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Issa TZ, Lin JS, Herrera F, Mailey B. Trends in the Surgical Management of Thoracic Outlet Syndrome. Hand (N Y) 2024; 19:367-373. [PMID: 36544244 PMCID: PMC11067839 DOI: 10.1177/15589447221141479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The operative treatment for thoracic outlet syndrome (TOS) varies in the United States. This may be due to differences in specialty training of the provider. We sought to identify which procedures are primarily performed by specialty, identify patient characteristics presenting for different neurogenic TOS surgical interventions, and describe the safety of TOS surgery. METHODS Patients treated for neurogenic TOS between 2016 and 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient characteristics, surgeon details, intraoperative variables, and complication outcomes were abstracted. Patient cohorts were stratified by type of operative intervention and by treating specialty. RESULTS Transthoracic first rib resection was the most common procedure performed for TOS relief (46.1%), followed by division of the scalene muscles with rib resection (23.9%) and brachial plexus exploration with decompression (19.4%). Vascular surgeons performed 87% of TOS repairs. Thirty-day complication rate was 3.5%. Addition of scalenectomy to first rib resection was common and resulted in increased operative time but did not increase early complication rate or readmission rate. CONCLUSION Patient characteristics and dispositions are similar between the various TOS operative approaches. All major surgical treatments for TOS have low complication rates. Transthoracic first rib resection performed by vascular surgeons remains the most common surgical treatment for patients with TOS in the United States. Despite neurogenic symptoms representing most cases, less than 10% of operations are performed by peripheral nerve specialists, highlighting a potential need for greater incorporation of TOS release into peripheral nerve practices.
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Tiongco RFP, Dellon AL. Histologic evidence of brachial plexus compression sites at the thoracic inlet and variations in formation of the lower trunk in cadavers. Microsurgery 2023; 43:588-596. [PMID: 37042225 DOI: 10.1002/micr.31037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/11/2023] [Accepted: 03/03/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND In thoracic "outlet" syndrome (TOS), pathologic evidence is well documented for vascular but not neurologic compression. We hypothesized that histologic evidence of compression would be identified at sites where the upper trunk was impacted by the anterior scalene muscle and the lower trunk by anatomic anomalies or the first rib. The purpose of this study was to investigate this hypothesis in human cadavers. MATERIALS AND METHODS Twenty-five cadavers' brachial plexuses were dissected and excised. Histologic and descriptive analysis was directed at juncture 1, the upper trunk and anterior scalene muscle, and juncture 2, C8 and T1 nerve roots (lower trunk) with the posterior border of the first rib. Measurements were obtained at the juncture of the T1 nerve root with the C8 nerve root in relationship to the first rib. RESULTS Histologic analysis demonstrated epineurial and perineurial fibrosis, myelin thinning, and Renaut bodies at junctures 1 and 2. Lower trunk formation occurred on or lateral to the first rib in 66% of specimens, with asymmetry in 32% of cadavers. A muscle of Albinus was present in 18% of cadavers. A large dorsal scapular artery coursed through 36% of plexuses with a high, arched subclavian artery. CONCLUSIONS We report histologic changes consistent with chronic compression of the upper and lower plexus in the thoracic inlet at hypothesized sites of brachial plexus compression that may correlate with clinical neck/shoulder (upper trunk) and "ulnar nervelike" (C8-T1/lower trunk) symptoms. Anatomic anomalies identified should alert the surgeon to variations of lower trunk formation at compression sites.
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Affiliation(s)
- Rafael Felix P Tiongco
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Lee Dellon
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Wagner ER, Gottschalk MB, Ahmed AS, Graf AR, Karzon AL. Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome. Tech Hand Up Extrem Surg 2023; 27:100-114. [PMID: 36515356 DOI: 10.1097/bth.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
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.
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Affiliation(s)
- Eric R Wagner
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA
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Diner C, Mathieu L, Vandendries C, Oberlin C, Belkheyar Z. Elective brachial plexus decompression in neurogenic thoracic outlet syndrome. HAND SURGERY & REHABILITATION 2023; 42:9-14. [PMID: 36574580 DOI: 10.1016/j.hansur.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 11/28/2022]
Abstract
We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- C Diner
- Department of Trauma, Orthopedic and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140 Clamart, France
| | - L Mathieu
- Department of Hand and Upper Extremity Surgery, Edouard Herriot Hospital, 5 Place d'Arsonval, 69003 Lyon, France; Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75005 Paris, France.
| | - C Vandendries
- RMX Center, 80 Avenue Felix Faure, 75015 Paris, France
| | - C Oberlin
- Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 Rue de la Folie Regnault, 75011 Paris, France
| | - Z Belkheyar
- Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 Rue de la Folie Regnault, 75011 Paris, France
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Jammeh ML, Ohman JW, Vemuri C, Abuirqeba AA, Thompson RW. Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes. Hand (N Y) 2022; 17:1055-1064. [PMID: 33504210 PMCID: PMC9608271 DOI: 10.1177/1558944720988079] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The clinical outcomes of reoperations for recurrent neurogenic thoracic outlet syndrome (NTOS) remain undefined. METHODS From 2009 to 2019, 90 patients with recurrent NTOS underwent anatomically complete supraclavicular reoperation after previous operation(s) performed at other institutions using either supraclavicular (Prev-SC = 48), transaxillary (Prev-TA = 31), or multiple/combination (Prev-MC = 11) approaches. Prospectively maintained data were analyzed retrospectively. RESULTS The mean patient age was 39.9 ± 1.4 years, 72% were female, and the mean interval after previous operation was 4.1 ± 0.6 years. The mean Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 62 ± 2, reflecting substantial preoperative disability. Residual scalene muscle was present in 100% Prev-TA, 79% Prev-SC, and 55% Prev-MC (P < .05). Retained/residual first rib was present in 90% Prev-TA, 75% Prev-SC, and 55% Prev-MC (P < .05). There were no differences in operative time (overall 210 ± 5 minutes), length of hospital stay (4.7 ± 0.2 days), or 30-day readmissions (7%). During follow-up of 5.6 ± 0.3 years, the improvement in QuickDASH scores was 21 ± 2 (36% ± 3%) (P < .01) and patient-rated outcomes were excellent in 10%, good in 36%, fair in 43%, and poor in 11%. CONCLUSIONS Anatomically complete decompression for recurrent NTOS can be safely and effectively accomplished by supraclavicular reoperation, regardless of the type of previous operation. Residual scalene muscle and retained/residual first rib are more frequently encountered after transaxillary operations than after supraclavicular or multiple/combined operations. Supraclavicular reoperation can achieve significant symptom reduction and functional improvement for approximately 90% of patients with recurrent NTOS.
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Yuen HLA, Tan E, Tran H, Chunilal SD. Idiopathic upper extremity deep vein thrombosis: A systematic review. Eur J Haematol Suppl 2022; 109:542-558. [PMID: 36053912 PMCID: PMC9804174 DOI: 10.1111/ejh.13842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Idiopathic upper extremity deep vein thrombosis (UEDVT) management is controversial and ranges from anticoagulation alone to the addition of further interventions such as thrombolysis and decompressive surgery. OBJECTIVES The objective of this systematic review was to assess the effects of anticoagulation alone compared to anticoagulation with additional interventions such as thrombolysis or decompressive surgery on the incidence of recurrent UEDVT and post-thrombotic syndrome (PTS) in patients with idiopathic UEDVT (including those associated with the oral contraceptive pill). PATIENTS/METHODS A systematic search was conducted for studies which focused on acute UEDVT treatment defined as therapies starting within 4 weeks of symptom onset. We limited studies to those that recruited 10 or more subjects and involved at least 6 weeks to 12 months anticoagulation alone or together with additional interventions with at least 6-month follow-up. Primary outcomes were symptomatic recurrent radiologically confirmed UEDVT and PTS. Secondary outcomes were symptomatic venous thromboembolism, bleeding and mortality. RESULTS We found seven studies which reported recurrent UEDVT rates and five that reported PTS rates. All studies were retrospective or cross-sectional. None compared anticoagulation alone to anticoagulation with additional intervention. Study heterogeneity precluded meta-analysis and risk of bias was moderate to serious. Recurrent UEDVT occurred in 0% to 12% post-anticoagulation alone and 0% to 23% post-additional interventions. PTS rates varied from 4% to 32% without severe PTS. Only limited studies reported on our secondary outcomes. CONCLUSION There is limited evidence behind idiopathic UEDVT management. Prospective comparative studies in this area are essential.
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Affiliation(s)
- Hiu Lam Agnes Yuen
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia,Monash UniversityMelbourneVictoriaAustralia
| | - Ee Tan
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Huyen Tran
- Monash UniversityMelbourneVictoriaAustralia
| | - Sanjeev Daya Chunilal
- Monash HaematologyMonash HealthMelbourneVictoriaAustralia,Monash UniversityMelbourneVictoriaAustralia
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Factors Associated with 30-Day Adverse Events After Brachial Plexus Neurolysis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:332-336. [DOI: 10.1016/j.jhsg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
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Review of Malpractice Litigation in the Diagnosis and Treatment of Venous & Lymphatic Disease. Ann Vasc Surg 2022; 88:274-282. [PMID: 35926792 DOI: 10.1016/j.avsg.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Malpractice claims involving nonthrombotic venous and lymphatic diseases and interventions have not been previously reported. We investigated common reasons for litigation, medical specialties involved, patient injuries, and case outcomes in malpractice litigation involving venous and lymphatic disease. METHODS Litigation cases entered into the Westlaw database from June 8th, 1984 to February 15th, 2018 were analyzed. Search terms included relevant words and phrases related to nonthrombotic venous, thoracic outlet syndrome and lymphatic disease and treatment. Data on physician specialty, malpractice claims, patient injuries jury outcomes, amount awarded to the plaintiff, and jury fees were collected and compared for each category. RESULTS A total of 144 cases were identified. 41 cases involved varicose veins, 11 spider veins, 35 thoracic outlet syndrome (TOS), 17 other venous diseases, and 40 lymphatic disease. Physician defendants were frequently vascular surgeons (23%) and general surgeons (15%). The majority of litigation claims involved "post-procedure complication" (77%), "lack of informed consent" (25%), "failure to diagnose & treat" (15%), and "intraoperative complications" (13%). The most common injuries were skin damage (27.8%), nerve damage (25%), and lymphedema (24%). Patient death occurred in 6% of cases. Out of venous malpractice cases with post-procedure complications, stab phlebectomy (27%) was the most common intervention followed by foam sclerotherapy (21%), rib resection (21%), laser spider vein removal (5%), and EVLT (3%). Of varicose vein cases, 15% included deep vein thrombosis or pulmonary embolism as post-procedure complications. In TOS rib resections, 65% of cases referenced nerve damage and 12% involved arterial injury. For lymphatic disease cases, general surgeons were frequently identified defendants (25%). Lymphedema (93%) and lymphangitis (7%) occurred as post-procedure complications after breast, gynecologic, orthopedic, and radiation procedures. A majority of complications occurred after breast cases (40%). Verdicts overall ruled in favor of the defendant in 71% (102/144) of cases and the plaintiff in 20% (29/144) of cases. Out of cases ruled in favor of the plaintiff, 31% were lymphatics, 24% varicose veins, and 24% TOS cases. Only 8% (12/144) of cases were settled and one outcome was unknown. The mean award was $820,193 (SD $1,226,008, Range $12,853 - $6,500,000). CONCLUSIONS The majority of venous and lymphatic litigation cases involve claims of post-procedure complications. Venous complications occurred after open and endovascular treatment of varicose veins, spider vein treatment, and surgical management of TOS. Lymphedema occurred after breast, oncology, and orthopedic procedures. These cases reflect opportunities for intervention to help potentially prevent litigation.
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9
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Convergent Validity of Thoracic Outlet Syndrome Index (TOSI). PHYSICAL ACTIVITY AND HEALTH 2022. [DOI: 10.5334/paah.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Efficacy of Supraclavicular Scalenotomy Followed by External Neurolysis without Rib Resection for Post-traumatic Neurogenic Thoracic Outlet Syndrome. Spine (Phila Pa 1976) 2021; 46:E632-E638. [PMID: 33306611 DOI: 10.1097/brs.0000000000003859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Most patients with neurogenic thoracic outlet syndrome (NTOS) have a history of trauma. Scar tissue formation within the scalene muscle and around the nerves after injury cause arm and hand symptoms. We report that supraclavicular scalenotomy followed by external neurolysis without rib resection is very effective as the surgical treatment.
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11
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Yuen HLA, Tran H, Chunilal S. Upper Extremity Deep Vein Thrombosis: Current Knowledge and Future Directions. Semin Thromb Hemost 2021; 47:677-691. [PMID: 33971684 DOI: 10.1055/s-0041-1725116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Upper extremity deep vein thrombosis (UEDVT) has been increasing in incidence due to the escalating use of central venous catheters such as peripherally inserted central catheters. UEDVT can be primary idiopathic or secondary to pacemaker leads, intravascular catheters or cancer. In comparison to conventional venous thromboembolism such as lower limb deep vein thrombosis or pulmonary embolism the risk factors, investigations, and management are not well defined. We review current evidence in primary and secondary UEDVT, highlighting areas in need of further research. We also explore the entity of venous thoracic outlet syndrome, which is said to be a risk factor for recurrent primary UEDVT and is the rationale behind surgical interventions.
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Affiliation(s)
- Hiu Lam Agnes Yuen
- Monash Haematology, Monash Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - Huyen Tran
- Department of Medicine, Monash University, Melbourne, Australia
| | - Sanjeev Chunilal
- Monash Haematology, Monash Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
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Pesser N, Goeteyn J, van der Sanden L, Houterman S, van Alfen N, van Sambeek MRHM, van Nuenen BFL, Teijink JAW. Feasibility and Outcomes of a Multidisciplinary Care Pathway for Neurogenic Thoracic Outlet Syndrome: A Prospective Observational Cohort Study. Eur J Vasc Endovasc Surg 2021; 61:1017-1024. [PMID: 33810976 DOI: 10.1016/j.ejvs.2021.02.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/14/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The North American Society for Vascular Surgery (SVS) reporting standards for neurogenic thoracic outlet syndrome (NTOS) were published in 2016 to produce consistency in the diagnosis and treatment of NTOS, but outcomes resulting from following these standards are not yet available. The results of a standardised multidisciplinary care pathway for NTOS based on the North American SVS reporting standards for NTOS are reported. METHODS Patients referred between August 2016 and December 2019 with suspected NTOS were evaluated in this single center prospective cohort study. Diagnosis and treatment were performed according to a care pathway based on the North American SVS reporting standards. The outcome of surgically treated patients was determined by the Derkash score, thoracic outlet syndrome disability scale (TDS), Cervical Brachial Score Questionnaire (CBSQ), Disability of the Arm Shoulder and Hands Dutch language version (DASH-DLV) and Short Form-12 (SF-12) at three, six, 12, and 24 months. RESULTS Of 856 referred patients, 476 (55.6%) patients were diagnosed with NTOS. Dedicated physiotherapy was successful in 186 patients (39.1%). Surgical treatment was performed in 290 (60.9%) patients of whom 274 were included in the follow up. At a mean follow up of 16.9 ± 9.2 months, significant improvement (p < .001) in TDS, CBSQ, DASH-DLV, and SF-12 scores was seen in the surgical group between baseline and all follow up intervals. Derkash outcome after surgical intervention was excellent in 83 (30.3%), good in 114 (41.6%), fair in 43 (15.7%), and poor in 34 (12.4%) of the patients. Complications occurred in 16 (5.8%) patients, and 32 (10.4%) patients experienced recurrent or persistent NTOS complaints. CONCLUSION A multidisciplinary care pathway based on the North American SVS reporting standards for NTOS helped to confirm the diagnosis in 56% of patients referred, and guided the selection of patients who might benefit from thoracic outlet decompression surgery after unsuccessful dedicated physiotherapy. Intermediate follow up showed good outcomes in the majority of surgically treated patients.
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Affiliation(s)
- Niels Pesser
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands
| | - Jens Goeteyn
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands
| | | | - Saskia Houterman
- Department of Education and Research, Catharina Hospital, the Netherlands
| | - Nens van Alfen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, the Netherlands
| | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; Department of Biomedical Technology, University of Technology Eindhoven, Eindhoven, the Netherlands
| | | | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands.
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Neurogenic Thoracic Outlet Syndrome with Supraclavicular Release: Long-Term Outcome without Rib Resection. Diagnostics (Basel) 2021; 11:diagnostics11030450. [PMID: 33807803 PMCID: PMC8002001 DOI: 10.3390/diagnostics11030450] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
Our aim was to define clinical long-term outcome of surgery for neurogenic thoracic outlet syndrome without rib resection, and to find factors predicting long-term results. For the 94 patients, the main outcomes were pain, numbness, weakness, and upper-extremity function. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a numerical rating system served as functional outcome measures. Mean follow-up was 12.9 years. Preoperative pain diminished from 7.8 to 2.2, numbness from 7.4 to 4.0, and weakness from 7.3 to 3.8. Grip strength increased from 25.7 to 31.8 kg. QuickDASH averaged at follow-up 37.1 and CBSQ 51.5. No correlation appeared between smoking and long-term results regarding pain, numbness, weakness, or functioning. Positive TOS provocative tests or intraoperative anatomical findings like consistency of the scaleni muscles showed no correlation with outcome. 82% of female and 57% of male patients reported that aid from this surgery had been excellent or good; 69% reported that surgery helped considerably for at least a mean 9.9 years. The risk for worse self-reported long-term outcome was higher among men, but neither BMI nor age at surgery associated with self-reported outcome. Pain, numbness, and weakness significantly decreased and function improved after supraclavicular release without rib resection. We found no significant preoperative nor per-operative factors predicting long-term results.
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George EL, Arya S, Rothenberg KA, Hernandez-Boussard T, Ho VT, Stern JR, Gelabert HA, Lee JT. Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States. Ann Vasc Surg 2021; 72:147-158. [PMID: 33340669 DOI: 10.1016/j.avsg.2020.10.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 09/29/2020] [Accepted: 10/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial, given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher versus lower volume centers. METHODS The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm (arterial [aTOS]), subclavian deep vein thrombosis (venous [vTOS]), or brachial plexus lesions (neurogenic [nTOS]). Basic descriptive statistics, nonparametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher and lower volume hospitals, respectively. RESULTS There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010 and 2015 (89.2% nTOS, 9.9% vTOS, and 0.9% aTOS) with annual case volume increasing significantly over time (P = 0.03). Higher volume centers (≥10 cases per year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma, or lymphatic leak) rates (adjusted odds ratio [OR] 0.71 [95% confidence interval 0.52-0.98]; P = 0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 [0.20-2.43]; P = 0.56) or vascular injuries/graft complications (aOR 0.71 [0.0.33-1.54]; P = 0.39). Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (P = 0.03). However, vTOS and aTOS had >2.5 times the odds of major complication compared with nTOS (OR 2.68 [1.88-3.82] and aOR 4.26 [1.78-10.17]; P < 0.001), and ∼10 times the odds of a vascular complication (aOR 10.37 [5.33-20.19] and aOR 12.93 [3.54-47.37]; P < 0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (P < 0.001). Total hospital charges were on average higher when surgery was performed in lower volume centers (<10 cases per year) compared with higher volume centers (mean $65,634 [standard deviation 98,796] vs. $45,850 [59,285]; P < 0.001). CONCLUSIONS The annual number of TOS operations has increased in the United States from 2010 to 2015, whereas complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher volume centers delivered higher value care: less or similar operative morbidity with lower total hospital charges.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Shipra Arya
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland, CA
| | | | - Vy-Thuy Ho
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Hugh A Gelabert
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jason T Lee
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Hawks C, Herrera-Nicol S, Pruzansky ME, Jenkins AL. Minimally Invasive Resection of Symptomatic Cervical Rib for Treatment of Thoracic Outlet Syndrome. World Neurosurg 2020; 139:219-222. [PMID: 32194276 DOI: 10.1016/j.wneu.2020.03.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/06/2020] [Accepted: 03/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurogenic thoracic outlet syndrome treatments have high morbidity and recurrence rates. We present for the first time to our knowledge a minimally invasive spine surgery technique for complete resection of a cervical rib via a costotransversectomy approach. CASE DESCRIPTION A patient with an 8-year history of progressive thoracic outlet syndrome presented with right C8 pain, weakness, and atrophy of her right forearm and thenar eminence. After neurogenic thoracic outlet syndrome was confirmed via electromyography and imaging revealed bilateral cervical ribs (right more than left), the patient underwent a minimally invasive spine surgery resection of the rib via a costotransversectomy and was discharged home the same day. The patient's pain and weakness gradually improved over a 2-year follow-up period. CONCLUSIONS Resection of a cervical rib via minimally invasive spine surgery costotransversectomy is safe and well tolerated compared with existing surgical treatments such as transaxillary, supraclavicular, and infraclavicular approaches.
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Affiliation(s)
| | - Sarah Herrera-Nicol
- Jenkins NeuroSpine, New York, New York, USA; Department of Neurosurgery, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Mark E Pruzansky
- HandSport Surgery Institute, New York, New York, USA; Department of Orthopedics, The Mount Sinai Hospital, New York, New York, USA
| | - Arthur L Jenkins
- Jenkins NeuroSpine, New York, New York, USA; Department of Orthopedics, The Mount Sinai Hospital, New York, New York, USA; Department of Neurosurgery, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York, USA.
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