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Fouasson-Chailloux A, Merle M, Duysens C, Falcone A, Daley P, Pomares G, Jager T. Nerve entrapment complicating neurogenic thoracic outlet syndrome surgery: A 10-year retrospective study. HAND SURGERY & REHABILITATION 2024; 43:101660. [PMID: 38342235 DOI: 10.1016/j.hansur.2024.101660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
Neurogenic thoracic outlet syndrome results from compression of the brachial plexus. The symptoms are mainly pain, upper-limb weakness and paresthesia. Management always starts with a rehabilitation program, but failure of rehabilitation may necessitate surgery. In practice, we observed that several patients developed secondary distal nerve entrapment in the months following surgery, with no preoperative compression. We aimed to assess the occurrence of distal nerve entrapment after surgery for neurogenic thoracic outlet syndrome in a retrospective cohort study. Seventy-four patients were included; 82% females; mean age, 39.4 ± 9.4 years. There were 36.5% with high intensity and 63.5% with low to moderate intensity work. Eighteen (24.3%) developed secondary upper-limb entrapment at 10.6 ± 5.8 months after surgery. Sixteen had a single entrapment and 2 had two different entrapments. In 10 cases (50%) the ulnar nerve was involved at the elbow, in 7 (35.0%) the radial nerve at the radial tunnel, and in 3 (15.0%) the median nerve. No differences were found between patients with and without secondary nerve entrapment in gender (p = 0.51), mean age (p = 0.44), symptom duration (p = 0.92) or work intensity (p = 0.26). Further studies are needed to confirm these results and to shed light on the underlying mechanisms.
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Affiliation(s)
- Alban Fouasson-Chailloux
- Institut Européen de la Main, Luxembourg L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg; Service de MPR Locomotrice et Respiratoire, Nantes Université, CHU Nantes, Nantes 44093 France; Institut Régional de Médecine du Sport (IRMS), Hôpital St Jacques, Nantes 44093, France.
| | - Michel Merle
- Institut Européen de la Main, Luxembourg L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
| | - Christophe Duysens
- Institut Européen de la Main, Luxembourg L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
| | - Andréa Falcone
- Institut Européen de la Main, Luxembourg L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
| | - Pauline Daley
- Service de MPR Locomotrice et Respiratoire, Nantes Université, CHU Nantes, Nantes 44093 France; Institut Régional de Médecine du Sport (IRMS), Hôpital St Jacques, Nantes 44093, France
| | - Germain Pomares
- Institut Européen de la Main, Luxembourg L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
| | - Thomas Jager
- Institut Européen de la Main, Luxembourg L-2540, Luxembourg; Medical Training Center, Hôpital Kirchberg, Luxembourg L-2540, Luxembourg
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Fouasson-Chailloux A, Jager T, Daley P, Falcone A, Duysens C, Estoppey D, Merle M, Pomares G. Possible role of the botulinum toxin in the management of neurogenic thoracic outlet syndrome: a systematic review. Eur J Phys Rehabil Med 2023; 59:706-713. [PMID: 37737048 PMCID: PMC10797639 DOI: 10.23736/s1973-9087.23.07815-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/31/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Thoracic outlet syndrome (TOS) is related to the compression and/or the traction of the upper-limb neurovascular bundle, responsible for a chronic painful impairment. Neurogenic TOS (NTOS) is the most common manifestation. It remains a challenging diagnosis and its treatment is also difficult. Botulinum toxin (BTX) has been described to help both the diagnosis and the symptoms improvement. EVIDENCE ACQUISITION A systematic literature research was performed using PubMed, ScienceDirect, and Embase databases to collect studies reporting the use of BTX in NTOS management. We followed the PRISMA guidelines, and the included studies were evaluated using the GRADE approach. EVIDENCE SYNTHESIS We included 10 original articles representing 555 patients. Various outcomes were considered, and results varied from a study to another. Symptoms relief varied from an absence of BTX effectiveness to 84.1% of improvement; relief duration was also reported from none to 88 days. BTX injections were debatable predictors of surgical procedure successes due to low evidence. There was a huge gap between the studies concerning side-effects of the BTX procedures, from none to 100% of the patients. CONCLUSIONS There is no evidence for considering BTX injection as a validated tool for the management of NTOS. There might be a slight effect on symptoms, but outcomes are very variable, which prevents further interpretations. The use of BTX should be evaluated in larger prospective cohorts with more standardized outcomes.
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Affiliation(s)
- Alban Fouasson-Chailloux
- European Hand Institute, Luxembourg, Luxembourg -
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg -
- Service of Motor and Respiratory Physical and Rehabilitation Medicine, Nantes University, CHU Nantes, Nantes, France -
- Regional Institute of Sports Medicine (IRMS), St Jacques Hospital, Nantes, France -
| | - Thomas Jager
- European Hand Institute, Luxembourg, Luxembourg
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg
| | - Pauline Daley
- Service of Motor and Respiratory Physical and Rehabilitation Medicine, Nantes University, CHU Nantes, Nantes, France
- Regional Institute of Sports Medicine (IRMS), St Jacques Hospital, Nantes, France
| | - Andrea Falcone
- European Hand Institute, Luxembourg, Luxembourg
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg
| | - Christophe Duysens
- European Hand Institute, Luxembourg, Luxembourg
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg
| | - Daniel Estoppey
- European Hand Institute, Luxembourg, Luxembourg
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg
| | - Michel Merle
- European Hand Institute, Luxembourg, Luxembourg
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg
| | - Germain Pomares
- European Hand Institute, Luxembourg, Luxembourg
- Medical Training Center, Kirchberg Hospital, Luxembourg, Luxembourg
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Use of Electroneuromyography in the Diagnosis of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11175206. [PMID: 36079135 PMCID: PMC9457272 DOI: 10.3390/jcm11175206] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022] Open
Abstract
Neurogenic thoracic outlet syndrome (NTOS) is a disabling condition. Its diagnosis remains challenging and is mainly guided by examination. Yet, electrophysiological evaluations are the gold standard for diagnosis of entrapment syndromes. We aimed to assess the interest of electrophysiological evaluation to diagnose NTOS. A systematic literature research was performed using PubMed, ScienceDirect, Embase, Cochrane and Google Scholar databases to collect studies reporting results of electrophysiological assessment of patients with NTOS. Then, a meta-analysis was conducted. Nine studies were eligible and concerned two hundred and thirteen patients. Results were heterogenous among studies and the quality of evidence was very low to moderate. Data could not evaluate sensitivity or specificity of electrophysiological evaluations for NTOS. The meta-analysis found significantly decreased amplitudes of medial antebrachial cutaneous nerve SNAP (sensory nerve action potential), ulnar SNAP, median CMAP (compound motor action potential) and ulnar CMAP. Needle examination found abnormalities for the abductor pollicis brevis, first dorsal interosseous and adductor digiti minimi. Unlike most upper-limb entrapment syndromes, nerve conduction assessment only provided clues in favour of NTOS. Decreased amplitude for ulnar SNAP, medial antebrachial cutaneous SNAP, median CMAP and ulnar CMAP should be assessed, as well as needle examination. Larger studies are needed to evaluate the sensitivity and specificity of electrophysiology in NTOS diagnosis.
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Fouasson-Chailloux A, Daley P, Menu P, Gadbled G, Bouju Y, Gautier G, Pomares G, Dauty M. Use of hand hydraulic dynamometers as an overall evaluation of the upper-limb weakness in patients with thoracic outlet syndrome. Front Neurol 2022; 13:919312. [PMID: 36046630 PMCID: PMC9420998 DOI: 10.3389/fneur.2022.919312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/01/2022] [Indexed: 02/02/2023] Open
Abstract
Patients with neurogenic thoracic outlet syndrome report pain and upper-limb weakness. They complain about weakness occurring on the entire upper-limb, especially at the hand and the shoulder levels. Hydraulic dynamometers can reliably assess the strength of the hand, and isokinetic shoulder testing can provide accurate and reliable evaluations of the rotators strength. Yet, isokinetic proximal assessment needs expensive tools, whereas hydraulic hand dynamometers are cheap and easy to use. We aimed to assess the correlation between the isokinetic shoulder strength and the hand grip and the key pinch strength. The grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. Isokinetic rotators strength tests were performed using a Humac Norm® dynamometer at 60 and 180°/s. One-hundred and thirty patients had been included, 72% of women, mean age of 39.8 ± 9.5. Symptomatic hands presented a strength deficit of 12.2% on the grip (p < 0.0001) and 10% on the key pinch (p = 0.01). Isokinetic strength was lower on the symptomatic shoulders at 60 and 180°/s concerning medial rotators [−10.3 and −8.8%, respectively (p = 0.02)] and lateral rotators [−10.8 and −10%, respectively (p = 0.04 and p = 0.03)]. There was a moderate correlation between the grip strength of the symptomatic upper-limbs and the isokinetic rotators strength (p < 0.001). The key pinch strength was moderately correlated to the isokinetic medial and lateral rotators strength at 60°/s (p < 0.001). Hand dynamometers could prove useful during medical consultations or in outpatient management to assess upper-limb overall weakness, but isokinetic measurement remains the gold standard for a precise evaluation.
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Affiliation(s)
- Alban Fouasson-Chailloux
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- IRMS, Institut Régional de Médecine du Sport, Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Nantes Université, ONIRIS, Nantes, France
- *Correspondence: Alban Fouasson-Chailloux
| | - Pauline Daley
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
| | - Pierre Menu
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- IRMS, Institut Régional de Médecine du Sport, Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Nantes Université, ONIRIS, Nantes, France
| | - Guillaume Gadbled
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU Nantes, Nantes Université, Nantes, France
| | - Yves Bouju
- Institut Main Atlantique, Saint Herblain, France
| | - Giovanni Gautier
- Explorations Fonctionnelles Vasculaires, CHU Nantes, Nantes Université, Nantes, France
| | - Germain Pomares
- Institut Européen de la Main, Hopital Kirchberg, Luxembourg, Luxembourg
| | - Marc Dauty
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- IRMS, Institut Régional de Médecine du Sport, Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Nantes Université, ONIRIS, Nantes, France
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Garraud T, Pomares G, Daley P, Menu P, Dauty M, Fouasson-Chailloux A. Thoracic Outlet Syndrome in Sport: A Systematic Review. Front Physiol 2022; 13:838014. [PMID: 35755427 PMCID: PMC9214221 DOI: 10.3389/fphys.2022.838014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
Thoracic outlet syndrome (TOS) is a rare and heterogeneous syndrome secondary to a compression of the neurovascular bundle in the thoracic outlet area. Muscle hypertrophy is recognized to induce vascular or neurogenic compression, especially in sports involving upper-arm solicitation. Athletes represent a distinctive population because of a specific management due to an ambitious objective, which is returning to high-level competition. We evaluated the scientific literature available for the management of TOS in athletes. Article research extended to March 2021 without other restriction concerning the date of articles publication. The search was performed independently by two assessors. A first preselection based on the article titles was produced, regarding their availability in English or French and a second preselection was produced after reading the abstracts. In case of doubt, a third assessor’s advice was asked. Case reports were selected only if the sport involved was documented, as well as the level of practice. Cohorts were included if data about the number and the sport level of athletes were detailed. Seventy-eight articles were selected including 40 case reports, 10 clinical studies and 28 reviews of literature. Baseball pitchers seem to be highly at risk of developing a TOS. The surgical management appears particularly frequent in this specific population. The prognosis of TOS in athletes seems to be better than in the general population, possibly due to their better physical condition and their younger age. Some studies showed interesting and encouraging results concerning return to previous sport level. Literature shows a strong link between TOS and certain sports. Unfortunately, this syndrome still lacks rigorous diagnostic criteria and management guidelines for athletes.
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Affiliation(s)
- Thomas Garraud
- Hôpital Privé du Confluent, Rhumatologie, Nantes, France.,Service de Médecine du Sport, CHU Nantes, Nantes, France
| | - Germain Pomares
- Institut Européen de la Main, Luxembourg. Luxembourg.,Medical Training Center, Hopital Kirchberg, Luxembourg. Luxembourg
| | - Pauline Daley
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France
| | - Pierre Menu
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France.,Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France.,IRMS, Institut Régional de Médecine du Sport, Nantes, France
| | - Marc Dauty
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France.,Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France.,IRMS, Institut Régional de Médecine du Sport, Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France.,Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France.,IRMS, Institut Régional de Médecine du Sport, Nantes, France
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