Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis

Factors correlating with positive electrodiagnostic findings for neurogenic thoracic outlet syndrome

INTRODUCTION

Diagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report the EDX findings in a cohort of patients who underwent surgery for nTOS and also analyze patient-related and intraoperative factors associated with positive EDX findings supportive of nTOS diagnosis.

METHODS

Baseline characteristics of patients, including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement, were gathered and analyzed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison.

RESULTS

A total of 30 consecutive patients were included in this study comprising 11 (36.7%) men and 19 (63.3%) women, with a mean age of 44.6 ± 17.6 years. Twenty-two (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and 1 (3.3%) patient with type 2 nTOS. In terms of nTOS pattern, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P < 0.05) were significantly associated with positive EDX findings.

CONCLUSIONS

Currently, EDX assessment may not be the best modality for diagnosis of nTOS. Interindividual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX.

Upper Vascular Thoracic Outlet Syndrome: A Case Study

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

Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome

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

Trends in the Surgical Management of Thoracic Outlet Syndrome

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.

Anterior Scalene Muscle Block Response Predicts Outcomes Following Thoracic Outlet Decompression

BACKGROUND

There is no definitive objective measure for diagnosis of thoracic outlet syndrome (TOS), and functional capacity testing on standardized rehabilitation exercises before and after an anterior scalene muscle block (ASMB) has the potential to serve as a predictor of response to surgery and to improve diagnostic accuracy in these cases.

METHODS

Patients evaluated for TOS underwent ASMB as a diagnostic test and were retrospectively reviewed. Functional capacity scores were recorded for patients performing repetitive motion exercises immediately before ASMB, 15 minutes after ASMB, and at a minimum of 6 weeks after thoracic outlet decompression (TOD). The primary outcome of interest was correlation between the pre- to post-ASMB difference and the pre-ASMB to postoperative difference with respect to 3 functional work capacity scores.

RESULTS

The average change in time-to-fatigue and work product between pre- and post-ASMB of all exercises was an increase of 39.5% and 53.8%, respectively. The greatest pre-ASMB to post-TOD difference was seen for the Extremity Abduction Stress Test with an average improvement of 109.7% and 150.4% for time-to-fatigue and work product, respectively. The degree of percent improvement post-ASMB correlated positively with the degree of percent improvement post-TOD for all exercises with respect to work product and time-to-fatigue.

CONCLUSIONS

Patient response to ASMB as measured by functional capacity on rehabilitation exercises predicted objective functional outcomes following TOD. Post-ASMB outcomes correlated with post-TOD outcomes. The ASMB can be used to assist in diagnosing TOS and provide a surrogate for expectation in patients considering undergoing neurogenic TOD.

Surgical Management of Neurogenic Thoracic Outlet Syndrome: Exploring the Efficacy of the Posterior Intermuscular Approach in Cases Involving Bone Anomalies

BACKGROUND AND OBJECTIVES

This article presents a cohort study focusing on neurogenic thoracic outlet syndrome (NTOS) caused by bone anomalies in the cervicothoracic region, specifically the extraforaminal area and the scalene triangle. Our aim was to contribute to understanding NTOS diagnosis and management, particularly in patients with bone anomalies, and to highlight the potential benefits of the posterior intermuscular approach as a surgical option in this particular patient group.

METHODS

We retrospectively evaluated the patients who underwent surgery for NTOS with accessory ribs or an elongated cervical vertebrae 7 (C7) transverse process (n = 9). Patients' clinical data, preoperative neurophysiological tests, cervical computed tomography (CT) scans, CT angiography, and postoperative cervical CT scans were reviewed. A single experienced surgeon used the posterior intermuscular approach on all patients. The accessory rib and/or elongated C7 transverse process and fibrous bands were removed; C7, C8, and T1 branches of the plexus were decompressed; and neurolysis was performed. Quality of life, a functional outcome, was measured by using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and pain was measured using visual analog scale scores.

RESULTS

The mean follow-up time after surgery was 7 months (range: 4-10 months). Before surgery, the mean DASH score was 55.8 ± 5.6. At the 3- and 6-month postoperative evaluations, the mean DASH scores decreased to 15.7 ± 5.8 and 15.4 ± 5.7, respectively. The mean visual analog scale score was 8.2/10 before surgery and decreased to 2.4/10 and 2.1/10 at the 3- and 6-month postoperative evaluations, respectively. All patients experienced good or excellent recovery at the 3- and 6-month postoperative evaluations.

CONCLUSION

Cervicothoracic extraforaminal area may be the primary site of nerve compression in NTOS, and posterior decompression using the posterior intermuscular approach can provide efficient access to extraforaminal nerve roots.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

Evaluation of the socioprofessional consequences of thoracic outlet syndrome

PURPOSE

Thoracic outlet syndrome (TOS) is a ductal syndrome that can have a significant functional impact. Various studies have highlighted positional factors and repetitive movements as risk factors for the development of TOS. However, there are few literature data on the socioprofessional consequences of TOS.

METHODS

We performed a prospective, cross-sectional, descriptive, multicentre study of workers having received a Doppler ultrasound diagnosis of TOS between December 17th, 2018, and March 16th, 2021. Immediately after their diagnosis, patients completed a self-questionnaire on the impact of TOS on their work activities. We assessed the frequency of TOS-related difficulties at work and the associated socioprofessional consequences. Trial Registration Number (TRN) is NCT03780647 and date of registration December 18, 2018.

RESULTS

Eighty-two participants (95.3%) reported difficulties at work. Seventy-seven of the participants with difficulties (94%) worked in the tertiary sector; these difficulties were due to prolonged maintenance of a posture, carrying loads, and repetitive movements. Although the majority of participants experienced organizational problems and lacked support at work, few of them had approached support organizations, expert and/or healthcare professionals.

CONCLUSIONS

TOS was almost always associated with difficulties at work (95.3%). However, poor awareness of sources of help or a perceived lack of need may discourage people with TOS from taking steps to resolve these difficulties. It is clear that the socioprofessional management of TOS requires significant improvements.

Considerations for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome: A Meta-Analysis of Patient-Reported Outcomes

PURPOSE

It remains unclear whether the first rib resection, performed via a supraclavicular (SCFRR) or transaxillary (TAFRR) approach, is necessary for patients with neurogenic thoracic outlet syndrome (nTOS). In a systematic review and meta-analysis, we performed a direct comparison of patient-reported functional outcomes following different surgical approaches for nTOS.

METHODS

The authors searched PubMed, Embase, Web of Science, Cochrane Library, PROSPERO, Google Scholar, and the gray literature. Data were extracted based on the procedure type. Well-validated patient-reported outcome measures were analyzed in separate time intervals. Random-effects meta-analysis and descriptive statistics were used where appropriate.

RESULTS

Twenty-two articles were included, with 11 discussing SCFRR (812 patients), 6 discussing TAFRR (478 patients), and 5 discussing rib-sparing scalenectomy (RSS; 720 patients). The mean difference between preoperative and postoperative Disabilities of the Arm, Shoulder and Hand score was significantly different comparing RSS (43.0), TAFRR (26.8), and SCFRR (21.8). The mean difference between preoperative and postoperative visual analog scale scores was significantly higher for TAFRR (5.3) compared to SCFRR (3.0). Derkash scores were significantly worse for TAFRR compared to RSS or SCFRR. RSS had a success rate of 97.4% based on Derkash score, followed by SCFRR and TAFRR at 93.2% and 87.9%, respectively. RSS had a lower complication rate compared to SCFRR and TAFRR. There was a difference in complication rates: 8.7%, 14.5%, and 3.6% for SCFRR, TAFRR, and RSS, respectively.

CONCLUSIONS

Mean differences in Disabilities of the Arm, Shoulder and Hand scores and Derkash scores were significantly better for RSS. Higher complication rates were reported after the first rib resection. Our findings suggest that RSS is an effective option for the treatment of nTOS.

TYPE OF STUDY/ LEVEL OF EVIDENCE

Therapeutic IV.

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.

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

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

Methods

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

Results

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

Conclusions

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

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.

Boney abnormalities cause arterial, venous, and/or neurogenic thoracic outlet syndrome

Background

Thoracic outlet syndrome (TOS) is a rare condition caused by compression of the neurovascular structures within the thoracic outlet. Different classifications of TOS exist depending on the neurovascular structure being compressed: neurogenic, venous, or arterial. Any of these forms can present independently or coexist with one other. TOS symptoms are sometimes precipitated by the presence of boney abnormalities that often require surgical intervention for ultimate resolution. This retrospective review will examine the presentations and outcomes of patients with TOS whose cause was a boney abnormality.

Methods

A total of 73 patients who underwent thoracic outlet surgery between 2016 and 2021 were retrospectively reviewed via electronic medical records. Twelve (16%) patients demonstrated boney abnormalities on presentation causing their symptoms. The patients with boney abnormalities were analyzed based on venous, arterial, or neurogenic TOS diagnosis.

Results

Of the 12 patients with boney abnormalities, 5 were classified as venous TOS, 6 patients as neurogenic TOS, and 1 as arterial TOS. The boney abnormalities were as follows: venous TOS: three clavicular fractures, one nonfused congenital clavicle, and one residual rib; neurogenic TOS: three fractured first ribs, one fractured clavicle, and two cervical ribs; and arterial TOS: fused first and second rib with bilateral cervical ribs and arterial compression. Postoperatively, there were no artery, vein, or nerve injuries. Five patients had a pneumothorax treated over night with a chest tube, and one patient had a superficial wound infection. The median hospital stay was 1 day. All patients completed physical therapy after surgery. All patients have symptom resolution at follow-up.

Conclusions

Patients with boney abnormalities constitute about one-fifth of patients who can present with all three forms of TOS: neurogenic, arterial, and venous, and some will have more than one of these presentations. Results in patients undergoing surgery with boney abnormalities causing thoracic outlet syndrome are excellent with symptom resolution and without substantial complications.

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

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

Relationships between the Clinical Test Results and Neurophysiological Findings in Patients with Thoracic Outlet Syndrome

A thoracic outlet syndrome (TOS) is the type of brachial plexus disorder most difficult to objectively assess using a clinical examination and differential diagnosis. Its symptoms can be frequently misdiagnosed, especially among others with cervical disc-root conflicts, plexopathies, and peripheral neuropathies. In this study, we aim to identify the correlations between positive Doppler ultrasonography results indicating pathological changes in the subclavian flow velocity, clinical tests, and chosen clinical neurophysiology recordings as proposed alternative or supplementary diagnostic tools for evaluating TOS patients. Sixty TOS patients with positive Doppler ultrasonography and Roos test results and sixty healthy people as a control group were bilaterally examined, and the results were compared. Pain intensity was assessed using a visual analogue scale (VAS). Sensory perceptions within C4–C8 dermatomes were assessed with Von Frey filament (FvF) tests. The activity of motor units in the proximal and distal muscles of the upper extremities was evaluated using surface electromyography (sEMG) during maximal contractions before and after a provocative raised hands test (RHT). An electroneurography (ENG) was used to evaluate the transmission of nerve impulses peripherally. Motor evoked potential (MEP) recordings, induced by the over-vertebral magnetic stimulation of the C5–C7 neuromeres, were used to examine motor transmissions from the cervical motor centres to the upper extremities muscles. The results revealed a relationship between positive Doppler test scores and pathological changes in the subclavian flow velocity through the results of the following diagnostic tools: a VAS score of 1.9 was detected on average, superficial sensory perception abnormalities were found in the innervation areas of the ulnar nerves detected by FvF tests, a decrease in the amplitudes of sEMG recordings was seen in distal rather than proximal muscles (especially following the RHT), a decrease in the motor and sensory peripheral transmissions of nerve impulses in the median, ulnar and cutaneous anterobrachial median nerves was seen, as well as MEP amplitudes recorded from the abductor pollicis brevis muscle. The provocative RHT combined with sEMG and MEP recordings can be considered accurate and objective clinical neurophysiology tools that could supplement the commonly used clinical tests. Such an approach may result in a more precise neurogenic TOS diagnostic algorithm.

Hydrodissection for the Treatment of Vascular Thoracic Outlet Syndrome

The following case explores the effectiveness of a new treatment modality for vascular thoracic outlet syndrome (vTOS). Few conservative treatments exist to alleviate symptoms of vTOS. In this case, a 25-year-old male was diagnosed with vTOS four months prior to presentation. A combination of poor posture, inactivity, and protruding screws from a prior clavicle fracture repair were compromising the subclavicular vasculature. Symptoms of claudication and a cold right arm/hand led the patient to seek medical treatment. Post failed physiotherapy and pharmacotherapy, the vascular surgeon advised for surgery. He was hesitant to undergo major surgical intervention; therefore, after exploring possible remedies, hydrodissection was chosen for its potential merit in this case. After hydrodissection was performed to decompress the subclavicular neurovascular bundle, the patient reported immediate alleviation of his symptoms. Post two-week and three-month follow-up, there was complete resolution of symptoms with no recurrence. Although there is a lack of literature supporting the use of hydrodissection to treat vTOS, this was a specific case in which hydrodissection demonstrated to be an effective treatment modality. The specific utilization of hydrodissection should be further studied to increase the literature base and increase awareness of its potential effectiveness for this and similar conditions.

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.

Utilizing Provocative Maneuvers Intraoperatively in Conjunction With IVUS to Diagnose vTOS: The New Gold Standard

Current methodologies of diagnosing and managing venous thoracic outlet syndrome (vTOS) remain controversial, as pertinent studies using modern advancements in medicine are limited. We present a case in which we innovatively used a modified Wright's test during venography coupled with intravascular ultrasound, which allowed us to definitively determine the etiology of a vTOS. (Level of Difficulty: Intermediate.).

Vascular thoracic outlet syndrome: Registry of 30-years of patient's outcomes at King Saud University Medical City, Riyadh, Saudi Arabia

OBJECTIVES

To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS).

METHODS

This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months).

RESULTS

A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases.

CONCLUSION

Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

Industrial exoskeletons for overhead work: Circumferential pressures on the upper arm caused by the physical human-machine-interface

This study investigated the pressures occurring within the arm human-machine-interfaces (HMI) of four different exoskeletons that support static and dynamic work at or above head level, and the effects of the HMI on neurovascular supply of the upper extremity using an orthopedic provocation maneuver with raised arms with and without the exoskeletons. Decreased time in the provocation maneuver with exoskeletons indicated a negative effect of the HMIs on the vascular and neural supply of the arm. Average pressure in the static situation was 3.2 ± 0.7 kPa and 4.4 ± 0.4 kPa with regular peak values of 6.5 ± 0.5 kPa in the dynamic task. These pressures were significantly higher than the pressure values that guarantee adequate tissue oxygenation. It remains unknown whether the way exoskeletons apply pressure affects vascular and neural supply to the arms, or whether the regular unloading during dynamic activity has a neutralizing effect.

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.

Intra and inter observer agreement in the mobility assessment of the upper thoracic costovertebral joints

BACKGROUND

Determining the mobility of the costovertebral joints might be important in patients with neck-upper thoracic pain. Little research has been performed on observer agreement when assessing the mobility of these joints.

PURPOSE

The purpose of this study was to determine intra- and inter-observer agreements when assessing costovertebral joint mobility of the upper three ribs in those with and without neck pain and to compare the difference between the Kappa and AC statistic.

METHODS

Forty-four participants, with and without current neck/upper-thoracic pain, were assessed by two raters. Raters applied a posterior to anterior pressure to the anatomical neck of the first three ribs bilaterally. Mobility was graded: normal, increased, or decreased. An AC1, for nominal data, AC2 for ordinal data, and the Kappa statistics were used to analyze the results. The AC statistics determines chance agreement different than Kappa.

RESULTS

AC1 showed "moderate to very good" (0.74-1.0) intra-rater reliability, while inter-rater reliability showed "fair to good" agreement (0.51-0.79). Using the AC2 Intra-rater reliability was "very good" and "almost perfect" (AC2: 0.93-1.0), while using the AC2 was "good to very good" and "good to almost perfect" (0.76-0.94). Kappa values for intra-rater reliability ranged from "fair to moderate" (0.38-0.54), while inter-rater reliability ranged from "poor to fair" (-0.10-0.26).

CONCLUSION

Posterior/anterior pressure is a reliable method to assess the mobility of the upper costovertebral joints. Assessing costovertebral mobility is important when establishing a movement diagnosis in patients with neck/upper thoracic pain.

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

Background

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

Methods

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

Results

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

Conclusions

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

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

BACKGROUND

There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To identify the most relevant clinical descriptors for diagnosing RCRSP.

METHODS

A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.

CONCLUSION

In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Evaluation and Management of Neurogenic Thoracic Outlet Syndrome with an Overview of Surgical Approaches: A Comprehensive Review

Neurogenic thoracic outlet syndrome (NTOS) represents a disorder believed to involve compression of one or more neurovascular elements as they exit the thoracic outlet. This comprehensive literature review will focus on the occurrence, classification, etiology, clinical presentation, diagnostic measures, and both nonoperative and operative therapies for NTOS. NTOS represents the most common subtype of thoracic outlet syndrome and can significantly impair quality of life. Botulinum toxin injection into the anterior scalene muscle, or even the middle scalene or pectoralis minor muscles, can reduce the symptoms of this syndrome. The best available evidence for botulinum toxin therapy to the cervicothoracic muscles supports the value of this treatment for reducing pain in the affected extremity, and for an approximate duration of 2 months or more. Surgical approaches and newer minimally invasive surgical approaches offer high rates of improvement in select centers.

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.

Measurement of interscalene space volume in diagnosis of thoracic outlet syndrome: a cadaver study

Background/aim

The aim of this study was to measure the volume of interscalene space in thoracic outlet region on cadavers and radiological images and to analyze the potential value of these measurements in diagnosis and treatment of thoracic outlet syndrome (TOS).

Materials and methods

The dimensions of the anterior interscalene space in 8 formalin-fixed human cadavers were studied by direct measurement and additionally evaluation of the volume of this space were done by using mold and volume calculation formula of square pyramid, due to resembling a pyramid. In the second phase of this study, interscalene space volume was calculated by formula and compared to calculations from computed tomography (CT) sections in 18 TOS and 16 control patients.

Results

There was a strong correlation between the volume calculated by formula (4.79 ± 2.18 cm3) and by mold (4.84 ± 1.58 cm3), (R = 0.934, p = 0.001) in cadavers. The average volume measured in TOS patients (2.05 ± 0.32 cm3) was significantly smaller than control patients (4.30 ± 1.85 cm3, p < 0.0001). There were excellent or good results in 14 patients whereas in 4 patients who had neurogenic TOS achieved fair results after surgery. In these 4 patients the average volumes of abnormal sides were close to the healthy sides.

Conclusion

In our study, volume of interscalene space in TOS patients was statistically smaller than control group. Also, the volume was even smaller in patients with excellent or good results after surgery. In this respect, volumetric measurements from CT sections could be used in diagnosis and treatment selection in TOS patients.

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

CASE

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

CONCLUSION

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

Clavicle Fractures With Associated Acute Neurovascular Injury

Descriptions of acute neurovascular injury after clavicle fracture are limited to case reports. The objectives of this study were to assess both the prevalence of acute neurovascular injury after midshaft clavicle fracture and the outcomes of early fracture stabilization. A retrospective chart review was conducted of all adult patients with midshaft clavicle fracture who were treated surgically at 2 tertiary care referral centers from January 2010 to March 2019. The records of patients who were identified as having clinical or radiographic evidence of neurovascular compromise were reviewed to assess for deficits on physical examination on presentation, relevant radiographic and electro-diagnostic findings, timing and type of fixation, and time until resolution of symptoms and radiographic union postoperatively. Of the 443 adult patients undergoing surgical treatment for displaced midshaft clavicle fracture, 3 (1%) experienced acute neurovascular compromise and underwent early fixation. In all cases, fracture displacement caused compression of adjacent neurovascular structures in the costoclavicular space. No lacerations of underlying neurovascular structures were encountered intraoperatively, suggesting a pattern of nerve contusion or vascular compression from the initial injury and fracture displacement. Postoperatively, 2 patients had full recovery of preoperative neurologic deficits and 1 patient experienced partial recovery of motor deficits with persistent neuropathic pain. There were no instances of symptomatic vascular insufficiency at final follow-up. Acute neurovascular injury as a result of compression of underlying structures in the costoclavicular space is a rare complication of displaced midshaft clavicle fracture. Early surgical decompression of compressed neurovascular structures and rigid clavicle osteosynthesis can lead to significant postoperative functional improvement. [Orthopedics. 2021;44(3):e390-e394.].

First rib dysfunction in patients with neck and shoulder pain: a Delphi investigation

BACKGROUND

First rib dysfunction is a possible cause of symptoms in patients with neck and/or shoulder pain.

OBJECTIVES

To explore therapists' perceptions of useful diagnostic criteria to identify first rib dysfunction.

METHODS

A Delphi survey over four rounds involving international manual therapy experts who were asked to agree on which items were most useful in identifying first rib dysfunction.

RESULTS

Consensus (>70% agreement) was reached on key aspects of first rib dysfunction being first rib mobility restriction, upper limb symptom distribution, and a subclassification into two subgroups was suggested. The main clinical findings suggested were: painful and restricted neck movements and shoulder girdle loading activities; positive Upper Limb Neural Test 1; direct palpation of first rib, neural structures, and scalene muscles; pain and hypomobility of first rib accessory movements with improvement after mobilization. The cervical rotation lateral-flexion test was considered a useful, although not widely used test among the experts. Its diagnostic accuracy and interpretation in isolation was questioned.

CONCLUSIONS

This Delphi study produced a cluster of clinical tests aimed to identify first rib dysfunction in patients with neck and/or shoulder conditions. However, these need to be tested out in further research to establish reliability and validity.

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

Objectives

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

Design

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

Setting

Department of the Vascular Studies, Royal Free Hospital.

Participants

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

Main outcome measures

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

Results

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

Conclusion

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

Nerve Compression Syndromes of the Shoulder

Nerve compression syndromes of the shoulder contribute to pain, paresthesia, and weakness of the upper extremity. This review examines the recent literature regarding thoracic outlet syndrome, suprascapular neuropathy, long thoracic nerve palsy, and quadrilateral space syndrome. Overlapping features are common among shoulder pathologies, and thus, key anatomical features, pathophysiology, clinical manifestations, diagnostic techniques, and treatments are highlighted for all aforementioned conditions.

Respiratory Dysfunction in Individuals With Thoracic Outlet Syndrome

OBJECTIVE

The purpose of this study was to compare pulmonary function and respiratory muscle strength and endurance in individuals with thoracic outlet syndrome (TOS) and healthy participants.

METHODS

Sixty-two individuals with TOS (mean age 30.81 ± 10.69 years; 10 male, 52 female) and 47 healthy individuals (mean age 30.64 ± 9.16 years; 14 male, 33 female) participated in this study. Pulmonary function testing was performed using a spirometer. Respiratory muscle strength (maximal inspiratory pressure [MIP] and maximal expiratory pressure [MEP]) were measured using a mouth pressure device. Respiratory muscle endurance was tested at 35% MIP and measured as the time in seconds from the start of the test to voluntary exhaustion.

RESULTS

Age distribution and physical characteristics were similar between the groups (P > .05). All pulmonary function parameters except for peak expiratory flow rate were similar in patients with TOS and healthy controls (P > .05). Patients with TOS had significantly lower peak expiratory flow rate, MIP, MIP%, MEP, MEP%, and respiratory muscle endurance compared with controls (P < .05). Forty-six patients with TOS (74.2%) had MIP values below the lower limit of the 95% CI of the control group (97.05-113.88 cmH₂O), and 53 patients with TOS (85.2%) had MEP values below the lower limit of the 95% CI of the control group (124.74-146.49 cmH₂O).

CONCLUSION

Expiratory flow rate and respiratory muscle strength and endurance may be adversely affected in TOS. Trunk muscles perform both postural and breathing functions. Therefore, disruption in one function may negatively affect the other.

Posterior cerebral artery stroke by reverse flow embolism in thoracic outlet syndrome - a case report

BACKGROUND

Arterial thoracic outlet syndrome is a rare condition characterized by a subclavian artery pathology associated with a bone abnormality. It is rarely associated with thromboembolic stroke. The mechanism of cerebral embolism associated with thoracic outlet syndrome have rarely been demonstrated. We present here a fully studied case with a high probability of reverse flow embolism.

CASE PRESENTATION

A 24-year-old man with a known arterial thoracic outlet syndrome presented with a right cerebral posterior artery brain infarction. An ultrasound examination depicted the compression of the right subclavian artery in the scalene defile with a post stenotic aneurysm and the presence of a floating thrombus in this aneurysm. There was a reverse flow during diastole in this aneurysm. Anticoagulation was carried out with the disappearance of the floating thrombus with no new clinical or brain MRI event. Corrective surgery of this thoracic outlet syndrome was performed one month after stroke.

CONCLUSION

Very few cases of stroke in arterial thoracic outlet syndrome have been described with thorough dynamic vascular imaging. To our knowledge, this is the fourth reported case that advocates for a reverse flow embolism mechanism in stroke associated with thoracic outlet syndrome, and the first to realize an extensive ultrasound and doppler workup.

Measurement of Outlet Pressures Favors Rib Resection for Decompression of Thoracic Outlet Syndrome

BACKGROUND

When conservative therapy for thoracic outlet syndrome fails, scalenectomy with or without first-rib resection (FRR) is the treatment of choice. We measured pressure in the costoclavicular space before and after FRR at time of neurogenic thoracic outlet syndrome release to evaluate whether FRR is required to completely decompress the costoclavicular space.

METHODS

Using a supraclavicular exposure for anterior-middle scalenectomy with FRR, costoclavicular space pressures were measured using a balloon catheter with the patient's arm in neutral anatomic position, secondarily, the arm abducted and externally rotated. Pressures were recorded in both arm positions before scalenectomy, after scalenectomy, and after FRR. Paired Student's t test was used to compare differences in group means for paired samples. Patient-reported outcomes were reported using the Derkash classification and quick disabilities of the arm, shoulder, and hand (qDASH) questionnaire.

RESULTS

Fifteen patients (16 cases) surgically treated for neurogenic thoracic outlet syndrome were included in this retrospective study. There was no significant difference in pressure change between arm positions before scalenectomy (161.56 ± 71.65 mm Hg difference) or after scalenectomy (148.5 ± 80.24 mm Hg difference). There was a significant difference in pressure change between post-scalenectomy and post-FRR arm positions; mean pressure change between arm positions after FRR was 50.56 ± 40.28 mm Hg. Mean postoperative qDASH score was 20 ± 23.2. All patients reported improvement in symptoms and functional status.

CONCLUSIONS

Supraclavicular first rib resection for management of neurogenic thoracic outlet syndrome can be safely performed with favorable outcomes. The pressure increase in the costoclavicular space caused by arm abduction and external rotation was significantly reduced only after FRR, raising concerns about potential incomplete costoclavicular space decompression with scalenectomy alone for neurogenic thoracic outlet syndrome management.

An overview of the findings of dynamic upper limbs’ arterial and venous duplex in cases of vascular thoracic outlet syndrome

Background

To describe the findings of the dynamic upper limb arterial and venous duplex in the assessment of vascular compression in cases of VTOS. This study was conducted on 58 patients with VTOS; they were evaluated by dynamic duplex examination.

Results

Vascular compression was subdivided into a venous compression that was detected in (84.4%,n = 49), arterial compression that was seen in (1.7%,n = 1), and combined arterial and venous compression that was present in (13.7%,n = 8); bilateral compression was existing in (94.4%,n = 55), compression at the scalene triangle was seen in (1.7%,n = 1), at the costo-clavicular space was seen in (91.3%,n = 53), and at the retro-pectoral space was depicted in (8.6%,n = 5).

Complicated arterial compression was detected in (1.7%,n = 1), whereas venous complications were seen in (6.8%,n = 4).

Conclusion

Dynamic duplex ultrasound offered a simple, noninvasive, and quick technique that can help in the evaluation of the vascular thoracic outlet syndrome without exposure to ionizing radiation or contrast media administration like that in CT; nevertheless, it is done with the patient in the upright position, thus avoiding the high false-negative results associated with the supine position that is used in the CT and MRI studies.

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

OBJECTIVE

To summarize the evidence on the accuracy of clinical tests to help confirm or refute a diagnosis of thoracic outlet syndrome (TOS).

METHODS

We searched 10 databases (January 1990 to February 2016) using relevant key words and medical subject headings terms. We considered diagnostic test accuracy studies comparing clinical tests for the diagnosis of TOS against a reference test. Cross-sectional, cohort, and case-control studies and randomized controlled trials were included. Risk of bias was appraised using QUADAS-2 and the Quality Appraisal of Reliability Studies checklist. We performed a qualitative synthesis of scientifically admissible studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used to report findings.

RESULTS

A total of 3932 articles were retrieved. After removal of duplicates, 1767 articles were screened for titles and abstract, leaving 494 articles for full-text review. Ten studies met the eligibility criteria and were assessed for risk of bias, 4 of which were included in the review. None of the included studies used the same index tests when comparing with a gold standard, and quality was poor. High clinical heterogeneity and the use of different comparators prevented from pooling results. Findings suggest that prescribing magnetic resonance imaging during provocative positioning to confirm a diagnosis of TOS may be useful. However, this is associated with a high false-positive rate of venous compression.

CONCLUSION

Little evidence currently supports the validity of clinical tests for the diagnosis of TOS. Future diagnostic accuracy studies should aim to use established methodological criteria and appropriate reporting guidelines to help validate clinical tests for diagnosing patients with TOS.

Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment

Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Practitioners must consider the pathology of thoracic outlet syndrome in their differential diagnosis for shoulder and upper extremity pain symptoms so that patients are directed appropriately to timely therapeutic interventions. Patients with a definitive etiology who have failed conservative management are ideal candidates for surgical correction. This manuscript will discuss thoracic outlet syndrome, occurrence, physical presentation, clinical implications, diagnosis, and management.

Thoracic outlet syndrome in a postoperative cervical spondylotic myelopathy patient: A case report

RATIONALE

Thoracic outlet syndrome (TOS) is a rare disease that presents with neurogenic and vascular symptoms similar to those of cervical spondylosis. However, making the diagnosis of TOS can be challenging due to a lack of standardized objective confirmatory tests.

PATIENT CONCERNS

A 66-year-old man presented with neck, supraclavicular, and right shoulder pain as well as numbness and weakness in the right arm after surgery to correct cervical spondylotic myelopathy (CSM).

DIAGNOSIS

Magnetic resonance imaging confirmed the diagnosis of CSM. He was diagnosed with TOS based on the manifestations and examination findings.

INTERVENTIONS

After surgery for CSM, nonoperative management was provided.

OUTCOMES

The patient reported pain relief and improving sensation in the shoulder and supraclavicular region.

LESSONS

Based on this case and the reviewed literature, to optimize the diagnosis and treatment of CSM, clinicians should consider preoperative differential diagnosis to preliminarily exclude it.

Concomitant neurogenic and vascular thoracic outlet syndrome due to multiple exostoses

We report a rare case of multiple hereditary exostosis where patient presented with bilateral base of neck exostoses with concurrent compression of brachial plexus and subclavian artery and vein. The patient was a young 26-year-old woman with chief complaints of pain in the left upper extremity, paresthesia in the left ring and little finger, and weakness in hand movement and grip. On referral, history, physical examination, radiological imaging, and electrodiagnostic tests evaluated the patient. Due to severe pain and disability in performing routine activities, surgical intervention was necessary. In the current case, the patient had thoracic outlet syndrome with concomitant venous, arterial, and neurogenic sub types. Radial pulse returned and pain associated with brachial plexus compression was resolved after the surgery.

Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions

The diagnosis of thoracic outlet syndrome (TOS) has long been a controversial and challenging one. Despite common presentations with pain in the neck and upper extremity, there are a host of presenting patterns that can vary within and between the subdivisions of neurogenic, venous, and arterial TOS. Furthermore, there is a plethora of differential diagnoses, from peripheral compressive neuropathies, to intrinsic shoulder pathologies, to pathologies at the cervical spine. Depending on the subdivision of TOS suspected, diagnostic investigations are currently of varying importance, necessitating high dependence on good history taking and clinical examination. Investigations may add weight to a diagnosis suspected on clinical grounds and suggest an optimal management strategy, but in this changing field new developments may alter the role that diagnostic investigations play. In this article, we set out to summarise the diagnostic approach in cases of suspected TOS, including the importance of history taking, clinical examination, and the role of investigations at present, and highlight the developments in this field with respect to all subtypes. In the future, we hope that novel diagnostics may be able to stratify patients according to the exact compressive mechanism and thereby suggest more specific treatments and interventions.

Paget-Schroetter syndrome: treatment of venous thrombosis and outcomes

Thoracic outlet syndrome (TOS) is a rare clinical entity with many etiologies. Venous thoracic outlet syndrome (VTOS), also called Paget-Schroetter syndrome (PSS), is a primary "effort" thrombosis. Here we will focus on the pathophysiology, anatomy, clinical presentation, treatments, and outcomes of VTOS. Treatment involves anticoagulation, catheter-directed thrombolysis, and surgical decompression. Early diagnosis and treatment can improve symptoms and quality of life.

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.

Experimental study of brachial plexus and vessel compression: evaluation of combined central and peripheral electrodiagnostic approach

Introduction

We sought to investigate the reliability of a new electrodiagnostic method for identifying Electrodiagnosis of Brachial Plexus & Vessel Compression Syndrome (BPVCS) in rats that involves the application of transcranial electrical stimulation motor evoked potentials (TES-MEPs) combined with peripheral nerve stimulation compound muscle action potentials (PNS-CMAPs).

Results

The latencies of the TES-MEP and PNS-CMAP were initially elongated in the 8-week group. The amplitudes of TES-MEP and PNS-CMAP were initially attenuated in the 16-week group. The isolateral amplitude ratio of the TES-MEP to the PNS-CMAP was apparently decreased, and spontaneous activities emerged at 16 weeks postoperatively.

Materials and Methods

Superior and inferior trunk models of BPVCS were created in 72 male Sprague Dawley (SD) rats that were divided into six experimental groups. The latencies, amplitudes and isolateral amplitude ratios of the TES-MEPs and PNS-CMAPs were recorded at different postoperative intervals.

Conclusions

Electrophysiological and histological examinations of the rats’ compressed brachial plexus nerves were utilized to establish preliminary electrodiagnostic criteria for BPVCS.

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation

Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior scalene. This results in possible impingement of BP nerves within the muscle belly and, therefore, predisposition for nTOS. We hypothesized that some cases of disputed nTOS result from these BP branching variants. We tested the association between BP piercing and nTOS symptoms, and evaluated the capability of ultrasonographic identification of patients with clinically relevant variations. Eighty-two cadaveric necks were first dissected to assess BP variation frequency. In 62.1%, C5, superior trunk, or superior + middle trunks pierced the anterior scalene. Subsequently, 22 student subjects underwent screening with detailed questionnaires, provocative tests, and BP ultrasonography. Twenty-one percent demonstrated atypical BP branching anatomy on ultrasound; of these, 50% reported symptoms consistent with nTOS, significantly higher than subjects with classic BP anatomy (14%). This group, categorized as a typical TOS, would be missed by provocative testing alone. The addition of ultrasonography to nTOS diagnosis, especially for patients with BP branching variation, would allow clinicians to visualize and identify atypical patient anatomy.