection with respect to both sensory and VAS scores, and the total and PPI scores approximated statistical significance. After 3 months, patients experienced a 29% decrease in the sensory component of their pain as well as an approximate 15% reduction in their VAS score. A single, CT-guided Botox injection into the ASM may offer an effective, minimally invasive treatment for NTOS.

Effect of upper extremity nerve damage on activity participation, pain, depression, and quality of life

PURPOSE

To explore the relationship between upper extremity nerve damage and activity participation, pain, depression, and perceived quality of life.

METHODS

A total of 49 patients with upper extremity nerve damage completed standardized measures of activity participation, pain, depression, and quality of life. We analyzed scores for all subjects and for 2 diagnostic groups: patients with compressive neuropathy and patients with nerve injury (laceration, tumor, and brachial plexus injury), and explored predictors of overall quality of life.

RESULTS

Participants had given up 21% of their previous daily activities; greater activity loss was reported in patients with nerve injury. Pain was moderate and 39% had signs of clinical depression. Physical and psychological quality of life ratings were below the norms. Activity loss was strongly associated with higher levels of depression and lower physical and psychological quality of life. Higher depression scores correlated strongly with lower overall quality of life. Greater pain correlated moderately with higher depression scores and weakly with quality of life; no statistical relationship was found between pain and physical quality of life. Activity participation and depression predicted 61% of the variance in overall quality of life in patients with nerve damage.

CONCLUSIONS

The results of this study suggest that hand surgeons and therapists caring for patients with nerve compression and nerve injury should discuss strategies to improve activity participation, and decrease pain and depression, to improve overall effect on quality of life throughout the recovery process. Depression screening and referral when indicated should be included in the overall treatment plan for patients with upper extremity nerve damage.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Thoracic outlet syndrome: an overview

Thoracic outlet syndrome is a non-specific label that encompasses the various presentations resulting from compression of neurovascular structures at the thoracic outlet. This overview focuses on its underlying aetiology and management.

Histopathological basis for neurogenic thoracic outlet syndrome. Laboratory investigation

OBJECT

To the best of the authors' knowledge, no report exists that has demonstrated the histopathological changes of neural elements within the brachial plexus as a result of cervical rib compression.

METHODS

Four hundred seventy-five consecutive human cadavers were evaluated for the presence of cervical ribs. From this cohort, 2 male specimens (0.42%) were identified that harbored cervical ribs. One of the cadavers was found to have bilateral cervical ribs and the other a single right cervical rib. Following gross observations of the brachial plexus and, specifically, the lower trunk and its relationship to these anomalous ribs, the lower trunks were submitted for immunohistochemical analysis. Specimens were compared with two age-matched controls that did not have cervical ribs.

RESULTS

The compressed plexus trunks were largely unremarkable proximal to the areas of compression by cervical ribs, where they demonstrated epi- and perineurial fibrosis, vascular hyalinization, mucinous degeneration, and frequent intraneural collagenous nodules. These histological findings were not seen in the nerve specimens in control cadavers. The epineurium was thickened with intersecting fibrous bands, and the perineurium appeared fibrotic. Many of the blood vessels were hyalinized. The nerve fascicles contained frequent intraneural collagenous nodules in this area, and focal mucinous degeneration was identified.

CONCLUSIONS

Cervical ribs found incidentally may cause histological changes in the lower trunk of the brachial plexus. The clinician may wish to observe or perform further evaluation in such patients.

A rare cause of thoracic outlet syndrome

First rib pathology can narrow the thoracic outlet thus producing compression of the brachial plexus and subclavian vessels. There have been only three case reports of neurogenic thoracic outlet syndrome (TOS) caused by a nonunion of the first rib and there have been no reports of a first rib malunion causing TOS. A rare case of TOS caused by a malunion of the first rib is presented.

The Relationship Between Magnetic Resonance Imaging Findings and Postural Maneuver and Physical Examination Tests in Patients With Thoracic Outlet Syndrome: Results of a Double-Blind, Controlled Study

OBJECTIVES

To investigate the differences in findings from magnetic resonance imaging (MRI) in the neutral and provocative positions, and to examine the relationship between these differences and the results of physical examination tests in patients with thoracic outlet syndrome (TOS).

DESIGN

Prospective.

SETTING

University physical medicine and rehabilitation outpatient and radiology clinics.

PARTICIPANTS

Twenty-nine patients and 12 healthy controls. All of the patients had positive bilateral TOS stress tests; control group participants were symptom free and had negative TOS stress tests bilaterally.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

All participants underwent Adson's test, the Halsted maneuver, and a hyperabduction test. All were evaluated with MRI while in 2 positions: the neutral position (upper extremities adducted) and in a provocative position. Measurements were obtained at the interscalene triangle, at the costoclavicular space, and at the retropectoralis minor space.

RESULTS

There was a significant difference in MRI findings between the neutral and provocative position in the patients (P<.05), but there were no significant differences in the control group. There was a significant difference in the positional change values in MRI between the patients and the control subjects (P<.05). The difference was found in the minimum costoclavicular distance between patients with a positive Halsted maneuver and a negative Halsted maneuver (P<.05).

CONCLUSIONS

Our findings indicate that MRI findings in patients in a provocative position are more valuable in the diagnosis of TOS, and these findings are in accord with findings from the physical evaluation tests.

Life-threatening acute and chronic thromboembolic pulmonary hypertension and subclavian vein thrombosis

Severe thromboembolic pulmonary hypertension is an infrequent but potentially fatal complication of effort thrombosis (Paget-Schroetter syndrome) of the upper extremity. It has been sporadically reported in the literature, but in most cases has affected young, otherwise healthy athletes. Because this syndrome has been rarely described, it is likely underdiagnosed, and optimal evaluation and treatment has not been established. We describe three young athletic persons who developed thrombosis of the subclavian vein after repetitive motion of the upper extremity, and in whom life-threatening pulmonary hypertension resulted from acute and chronic pulmonary emboli. We then review the mechanism, clinical presentation, diagnosis, and available therapeutic modalities.

The axillary arch: anatomy and suggested clinical manifestations

The purpose of this commentary is to describe bilateral anomalous bands of the latissimus dorsi muscle observed in an 81-year-old male embalmed cadaver, and to discuss the possible clinical implications of this anomaly. The musculotendinous bands tautened and compressed the underlying axillary vessels, and the musculocutaneous, median, and ulnar nerves during passive abduction/external rotation of the shoulder. Similar variations found in the latissimus dorsi muscles in this commentary have been reported in the anatomical and surgical literature. These reports include descriptions of the anomalous bands of the latissimus dorsi attaching to the coracoid process, pectoralis major muscle, and fascia of the coracobrachialis muscle. The potential presence of an axillary arch presents several clinical considerations for the physical therapist. The existence of an axillary arch should be considered in patients with signs and symptoms consistent with upper extremity neurovascular compromise similar to thoracic outlet syndrome. Including this variant in the differential diagnostic process may assist physical therapists in the management of patients with signs and symptoms consistent with thoracic outlet syndrome.

Treatment of nonaortic aneurysms in the endograft era: aneurysms of the innominate and subclavian arteries

Although open aneurysm repair remains the standard of care, the advent of endoluminal techniques and stent grafts has significant potential to improve treatment of aneurysms of the innominate and subclavian arteries. Regardless of the modality chosen, therapy must be individualized and treatments tailored on the basis of anatomic and etiologic considerations. Occasionally, definitive treatment of an aneurysm with endoluminal stent-graft placement is possible for focal aneurysms or pseudoaneurysms of the innominate or subclavian arteries. In other situations, endoluminal grafting may be combined with open repair to allow for the benefits of both techniques. Ultimately long-term follow-up data are necessary to determine whether the durability of the endoluminal approach warrants more widespread use.

Thoracic outlet syndrome

OBJECTIVE

Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. We provide a review of this difficult-to-treat disorder, including a brief overview, clinical presentations, surgical anatomy, treatment options, and outcomes.

METHODS

TOS represents a spectrum of disorders encompassing three related syndromes: compression of the brachial plexus (neurogenic TOS), compression of the subclavian artery or vein (vascular TOS), and the nonspecific or disputed type of TOS. Neurovascular compression may be observed most commonly in the interscalene triangle, but it also has been described in the costoclavicular space and in the subcoracoid space. Patients present with symptoms and signs of arterial insufficiency, venous obstruction, painless wasting of intrinsic hand muscles, paresthesia, and pain. A careful and detailed medical history and physical examination are the most important diagnostic tools for proper identification of TOS. Electromyography, nerve conduction studies, and imaging of the cervical spine and the chest also can provide helpful information regarding diagnosis. Clinical management usually starts with conservative treatment including exercise programs and physical therapy; when these therapies fail, patients are considered for surgery. Two of the most commonly used surgical approaches are the supraclavicular exposure and the transaxillary approach with first rib resection. On occasion, these approaches may be combined or, alternatively, posterior subscapular exposure may be used in selected patients.

CONCLUSION

TOS is perhaps the most difficult entrapment neuropathy encountered by neurosurgeons. Surgical intervention is indicated for vascular and true neurogenic TOS and for some patients with the common or nonspecific type of TOS in whom nonoperative therapies fail. With careful patient selection, operative intervention usually yields satisfactory results.

Shoulder posture and median nerve sliding

BACKGROUND

Patients with upper limb pain often have a slumped sitting position and poor shoulder posture. Pain could be due to poor posture causing mechanical changes (stretch; local pressure) that in turn affect the function of major limb nerves (e.g. median nerve). This study examines (1) whether the individual components of slumped sitting (forward head position, trunk flexion and shoulder protraction) cause median nerve stretch and (2) whether shoulder protraction restricts normal nerve movements.

METHODS

Longitudinal nerve movement was measured using frame-by-frame cross-correlation analysis from high frequency ultrasound images during individual components of slumped sitting. The effects of protraction on nerve movement through the shoulder region were investigated by examining nerve movement in the arm in response to contralateral neck side flexion.

RESULTS

Neither moving the head forward or trunk flexion caused significant movement of the median nerve. In contrast, 4.3 mm of movement, adding 0.7% strain, occurred in the forearm during shoulder protraction. A delay in movement at the start of protraction and straightening of the nerve trunk provided evidence of unloading with the shoulder flexed and elbow extended and the scapulothoracic joint in neutral. There was a 60% reduction in nerve movement in the arm during contralateral neck side flexion when the shoulder was protracted compared to scapulothoracic neutral.

CONCLUSION

Slumped sitting is unlikely to increase nerve strain sufficient to cause changes to nerve function. However, shoulder protraction may place the median nerve at risk of injury, since nerve movement is reduced through the shoulder region when the shoulder is protracted and other joints are moved. Both altered nerve dynamics in response to moving other joints and local changes to blood supply may adversely affect nerve function and increase the risk of developing upper quadrant pain.

Epineurectomy for thoracic outlet syndrome

The authors' approach to patients with TOS starts with a thorough evaluation, including a detailed history, physical examination, electromyography, and radiographs. Once the work-up is complete a treatment plan is formulated with the patient. All diagnoses are prioritized, together with various options for treatment of each. Therapy is initiated when appropriate and a surgical plan addresses the worst nerve entrapments sequentially. The authors' favored procedure for TOS release is an anterior scalenectomy with epineurectomy, with decompression of any structures impinging on the brachial plexus. The authors encourage patients to attend therapy for approximately 3 months after surgery, and to follow a home program of rehabilitation to maximize their gains and decrease the chance of recurrence.

Compressive neuropathies of the upper extremity

Although any peripheral nerve may be compressed anywhere along its course, nerve compression syndromes typically occur at predictable sites with predictable clinical presentations. A detailed history and physical examination can establish a diagnosis, and electrodiagnostic studies and at times imaging can confirm it. Physicians should adopt a systematic approach of diagnosing and treating these types of nerve lesions. The physician and the patient can be rewarded with favorable outcomes.