General Overview and Diagnostic (Imaging) Techniques for Neurogenic Thoracic Outlet Syndrome

Case Report of a Hemangioblastoma Originating from the T1 Spinal Nerve Treated with in Toto Resection, Hemicorporectomy and Pedicle Screw Stabilization

Introduction

Previously, only 40 cases with extradural hemangioblastoma at the spinal nerve (none at the T1 nerve root) have been described in the medical literature. In toto, resection of this hypervascular tumor is essential to avoid bleeding complications. Surgery for hemangioblastoma at the cervicothoracic junction is complex and nerve resection of the T1 results in specific neurodeficits of the hand muscles which are not well known.

Case Report

A 34-year-old woman was diagnosed with a slowly growing tumor located at the left foramen T1/T2. Pressure from the tumor resulted in Horner's syndrome and pain and paresthesia in the upper extremity. The tumor was resected in toto through a posterior midline approach and rib resection and transection of the left T1 and T2 spinal nerves. T2 hemicorporectomy and spinal stabilization were performed to gain access to and mobilize the tumor ventrally. Ptosis decreased after surgery and no neurodeficit was observed except the expected deficit (no deficit was present preoperatively) caused by the T1 resection specifically a small decrease in strength of the abductor and flexor pollicis brevis and opponens pollicis and the lateral two lumbricals. Histological examination of the tumor demonstrated a hemangioblastoma. von Hippel-Lindau disease was ruled out by genetic testing of the patient's blood. Eight-month postoperatively, all pre-operative symptoms had decreased considerably and the radiographic examination shoved unchanged pedicle screw/rod stabilization of the cervicothoracic junction.

Conclusion

Hemangioblastoma is a rare hypervascular tumor very rarely located at the spinal nerve. The tumor should be resected in toto to avoid recurrence and bleeding. In the current case, the location was at the T1 root necessitating complex surgery with laminectomies and hemicorporectomy of T2 and a posterior rib resection/thoracotomy. Spinal stabilization is mandatory. Preferably embolization should be performed preoperatively. T1 transection results in a specific neurodeficit which should be explained to the patient preoperatively. The patients should undergo genetic testing for Hippel-Lindau disease.

Thoracic outlet syndrome caused by superior mediastinal mass: A case report

INTRODUCTION

Thoracic outlet syndrome (TOS) caused by superior mediastinal soft tissue mass has never been reported in the literature, the aim of this study is to discuss a case of TOS caused by a superior mediastinal mass in which the histopathological examinations of the mass showed vascular malformation.

CASE REPORT

A 45-year-old female presented with left upper limb pain and numbness for three months, associated with swelling and attacks of shortness of breath. Imaging studies showed soft tissue mass involving the superior mediastinum. The condition of the patient deteriorated and the signs and symptoms of TOS became clearer, all provocative tests and nerve conduction studies were positive. The patient underwent thoracic outlet decompression. The patient did not respond and the symptoms deteriorated further. After a multidisciplinary board discussion, the patient was prepared for median sternotomy under general anesthesia. A total resection of the mass was done. The patient was totally relieved a few hours after the operation.

DISCUSSION

The etiology of TOS can be multifaceted. Several factors contribute to its onset, and these can be categorized as congenital or acquired. Congenital causes include anatomical anomalies such as a cervical rib, or an elongated transverse process of the cervical vertebrae. These anatomical deviations can reduce the size of the thoracic outlet and make it prone to compression.

CONCLUSION

Although it is rare, TOS could be due to superior mediastinal mass and the treatment of choice is total resection either through median sternotomy or thoracoscopic procedure.

The Morphology of the Dorsal Part of the First Rib in Neurogenic Thoracic Outlet Syndrome Patients: A Retrospective Clinical Study

BACKGROUND

The recurrence or persistence of symptoms after thoracic outlet decompression (TOD) in patients with neurogenic thoracic outlet syndrome (NTOS) is not uncommon. Some authors have shown significantly better clinical outcomes in patients who underwent TOD with exarticulation of the first rib compared to a group who underwent TOD with preservation of the dorsal portion of the first rib. Several other case series have shown significant improvement after redo surgery with removal of the dorsal first rib remnant. This indicates the importance of the dorsal part of the first rib in NTOS. However, radical exarticulation may not always be necessary. In this study, we tried to answer the question of whether there is a morphological difference in the dorsal part of the first rib in NTOS patients that might help in the diagnosis and treatment of NTOS.

METHODS

We used the CT data of 21 NTOS patients who underwent TOD surgery and measured the dorsal part of the first rib, then compared them with a quota sample.

RESULTS

We found no difference in the dorsal part of the first rib between NTOS patients and the quota sample in our data.

CONCLUSIONS

As there was no detectable difference, we were not able to use these data to help decide whether exarticulation is necessary in achieving adequate symptom relief. Therefore, we advocate exarticulation of the first rib when TOD is indicated.

Possible role of the botulinum toxin in the management of neurogenic thoracic outlet syndrome: a systematic review

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.

Innovative Imaging Techniques: Nice to Have or Essential to Treat Complex Diseases?

Nowadays, a substantial number of our patients have multimorbidity, and need treatment for complex diseases [...].