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Abdalla BA, Kakamad FH, Namiq HS, Asaad SK, Abdullah AS, Mustafa AM, Ghafour AK, Kareem HO, Ahmed SQM, Mohammed BA, Hasan KM, Mohammed SH. Pediatric thoracic outlet syndrome: a systematic review with metadata. Pediatr Surg Int 2024; 40:186. [PMID: 39003407 DOI: 10.1007/s00383-024-05769-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Thoracic outlet syndrome (TOS) typically considered a condition of the adult population; it is often disregarded in children and adolescents due to its limited recognition within the pediatrics. The current study aims to systematically review and provide insights into TOS among pediatric patients. METHODS PubMed, Scopus, Web of Science, and Google Scholar databases were thoroughly searched for English language studies published until March 15th, 2024. The study included those articles focusing on pediatric or adolescent individuals diagnosed with TOS. Data collected from studies encompassed date of publication, number of participants or reported cases, age (years), gender of participants, type of TOS, affected side, type of treatment, surgical approach, bony abnormality, duration of symptoms (months), outcome, and follow-up time duration (months). RESULTS The current study comprised 33 articles, 21 of which were case reports, 10 of which were case series, and the remaining were cohort studies. In this study, 356 patients were included. Females constituted 234 (65.73%) of the patient population. Among TOS types, neurogenic TOS was found among 201 (56.5%) patients. Sporting-related activity or physical activity was present in 193 (54%) patients, followed by a history of trauma in 27 (7%) patients. CONCLUSIONS Pediatric patients exhibited a higher percentage of vascular TOS than their adult counterparts, with the supraclavicular approach emerging as the preferred treatment method. Sports-related activities were identified as the primary risk factor associated with pediatric TOS.
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Affiliation(s)
- Berun A Abdalla
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
- Kscien Organization for Scientific Research (Middle East Office), Hamdi Street, Sulaymaniyah, Kurdistan, Iraq
| | - Fahmi H Kakamad
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq.
- Kscien Organization for Scientific Research (Middle East Office), Hamdi Street, Sulaymaniyah, Kurdistan, Iraq.
- College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq.
- Doctors City, Building 11, Apartment 50, Sulaimani, 46001, Iraq.
| | - Hiwa Shafiq Namiq
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
- College of Pharmacy, Department of Basic Science, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Saywan Kakarash Asaad
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
- College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Aland S Abdullah
- College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Ayman M Mustafa
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Abdullah K Ghafour
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
- Shahid Peshraw Hospital, Chamchamal, Sulaymaniyah, Kurdistan, Iraq
| | - Honar O Kareem
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Samen Qadir Mohammed Ahmed
- Xzmat Polyclinic, Rizgari, Kalar, Sulaymaniyah, Kurdistan, Iraq
- College of Medicine, University of Garmian, Kalar, Kurdistan Region, Iraq
| | - Bilal A Mohammed
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Karzan M Hasan
- Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq
| | - Shvan H Mohammed
- Kscien Organization for Scientific Research (Middle East Office), Hamdi Street, Sulaymaniyah, Kurdistan, Iraq
- Xzmat Polyclinic, Rizgari, Kalar, Sulaymaniyah, Kurdistan, Iraq
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Ncheye MS, Mrimba PM, Dekker M, Massawe H, Mwanga D, Rabiel H. Spinal ganglioneuroma with extension to the brachial plexus. The challenges for total surgical excision, a case report. Int J Surg Case Rep 2024; 119:109756. [PMID: 38754158 PMCID: PMC11109351 DOI: 10.1016/j.ijscr.2024.109756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Ganglioneuromas are benign neurogenic tumors that arise from the sympathetic ganglia. They are less aggressive compared to the more immature neuroblastomas and ganglioneuroblastomas but can grow to exert mass effect on surrounding tissues. PRESENTATION OF CASE A 7 years old girl who presented with progressive quadriplegia for 4 months. On examination, she had a right supra-clavicular mass with reduced power in the right hand than the left. Power in the lower limbs was also reduced with hyper-reflexia, clonus and Babinski positive. Laboratory investigations were unremarkable and Chest X-Ray showed a widened mediastinum. Magnetic Resonance Imaging (MRI) scan revealed an extra-medullary spinal tumor at C6/C7 extending laterally on the right through the C6/7 neuro-foramen to the para-spinal tissue and brachial plexus. A C6/7 laminectomy with Spinal cord decompression by partial resection of the tumor was done. Histology of the resected tissue showed ganglioneuroma. DISCUSSION The presentation of Ganglioneuromas is usually asymptomatic until they are huge enough to exert mass effect on surrounding tissue. Most are located in the posterior mediastinum, retro-peritoneum and neck. Due to this, it may be very challenging to achieve total resection especially when they surround major vessels or nerves. A multi-disciplinary approach is needed for the best surgical outcomes but this is not always realized in our setting. CONCLUSION In resource limited settings, more collaboration and training is needed to realize appropriate management of complex surgical conditions. Although complications are not uncommon, total surgical excision is necessary to prevent recurrence and progression of Ganglioneuromas.
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Affiliation(s)
- Mathias S Ncheye
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania; Department of Orthopedics and Trauma, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania.
| | - Peter Magembe Mrimba
- Department of Orthopedics and Trauma, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Marieke Dekker
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Honest Massawe
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania; Department of Orthopedics and Trauma, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Daniel Mwanga
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania; Department of Orthopedics and Trauma, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Happiness Rabiel
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania; Department of Neurosurgery, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
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Beason AM, Thayer JA, Arras N, Franke JD, Mailey BA. Anterior Scalene Muscle Block Response Predicts Outcomes Following Thoracic Outlet Decompression. Hand (N Y) 2024; 19:361-366. [PMID: 36341588 PMCID: PMC11067833 DOI: 10.1177/15589447221131850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Austin M. Beason
- Southern Illinois University School of Medicine, Springfield, USA
| | - Jacob A. Thayer
- Southern Illinois University School of Medicine, Springfield, USA
| | - Norma Arras
- Southern Illinois University School of Medicine, Springfield, USA
| | - Jacob D. Franke
- Southern Illinois University School of Medicine, Springfield, USA
| | - Brian A. Mailey
- Southern Illinois University School of Medicine, Springfield, USA
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Betancourt A, Benrashid E, Gupta PC, McGinigle KL. Current concepts in clinical features and diagnosis of thoracic outlet syndrome. Semin Vasc Surg 2024; 37:3-11. [PMID: 38704181 DOI: 10.1053/j.semvascsurg.2024.01.005] [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: 10/21/2023] [Revised: 12/14/2023] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
The diagnosis and clinical features of thoracic outlet syndrome have long confounded clinicians, owing to heterogeneity in symptom presentation and many overlapping competing diagnoses that are "more common." Despite the advent and prevalence of high-resolution imaging, along with the increasing awareness of the syndrome itself, misdiagnoses and untimely diagnoses can result in significant patient morbidity. The authors aimed to summarize the current concepts in the clinical features and diagnosis of thoracic outlet syndrome.
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Affiliation(s)
- Alexis Betancourt
- Division of Vascular Surgery, University of North Carolina at Chapel Hill, Burnett Womack Building, 3(rd) Floor, Campus Box 7212, Chapel Hill, NC, 27599
| | - Ehsan Benrashid
- University Surgical Associates, University of Tennessee at Chattanooga, Chattanooga, TN
| | - Prem Chand Gupta
- Department of Vascular and Endovascular Surgery, Care Hospital, Banjara Hills, Hyderabad, India
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina at Chapel Hill, Burnett Womack Building, 3(rd) Floor, Campus Box 7212, Chapel Hill, NC, 27599.
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Peled ZM, Gfrerer L. Introduction to VSI: Migraine surgery in JPRAS open. JPRAS Open 2024; 39:217-222. [PMID: 38293285 PMCID: PMC10827495 DOI: 10.1016/j.jpra.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 02/01/2024] Open
Affiliation(s)
- Ziv M. Peled
- Peled Plastic Surgery, 2100 Webster Street, Suite 109, San Francisco, CA 94115, United States
| | - Lisa Gfrerer
- Surgery Plastic and Reconstructive Surgery Weill Cornell Medicine, 425 East 61st Street, 10th Floor, New York, NY 10065, United States
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Stegemann E, Larbig J, Stegemann B, Portig I, Prescher H, Bürger T. Validity of Ultrasound for the Diagnosis of Arterial Thoracic Outlet Syndrome. EJVES Vasc Forum 2024; 61:92-98. [PMID: 38455254 PMCID: PMC10917999 DOI: 10.1016/j.ejvsvf.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/30/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Objective Thoracic outlet syndrome (TOS) is a rare disorder mostly seen in younger individuals. Although patient wellbeing is relevantly impaired, it often takes a long time before the diagnosis is made. Digital subtraction angiography (DSA) is routinely used despite its radiation exposure, which is a major concern in this young patient population. Moreover, DSA offers limited opportunities for functional assessment. By contrast, ultrasonography is widely accessible without causing radiation exposure and allows for flexible functional assessment. The main goal of the study was to investigate whether ultrasound (US) was a viable alternative to DSA in diagnosing arterial TOS (aTOS). Methods Patients, referred to a tertiary centre for evaluation of suspected TOS, were recruited into the study. DSA was routinely performed with the patient's arms both in the raised (abducted) and neutral (adducted) position. Two vascular surgeons and two radiologists assessed the resulting images for the presence of aTOS. Additionally, two examiners performed US according to a standardised protocol. The reference for presence of aTOS was the DSA based interdisciplinary vascular conference consensus. Inter-rater agreement and latent class analysis (LCA) were performed between assessors and diagnostic methods. Results Fifty one consecutive patients (two thirds female) aged 39.3 ± 13.0 years were included within 11 months. US agreement was excellent at 0.94 (0.841-0.980), DSA agreement for vascular surgeons was good at 0.779 (0.479-1.000), whereas it was moderate at 0.546 (0.046-1.000) for radiologists. Results suggest that DSA is untenable as the gold standard for aTOS diagnosis. In LCA, US was shown to be a reliable diagnostic tool for the detection of aTOS. Conclusion US examination is a valid test for the detection of haemodynamically relevant compression of arteries in the diagnostic work up of aTOS using a standardised protocol. The role of DSA as the gold standard should be reviewed and needs to be reconsidered.
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Affiliation(s)
- Emilia Stegemann
- Philipps Universität Marburg, Marburg, Germany
- Klinik für Kardiologie, Angiologie und Intern. Intensivmedizin, Universitätsklinikum Gießen und Marburg Standort Marburg, Marburg, Germany
- Klinik für Allgemeine Innere Medizin, Diabetologie und Angiologie, AGAPLESION DIAKONIE KLINIKEN KASSEL, Kassel, Germany
| | - Jana Larbig
- Klinik für Allgemeine Innere Medizin, Diabetologie und Angiologie, AGAPLESION DIAKONIE KLINIKEN KASSEL, Kassel, Germany
| | | | - Irene Portig
- Philipps Universität Marburg, Marburg, Germany
- Klinik für Allgemeine Innere Medizin, Diabetologie und Angiologie, AGAPLESION DIAKONIE KLINIKEN KASSEL, Kassel, Germany
| | - Hans Prescher
- Klinik für Gefäß- und Endovaskuläre Chirurgie, AGAPLESION DIAKONIE KLINIKEN KASSEL, Kassel, Germany
| | - Thomas Bürger
- Klinik für Gefäß- und Endovaskuläre Chirurgie, AGAPLESION DIAKONIE KLINIKEN KASSEL, Kassel, Germany
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Fox R, Lassner F, Prescher A. The Morphology of the Dorsal Part of the First Rib in Neurogenic Thoracic Outlet Syndrome Patients: A Retrospective Clinical Study. J Pers Med 2024; 14:150. [PMID: 38392583 PMCID: PMC10890555 DOI: 10.3390/jpm14020150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
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.
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Affiliation(s)
- Robert Fox
- Institute of Molecular and Cellular Anatomy, RWTH Aachen University, 52074 Aachen, Germany
| | | | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy, RWTH Aachen University, 52074 Aachen, Germany
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Slouma M, Ben Dhia S, Cheour E, Gharsallah I. Acroparesthesias: An Overview. Curr Rheumatol Rev 2024; 20:115-126. [PMID: 37921132 DOI: 10.2174/0115733971254976230927113202] [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: 04/09/2023] [Revised: 08/09/2023] [Accepted: 08/18/2023] [Indexed: 11/04/2023]
Abstract
Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.
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Affiliation(s)
- Maroua Slouma
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Siwar Ben Dhia
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Elhem Cheour
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
- Pain Treatment Center, La Rabta Hospital, Tunis, Tunisia
| | - Imen Gharsallah
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
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Martínez-Cárdenas EK, Torres-Parlange A, Sotelo-Carbajal J, Hernández-Zamora RE, García-Ledezma A, Torres-Salazar QL. Case report on the diagnosis of vascular thoracic outlet syndrome followed by mechanical thrombectomy. Int J Surg Case Rep 2023; 113:109019. [PMID: 37988987 PMCID: PMC10667732 DOI: 10.1016/j.ijscr.2023.109019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/26/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The thoracic outlet syndrome is characterized by compression of the brachial plexus or subclavian vessels due to anatomical alterations of the thoracic cavity. Vascular presentation is rare and includes thromboembolism and edema in the upper limb, and the diagnosis is often elusive due to its rarity. In this case, we describe a vascular thoracic outlet syndrome presentation whose diagnosis through angiography was achieved after a mechanical thrombectomy. CASE PRESENTATION We report a 43-year-old female patient with pain in the right upper limb, accompanied by edema and mild violet discoloration, without risk factors for hypercoagulability, with D-dimer levels within normal values. Mechanical thrombectomy with AngioJET was performed via an endovascular approach, with the extraction of multiple clots, confirming the presence of thoracic outlet syndrome as the underlying cause of the current condition. CLINICAL DISCUSSION AND CONCLUSIONS Venous thoracic outlet syndrome is a challenging entity to diagnose; however, it should be considered in cases of deep vein thrombosis of the subclavian vein and confirmed by angiography after a thrombectomy.
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Affiliation(s)
| | - Adrian Torres-Parlange
- Hospital General "5 de Diciembre" of the Security Institute for the Service of State Workers, México
| | - Jorge Sotelo-Carbajal
- Hospital General Regional No. 1 Tijuana, Baja California, Mexican Institute of Social Security, México
| | | | - Arnold García-Ledezma
- Hospital General Regional No. 1 Tijuana, Baja California, Mexican Institute of Social Security, México
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Maślanka K, Zielinska N, Karauda P, Balcerzak A, Georgiev G, Borowski A, Drobniewski M, Olewnik Ł. Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature. J Clin Med 2023; 12:6811. [PMID: 37959276 PMCID: PMC10648912 DOI: 10.3390/jcm12216811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
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.
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Affiliation(s)
- Krystian Maślanka
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Piotr Karauda
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Adrian Balcerzak
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
| | - Georgi Georgiev
- Department of Orthopaedics and Traumatology, University Hospital Queen Giovanna—ISUL, Medical University of Sofia, 1527 Sofia, Bulgaria;
| | - Andrzej Borowski
- Orthopaedics and Paediatric Orthopaedics Department, Medical University of Lodz, 90-419 Lodz, Poland; (A.B.); (M.D.)
| | - Marek Drobniewski
- Orthopaedics and Paediatric Orthopaedics Department, Medical University of Lodz, 90-419 Lodz, Poland; (A.B.); (M.D.)
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-419 Lodz, Poland; (K.M.); (N.Z.); (P.K.); (A.B.)
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Blunt J, Avila L, Temple M, Thornton J. Exercise-induced deep vein thrombosis in the subclavian vein in an elite female athlete. BMJ Case Rep 2023; 16:e253751. [PMID: 37666570 PMCID: PMC10481743 DOI: 10.1136/bcr-2022-253751] [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] [Indexed: 09/06/2023] Open
Abstract
An adolescent female presented to the emergency room with pain, swelling and a palpable lump in the right axilla following activity on a rowing ergometer. The differential diagnosis at the time of presentation was deep vein thrombosis, mass compression and cellulitis. An ultrasound scan revealed an occlusive thrombus of the right axillary and subclavian veins, basilic vein and proximal cephalic vein. The patient underwent pharmacomechanical thrombolysis followed by catheter-directed thrombolysis. Dynamic venogram testing revealed venous thoracic outlet syndrome (VTOS) and a transaxillary first rib resection was performed to decompress the costoclavicular space. Genetic testing revealed the patient was heterozygous for factor V Leiden. Two rounds of balloon dilatation plasty were performed to relieve recurring symptoms due to scarring and persisting compression, 1 and 3 years post rib resection. After extensive shared decision-making, the patient returned to sport, reporting only intermittent symptoms of post-thrombotic syndrome. This case sheds light on the importance of early diagnosis of VTOS for successful return to sport.
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Affiliation(s)
- Jacqueline Blunt
- Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura Avila
- Department of Pediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Temple
- Medical Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Thornton
- Family Medicine, Western University, London, Ontario, Canada
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Olson EM, Dyrek P, Harris T, Fereydooni A, Lee JT, Kussman A, Roh E. Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment. Clin J Sport Med 2023; 33:467-474. [PMID: 37207307 DOI: 10.1097/jsm.0000000000001162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/13/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions. DESIGN Retrospective chart review. SETTING Single institution. PARTICIPANTS Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded. INDEPENDENT VARIABLES Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided. MAIN OUTCOME MEASURES Rate of return to play (RTP) to collegiate athletics. RESULTS Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery. CONCLUSIONS Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks. CLINICAL RELEVANCE This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.
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Affiliation(s)
| | - Paige Dyrek
- Stanford University, Department of Orthopaedic Surgery, Palo Alto
| | - Taylor Harris
- Stanford University, School of Medicine, Palo Alto and
| | | | - Jason T Lee
- Stanford University, Division of Vascular Surgery, Palo Alto
| | - Andrea Kussman
- Stanford University, Department of Orthopaedic Surgery, Palo Alto
| | - Eugene Roh
- Stanford University, Department of Orthopaedic Surgery, Palo Alto
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Chen D, Gong W, Wang J, Hao J, Zhao R, Zheng M. Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography. BMC Musculoskelet Disord 2023; 24:690. [PMID: 37644436 PMCID: PMC10463735 DOI: 10.1186/s12891-023-06762-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus (BP) is difficult to diagnosis. This study aimed to summarize the features of thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus observed on high-frequency ultrasonography (HFUS). METHODS The ultrasound data of 27 patients who had TOS with the lower trunk compression of brachial plexus were collected and eventually confirmed by surgery. The imaging data were compared, and the pathogenesis of TOS was analyzed on the basis of surgical data. RESULTS TOS occurred predominantly in females (70.4%). Most cases had unilateral involvement (92.6%), mainly on the right side (66.7%). The HFUS features of TOS can be summarized as follows: (1) Lower trunk compression. HFUS revealed focal thinning that reflected compression at the level of the lower trunk; furthermore, the distal part of the nerve was thickened for edema (Affected side: 0.49 ± 0.12 cm vs. Healthy side: 0.38 ± 0.06, P = 0.009), and the cross-sectional area of brachial plexus cords was markedly greater on the injured side than on the healthy side (0.95 ± 0.08 cm² vs. 0.65 ± 0.11 cm², P = 0.004). (2) Hyperechoic fibromuscular bands behind the compressed nerve (mostly the scalenus minimus muscle). (3) Abnormal bony structures: cervical ribs or elongated transverse processes of the 7th cervical vertebra (C7). Surgical results showed that the etiological factors contributing to TOS were (1) muscle hypertrophy and/or fibrosis (100%) and (2) cervical ribs/elongated C7 transverse processes (20.7%). CONCLUSION TOS with the lower trunk compression of brachial plexus can be diagnosed accurately and reliably by high-frequency ultrasound.
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Affiliation(s)
- Dingzhang Chen
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Wenqing Gong
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Jing Wang
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Jikun Hao
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Rui Zhao
- Department of Hand-Surgery, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Minjuan Zheng
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China.
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Wagner ER, Gottschalk MB, Ahmed AS, Graf AR, Karzon AL. Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome. Tech Hand Up Extrem Surg 2023; 27:100-114. [PMID: 36515356 DOI: 10.1097/bth.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Neurogenic thoracic outlet syndrome is a challenging condition to diagnose and treat, often precipitated by the triad of repetitive overhead activity, pectoralis minor contracture, and scapular dyskinesia. The resultant protracted scapular posture creates gradual repetitive traction injury of the suprascapular nerve via tethering at the suprascapular notch and decreases the volume of the brachial plexus cords and axillary vessels in the retropectoralis minor space. A stepwise and exhaustive diagnostic protocol is essential to exclude alternate pathologies and confirm the diagnosis of this dynamic pathologic process. Ultrasound-guided injections of local anesthetic or botulinum toxin are a key factor in confirming the diagnosis and prognosticating potential response from surgical release. In patients who fail over 6 months of supervised physical therapy aimed at correcting scapular posture and stretching of the pectoralis minor, arthroscopic surgical release is indicated. We present our diagnostic algorithm and technique for arthroscopic suprascapular neurolysis, pectoralis minor release, brachial plexus neurolysis, and infraclavicular thoracic outlet decompression.
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Affiliation(s)
- Eric R Wagner
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA
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15
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Teijink SBJ, Pesser N, Goeteyn J, Barnhoorn RJ, van Sambeek MRHM, van Nuenen BFL, Gelabert HA, Teijink JAW. General Overview and Diagnostic (Imaging) Techniques for Neurogenic Thoracic Outlet Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13091625. [PMID: 37175016 PMCID: PMC10178617 DOI: 10.3390/diagnostics13091625] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Thoracic outlet syndrome is an uncommon and controversial syndrome. Three different diagnoses can be made based on the compressed structure, arterial TOS, venous TOS, and neurogenic TOS, though combinations do exist as well. Diagnosing NTOS is difficult since no specific objective diagnostic modalities exist. This has resulted in a lot of controversy in recent decades. NTOS remains a clinical diagnosis and is mostly diagnosed based on the exclusion of an extensive list of differential diagnoses. To guide the diagnosis and treatment of TOS, a group of experts published the reporting standards for TOS in 2016. However, a consensus was not reached regarding a blueprint for a daily care pathway in this document. Therefore, we constructed a care pathway based on the reporting standards for both the diagnosis and treatment of NTOS patients. This care pathway includes a multidisciplinary approach in which different diagnostic tests and additional imaging techniques are combined to diagnose NTOS or guide patients in their treatment for differential diagnoses. The aim of the present work is to discuss and explain the diagnostic part of this care pathway.
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Affiliation(s)
- Stijn B J Teijink
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Niels Pesser
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Jens Goeteyn
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Renée J Barnhoorn
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- Department of Biomedical Technology, University of Technology Eindhoven, 5612 AJ Eindhoven, The Netherlands
| | - Bart F L van Nuenen
- Department of Neurology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6229 HX Maastricht, The Netherlands
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16
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Stern E, Karzon AL, Hussain ZB, Khawaja SR, Cooke HL, Pirkle S, Bowers RL, Gottschalk MB, Wagner ER. Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain. JBJS Case Connect 2023; 13:01709767-202306000-00024. [PMID: 37146169 DOI: 10.2106/jbjs.cc.22.00804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Elinor Stern
- Department of Orthopaedic Surgery Emory University, Atlanta, Georgia
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17
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Díaz-Baamonde A, Peláez-Cruz R, Téllez MJ, Lantis J, Ulkatan S. Median nerve somatosensory evoked potential alarm related to head and neck positioning for carotid surgery. J Clin Monit Comput 2023; 37:699-704. [PMID: 35960492 DOI: 10.1007/s10877-022-00904-3] [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: 03/09/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
Head positioning in carotid surgery represents an often overlooked but sensitive period in the surgical plan. A 53-year-old male presented a significant decrement in median nerve somatosensory evoked potential (mSEP) following head and neck positioning for carotid pseudoaneurysm repair before skin incision.Neurophysiological monitoring was performed with mSEP and electroencephalography early during the patient's preparation and surgery. Within five minutes after rotation and extension of the head to properly expose the surgical field, the contralateral m-SEP significantly decreased in both cortical (N20/P25) and subcortical (P14/N18) components. Partial neck correction led to m-SEP improvement, allowing to proceed with the carotid repair. We discuss possible underlying pathophysiological mechanisms responsible for these changes and highlight the relevance of an early start on monitoring to avoid neurological deficits.
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Affiliation(s)
- Alba Díaz-Baamonde
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA.
| | | | - Maria J Téllez
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
| | - John Lantis
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
| | - Sedat Ulkatan
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
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Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4829. [PMID: 36875924 PMCID: PMC9984160 DOI: 10.1097/gox.0000000000004829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/04/2023] [Indexed: 03/06/2023]
Abstract
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.
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Ogawa T, Onishi S, Mamizuka N, Yoshii Y, Ikeda K, Mammoto T, Yamazaki M. Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13020319. [PMID: 36673129 PMCID: PMC9858151 DOI: 10.3390/diagnostics13020319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.
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Affiliation(s)
- Takeshi Ogawa
- Department of Orthopedic Surgery, National Hospital Organization Mito Medical Center, 280 Sakuranosato, Ibarakimachi 311-3193, Japan
- Department of Orthopedic Surgery and Sports Medicine, Mito Clinical Education and Training Center, University of Tsukuba Hospital, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito 310-0015, Japan
| | - Shinzo Onishi
- Department of Orthopedic Surgery and Sports Medicine, Mito Clinical Education and Training Center, University of Tsukuba Hospital, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito 310-0015, Japan
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
| | - Naotaka Mamizuka
- Baseball and Sports Clinic, 2-228-1 Kosugi, Park City Musashikosugi the Garden Towers West 1st Floor W4, Nakahara-Ward, Kawasaki 211-0063, Japan
| | - Yuichi Yoshii
- Department of Orthopedic Surgery, Tokyo Medical University Ibaraki Medical Center, Ami 300-0395, Japan
- Correspondence: ; Tel.: +81-298871161
| | - Kazuhiro Ikeda
- Department of Orthopedic Surgery, Kikkoman General Hospital, Noda 278-0005, Japan
| | - Takeo Mammoto
- Department of Orthopedic Surgery and Sports Medicine, Mito Clinical Education and Training Center, University of Tsukuba Hospital, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito 310-0015, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
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20
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Lassner F, Becker M, Prescher A. Relevance of Costovertebral Exarticulation of the First Rib in Neurogenic Thoracic Outlet Syndrome: A Retrospective Clinical Study. J Pers Med 2023; 13:jpm13010144. [PMID: 36675805 PMCID: PMC9861701 DOI: 10.3390/jpm13010144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
Purpose: The failure rate for operative decompression in neurogenic thoracic outlet syndrome (NTOS) is high compared to more distal nerve compression syndromes, such as cubital or carpal tunnel syndrome. Herein, we aimed to determine if a more radical approach, namely costovertebral exarticulation of the first rib, may improve the postoperative results in patients with NTOS. Methods: From October 2002 to December 2020, 105 operative decompressions in 95 patients were evaluated; in 10 cases, decompressions were performed bilaterally. We presented the clinical outcomes of 59 exarticulations compared to those of 46 conventional resections. Evaluation was performed at a minimum of one year post-operation using the DASH questionnaire. Results: The exarticulation group presented with significantly better clinical outcomes (two-sample t-test assuming unequal variances, p < 0.001). Conclusions: This study showed that significantly better results were obtained when exarticulation of the first rib was performed in patients with NTOS. This finding supports the hypothesis that, in certain cases, the proximal portion of the first rib plays a pivotal role in the pathogenesis of NTOS.
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Affiliation(s)
- Franz Lassner
- Pauwelsklinik, Boxgraben 56, 52064 Aachen, Germany
- Correspondence: ; Tel.: +49-241-900-8630; Fax: +49-241-900-8595
| | | | - Andreas Prescher
- Institute für Molecular und Cellular Anatomy, Aachen University, Pauwelsstr. 30, 52074 Aachen, Germany
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Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023. [PMID: 37521545 PMCID: PMC10382898 DOI: 10.1016/j.jhsg.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
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.
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Xu K, Zhang Z, Li Y, Song L, Gou J, Sun C, Li J, Du S, Cao R, Cui S. Botulinum Toxin A, a Better Choice for Skeletal Muscle Block in a Comparative Study With Lidocaine in Rats. J Pharmacol Exp Ther 2022; 383:227-237. [PMID: 36116794 DOI: 10.1124/jpet.122.001313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/06/2022] [Indexed: 01/07/2023] Open
Abstract
A positive response to scalene muscle block (SMB) is an important indication for the diagnosis of thoracic outlet syndrome. Lidocaine injection is commonly used in clinical practice in SMB, although there have been some cases of misdiagnosis. Botulinum toxin A (BTX-A) is one of the therapeutic agents in SMB, but whether it is also indicated for SMB diagnosis is controversial. To evaluate the muscle block efficiency of these two drugs, the contraction strength was repeatedly recorded on tibialis anterior muscle in rats. It was found that at a safe dosage, 2% lidocaine performed best at 40 μL, but it still exhibits an unsatisfactory partial blocking efficiency. Moreover, neither lidocaine injection in combination with epinephrine or dexamethasone nor multiple locations injection could improve the blocking efficiency. On the other hand, injections of 3, 6, and 12 U/kg BTX-A all showed almost complete muscle block. Gait analysis showed that antagonistic gastrocnemius muscle, responsible for heel rising, was paralyzed for nonspecific blockage in the 12 U/kg BTX-A group, but not in the 3 U/kg or 6 U/kg BTX-A group. Cleaved synaptosomal associated protein 25 (c-SNAP 25) was stained to test the transportation of BTX-A, and was additionally observed in the peripheral muscles in 6 and 12 U/kg groups. c-SNAP 25, however, was barely detectable in the spinal cord after BTX-A administration. Therefore, our results suggest that low dosage of BTX-A may be a promising option for the diagnostic SMB of thoracic outlet syndrome. SIGNIFICANCE STATEMENT: Muscle block is important for the diagnosis and treatment of thoracic outlet syndrome and commonly performed with lidocaine. However, misdiagnosis was observed sometimes. Here, we found that intramuscular injection of optimal dosage lidocaine only partially blocked the muscle contraction in rats, whereas low-dosage botulinum toxin, barely used in diagnostic block, showed almost complete block without affecting the central nervous system. This study suggests that botulinum toxin might be more suitable for muscle block than lidocaine in clinical practice.
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Affiliation(s)
- Ke Xu
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Zhan Zhang
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yueying Li
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Lili Song
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jin Gou
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Chengkuan Sun
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jiayang Li
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shuang Du
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Rangjuan Cao
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Shusen Cui
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
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Thoracic outlet syndrome: a retrospective analysis of robotic assisted first rib resections. J Robot Surg 2022; 17:891-896. [DOI: 10.1007/s11701-022-01486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
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Ahmed AS, Graf AR, Karzon AL, Graulich BL, Egger AC, Taub SM, Gottschalk MB, Bowers RL, Wagner ER. Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:469-488. [PMID: 37588453 PMCID: PMC10426640 DOI: 10.1016/j.xrrt.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
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.
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Affiliation(s)
- Adil S. Ahmed
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexander R. Graf
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Anthony L. Karzon
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Anthony C. Egger
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah M. Taub
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael B. Gottschalk
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert L. Bowers
- Department of Orthopaedic Surgery, Sports Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric R. Wagner
- Department of Orthopaedic Surgery, Hand & Upper Extremity Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Panther EJ, Reintgen CD, Cueto RJ, Hao KA, Chim H, King JJ. Thoracic outlet syndrome: a review. J Shoulder Elbow Surg 2022; 31:e545-e561. [PMID: 35963513 DOI: 10.1016/j.jse.2022.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Eric J Panther
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christian D Reintgen
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Harvey Chim
- Department of Plastic and Reconstructive Surgery, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
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A clinical case of a combined endoscopic treatment: brachial plexus decompression in the thoracic aperture and subacromial spacer implantation. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract109942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Thoracic outlet syndrome compression of the brachial plexus in the area between the clavicle and the first rib is a commonly spread and important pathology. It occurs, as usual, after a trauma or due to an anatomical malformation of this area. Thoracic outlet syndrome can be combined with a shoulder joint pathology. In the case of a conservative treatment's failure, the standard surgical procedure is decompression of the brachial plexus in the thoracic aperture. This procedure is usually done via an open approach. The development of the endoscopic surgical technique of decompression allows reducing the risk of complications and recurrences, improving the cosmetic result and relieving the rehabilitation period. Clinical case description: A 73-year-old female patient with a clinical picture of posttraumatic brachial plexopathy and a massive shoulder rotator cuff tear. The patient underwent a conservative treatment for 6 months after the trauma without a significant improvement. To confirm the diagnosis, ENMG and an ultrasound investigation of the brachial plexus, as well as MRI of the shoulder joint were performed. Simultaneous shoulder joint arthroscopy with subacromial spacer implantation and brachial plexus decompression in the thoracic aperture were performed to the patient. According to the VAS-scale (Visual Analogue Scale), the severity of pain syndrome before the surgery was 10 cm, while 6 months after the surgery, it decreased to 1 cm. According to the DASH scale (Disabilities of the Arm, Shoulder, and Hand), the dysfunction of the of shoulder joint before the surgery was 76 points, while 6 months after the surgery, it decreased to 12 points. The range of motion in the shoulder joint before the surgery was as follows: flexion 105, abduction 95, external rotation 15, which increased to 160, 165, and 45, respectively, 6 months after the surgery. Conclusion: The results allow us to characterize the method of simultaneous shoulder joint arthroscopy and endoscopic decompression of the brachial plexus in the thoracic aperture as a low-traumatic and effective technique. The technique provides complete brachial plexus decompression in the thoracic aperture which promotes restoration of the function of the upper extremity and shoulder joint, and elimination of pain syndrome from the upper extremity area.
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Milenovic N, Klasnja A, Skrbic R, Popovic Petrovic S, Lukac S, Devecerski G. Sleep Problems and Disabilities of the Arm, Shoulder, and Hand in Persons with Thoracic Outlet Syndrome-A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12486. [PMID: 36231785 PMCID: PMC9566055 DOI: 10.3390/ijerph191912486] [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: 08/22/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
Thoracic outlet syndrome (TOS) arises as a result of a specific relationship among the anatomical structures that may cause compression in the muscles, nerves, and/or blood vessels in the neck, thereby compromising the local circulation. The aim of the current study was to establish the presence of sleep disturbance and disability in the shoulder, arm, and hand in individuals affected by TOS, as well as to ascertain if there are any differences in these findings relative to TOS-free individuals. The study sample comprised 82 TOS patients and 81 TOS-free individuals aged 19-66 years. Data were gathered by administering the Disabilities of the Arm, Shoulder, and Hand (DASH) and Pittsburgh Sleep Quality Index (PSQI) instruments. The results showed that both the DASH (t = -13.21, p < 0.001) and PSQI (t = -7.27, p < 0.001) scores obtained by the TOS group were higher relative to the controls and were strongly and positively correlated (ρ = 0.58, p < 0.01). As positive DASH scores may be indicative of TOS, they signal the need for further diagnostic evaluations. In individuals in whom TOS is already diagnosed, high DASH scores imply that further sleep quality assessments are required, as compromised sleep patterns may undermine quality of life.
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Affiliation(s)
- Natasa Milenovic
- Faculty of Medicine, University of Novi Sad, 21 137 Novi Sad, Serbia
- The Special Hospital for Rheumatic Diseases, 21 137 Novi Sad, Serbia
| | | | - Renata Skrbic
- Faculty of Medicine, University of Novi Sad, 21 137 Novi Sad, Serbia
| | - Svetlana Popovic Petrovic
- Faculty of Medicine, University of Novi Sad, 21 137 Novi Sad, Serbia
- Oncology Institute of Vojvodina, 21 204 Sremska Kamenica, Serbia
| | - Sonja Lukac
- Faculty of Medicine, University of Novi Sad, 21 137 Novi Sad, Serbia
- Center of Radiology, University Clinical Center of Vojvodina, 21 137 Novi Sad, Serbia
| | - Gordana Devecerski
- Faculty of Medicine, University of Novi Sad, 21 137 Novi Sad, Serbia
- Department at the Clinic for Medical Rehabilitation, University Clinical Center of Vojvodina, 21 137 Novi Sad, Serbia
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Altuwaijri TA. Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome. Medicine (Baltimore) 2022; 101:e30360. [PMID: 36086770 PMCID: PMC10980469 DOI: 10.1097/md.0000000000030360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/20/2022] [Indexed: 11/26/2022] Open
Abstract
Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity, specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity, specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%, respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone. The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.
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Affiliation(s)
- Talal A. Altuwaijri
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Factors Associated with 30-Day Adverse Events After Brachial Plexus Neurolysis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:332-336. [DOI: 10.1016/j.jhsg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
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Cavanna AC, Giovanis A, Daley A, Feminella R, Chipman R, Onyeukwu V. Thoracic outlet syndrome: a review for the primary care provider. J Osteopath Med 2022; 122:587-599. [PMID: 36018621 DOI: 10.1515/jom-2021-0276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/16/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Angela C Cavanna
- Department of Clinical Medicine, Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Athina Giovanis
- Department of Osteopathic Manipulative Medicine, Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Alton Daley
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Ryan Feminella
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Ryan Chipman
- Touro College of Osteopathic Medicine, Middletown, NY, USA
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31
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Weiss K, Grünert J, Knechtle B. [Please Don't Forget the Neurogenic Thoracic Outlet Syndrome]. PRAXIS 2022; 111:632-638. [PMID: 35975409 DOI: 10.1024/1661-8157/a003870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Please Don't Forget the Neurogenic Thoracic Outlet Syndrome Abstract. We report the case of a 52-year-old patient who was treated for years for headaches, pain in the neck and arms, and sweating. Despite various therapeutic approaches there was no improvement in the symptoms. Further investigations showed a bilateral thoracic outlet syndrome in the status after multiple bilateral rib fractures after a fall from a window at the age of 18. After the operation of a bilateral thoracic outlet syndrome, the headache disappeared almost completely and there was no more sweating.
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Affiliation(s)
- Katja Weiss
- Medbase St. Gallen am Vadianplatz, St. Gallen, Schweiz
| | - Jörg Grünert
- Klinik für Hand-, Plastische und Wiederherstellungschirurgie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Beat Knechtle
- Medbase St. Gallen am Vadianplatz, St. Gallen, Schweiz
- Institut für Hausarztmedizin, Universität Zürich, Zürich, Schweiz
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Jammeh ML, Yang A, Abuirqeba AA, Ohman JW, Thompson RW. Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series. Oper Neurosurg (Hagerstown) 2022; 23:125-132. [PMID: 35838452 PMCID: PMC9287103 DOI: 10.1227/ons.0000000000000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/16/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge. OBJECTIVE To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS. METHODS From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively. RESULTS The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P < .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P < .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P < .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%. CONCLUSION Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.
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Affiliation(s)
- Momodou L. Jammeh
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alexander Yang
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Division of Neurosurgery, Department of Surgery, Creighton University, Omaha, Nebraska, USA
| | - Ahmmad A. Abuirqeba
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J. Westley Ohman
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert W. Thompson
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Arnold MT, Hart CM, Greig DE, Trikha R, Gelabert HA, Jones KJ. Thoracic Outlet Syndrome in Major League Baseball Pitchers: Return to Sport and Performance Metrics After Rib Resection. Orthop J Sports Med 2022; 10:23259671221079835. [PMID: 35494495 PMCID: PMC9047814 DOI: 10.1177/23259671221079835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Thoracic outlet syndrome (TOS) is a rare injury that affects Major League
Baseball (MLB) pitchers and is often corrected with surgical resection of
the first rib. There are limited return-to-play (RTP) data for this surgery
in MLB pitchers. Hypothesis: It was hypothesized that MLB pitchers who undergo first rib resection for TOS
will show (1) a high rate of RTP, (2) no difference in postoperative career
length compared with controls, (3) no difference in pre- and postoperative
performance, and (4) no difference in postoperative performance compared
with controls. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective cohort study evaluated MLB pitchers with neurogenic or
vascular TOS who underwent rib resection surgery between January 1, 2001,
and December 31, 2019. Players were identified through public injury reports
from press releases, the MLB website, MLB team injury reports, and blogs. A
demographics- and performance-matched control group was generated for
comparison. Each player in the control group was given an index year that
corresponded to the surgery year of the case group. Performance data
included innings pitched (IP), games played (GP), earned run average (ERA),
complete GP, shutouts, saves, hits, runs, home runs (HR), walks, strikeouts
(K), walks plus hits per IP (WHIP), and earned runs (ER). Results: We identified 26 MLB pitchers who underwent rib resection for neurogenic or
vascular TOS; 21 players (81%) had a successful RTP. Pitchers were 30 ± 3.6
years old at the time of surgery and had played 6.2 ± 3.5 seasons before
undergoing surgery. Average postoperative career length was 3.1 ± 2.0
seasons, with an average time from surgery to RTP being 10 ± 4.7 months.
Pitchers who RTP showed no significant differences in performance metrics
compared with controls. Players pitch 0.94 (P < .05)
more IP/GP in the season directly following RTP compared with the season
before surgical intervention. Conclusion: MLB pitchers undergoing rib resection for TOS demonstrated (1) high RTP rates
following rib resection, (2) no difference in postoperative career length
compared with controls, (3) improvement in postoperative performance, and
(4) no difference in postoperative performance compared with controls.
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Affiliation(s)
- Michael T. Arnold
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christopher M. Hart
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Danielle E. Greig
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rishi Trikha
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hugh A. Gelabert
- Department of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Camporese G, Bernardi E, Venturin A, Pellizzaro A, Schiavon A, Caneva F, Strullato A, Toninato D, Forcato B, Zuin A, Squizzato F, Piazza M, Stramare R, Tonello C, Di Micco P, Masiero S, Rea F, Grego F, Simioni P. Diagnostic and Therapeutic Management of the Thoracic Outlet Syndrome. Review of the Literature and Report of an Italian Experience. Front Cardiovasc Med 2022; 9:802183. [PMID: 35391849 PMCID: PMC8983020 DOI: 10.3389/fcvm.2022.802183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
The Thoracic Outlet Syndrome is a clinical potentially disabling condition characterized by a group of upper extremity signs and symptoms due to the compression of the neurovascular bundle passing through the thoracic outlet region. Because of the non-specific nature of signs and symptoms, to the lack of a consensus for the objective diagnosis, and to the wide range of etiologies, the actual figure is still a matter of debate among experts. We aimed to summarize the current evidence about the pathophysiology, the diagnosis and the treatment of the thoracic outlet syndrome, and to report a retrospective analysis on 324 patients followed for 5 years at the Padua University Hospital and at the Naples Fatebenefratelli Hospital in Italy, to verify the effectiveness of a specific rehabilitation program for the syndrome and to evaluate if physical therapy could relieve symptoms in these patients.
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Affiliation(s)
- Giuseppe Camporese
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Enrico Bernardi
- Department of Emergency and Accident Medicine, Hospital of Treviso, Treviso, Italy
| | - Andrea Venturin
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alice Pellizzaro
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alessandra Schiavon
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Francesca Caneva
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alessandro Strullato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Daniele Toninato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Beatrice Forcato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Andrea Zuin
- Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Francesco Squizzato
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Michele Piazza
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Roberto Stramare
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Chiara Tonello
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Naples Buon Consiglio Fatebenefratelli Hospital, Naples, Italy
| | - Stefano Masiero
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Federico Rea
- Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Franco Grego
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Department of Internal Medicine, General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, University Hospital of Padua, Padua, Italy
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Gkikas A, Lampridis S, Patrini D, Kestenholz PB, Azenha LF, Kocher GJ, Scarci M, Minervini F. Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review. Front Surg 2022; 9:848972. [PMID: 35350142 PMCID: PMC8957785 DOI: 10.3389/fsurg.2022.848972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThoracic 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.MethodsWe 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.ResultsBetween 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.ConclusionsRobotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.
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Affiliation(s)
- Andreas Gkikas
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
| | - Savvas Lampridis
- Department of Thoracic Surgery, 424 General Military Hospital, Thessaloniki, Greece
| | - Davide Patrini
- Department of Thoracic Surgery, University College London Hospitals, London, United Kingdom
| | - Peter B. Kestenholz
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Luis Filipe Azenha
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Gregor Jan Kocher
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Scarci
- Department of Thoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
- *Correspondence: Fabrizio Minervini
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Shahab A, Mahadewa TGB, Sadewo W, Mardhika PE, Awyono S, Putra MB, Monica M. Novel Use of Ali Shahab Score as a Diagnostic Tool and Decision of Surgical Management in Scalenus Syndrome: A Case Series. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Scalenus syndrome is a collection of symptoms as the consequences of nerve and vascular compression within the scalene triangle. However, the entity has long been forgotten in publications and is difficult to recognize. The diagnosis of scalenus syndrome is mainly based on clinical findings. The Ali Shahab score is a new scoring system, generated based on clinical symptoms of scalenus syndrome.
AIM: In this study, we presented a case series of scalenus syndrome patients who were diagnosed and decide to be managed surgically based on Ali Shahab score. We also reported post-operative outcomes following scalenectomy in our series.
METHODS: This was a case series including patients with scalenus syndrome in Gatot Soebroto Army Hospital, Indonesia, and Siloam Asri Hospital, Indonesia, between 2016 and 2021. The diagnosis of scalenus syndrome was made based on Ali Shahab score with a value of more than 7. All patients were performed scalenectomy to decompress the stenotic subclavian artery and brachial plexus from surrounding fibrotic tissue. Eligible subjects were assessed for sex, side of symptoms, pre-operative and post-operative Ali Shahab score, and post-operative outcome.
RESULTS: We included 96 patients with scalenus syndrome in this case series. Most of the included patients were male (59.4%) and experienced scalenus syndrome on the right side (76%). The average pre-operative Ali Shahab score in our series was 7.12 ± 0.48 and the post-operative score was 0.11 ± 0. Regarding post-operative outcomes, more than half of the patients experienced symptoms reduction with 38.5% of patients experiencing complete resolution of symptoms following scalenectomy.
CONCLUSION: The application of the Ali Shahab score may be used as a diagnostic tool and decision of surgical management for scalenus syndrome patients. Decompression of the subclavian artery and releasing brachial plexus from surrounding fibrotic tissue can improve clinical symptoms in scalenus syndrome patients.
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Endara SA, Dávalos GA, Fierro CH, Montero RA, Molina GA. Paget-Schroetter syndrome in an active young female after unsupervised exercise. Int J Surg Case Rep 2022; 91:106788. [PMID: 35101717 PMCID: PMC8808051 DOI: 10.1016/j.ijscr.2022.106788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Thoracic outlet syndrome (TOS) is a rare syndrome caused by compression of one of the three neurovascular structures in their passage from the cervical area toward the axilla and proximal arm either at the interscalene triangle, the costoclavicular triangle, or the sub coracoid space. The mainstay of management is nonsurgical; however, surgery may be needed when patients persist with symptoms despite conservative management and when vascular structures are involved. Symptoms are non-specific and require high clinical awareness since this pathology tends to affect otherwise healthy young patients. CASE PRESENTATION We present the case of a 45-year-old female without any past medical history. She was active and did plenty of exercises. After a high-intensity routine without any guidance, she presented with acute upper limb swelling with pain. After further examination, a venous thoracic outlet syndrome was identified and treated without complications. CLINICAL DISCUSSION & CONCLUSION Venous TOS is a rare pathology associated with high long-term morbidity and disability if left untreated; heightened clinical awareness of the possibility of acute thrombosis obstructing venous return and producing these rare symptoms should lead the medical team to assess the patient further and lead to the appropriate medical and surgical intervention.
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Affiliation(s)
- Santiago A Endara
- Hospital Metropolitano, Department of Surgery, Division of Cardiothoracic Surgery, Quito, Ecuador.
| | - Gerardo A Dávalos
- Hospital Metropolitano, Department of Surgery, Division of Cardiothoracic Surgery, Quito, Ecuador
| | - Christian H Fierro
- Hospital Metropolitano, Department of Internal Medicine, Division of Cardiology, Quito, Ecuador
| | - R Alejandra Montero
- Hospital Metropolitano, Department of Internal Medicine, Division of Radiology, Quito, Ecuador
| | - Gabriel A Molina
- Hospital Metropolitano, Department of Surgery, Ecuador; Universidad San Francisco de Quito, Ecuador
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Bowers RL, Cherian C, Zaremski JL. A Review of Upper Extremity Peripheral Nerve Injuries in Throwing Athletes. PM R 2022; 14:652-668. [PMID: 35038233 DOI: 10.1002/pmrj.12762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/13/2021] [Accepted: 12/17/2021] [Indexed: 11/07/2022]
Abstract
Peripheral nerve injuries in the upper extremities may be common in throwing athletes as the throwing motion places extreme stress on the dominant arm. The combination of extreme stress along with repetitive microtrauma from throwing uniquely places the throwing athlete at elevated risk of upper extremity peripheral nerve injury. However, because symptoms can be non-specific and frequent co-exist with pathology in the upper extremity, the diagnosis of peripheral nerve injury is often delayed. Diagnosis of peripheral nerve injuries may require a combination of history and physical exam, diagnostic imaging, electrodiagnostic testing, and diagnostic ultrasound guided injections. The primary management should include physical therapy focusing on throwing mechanics and kinetic chain evaluation. However, some athletes require surgical intervention if symptoms do not improve with conservative management. The purpose of this focused narrative review is to highlight upper extremity peripheral neuropathies reported in throwing athletes and to provide an overview of the appropriate clinical diagnosis and management of the throwing athlete with a peripheral nerve injury. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert L Bowers
- Assistant Professor of Rehabilitation Medicine, Emory University School of Medicine, Emory Sports Medicine Center, Atlanta, Georgia, USA
| | - Chris Cherian
- Department of Sports Medicine, Rothman Orthopaedics, Paramus, New Jersey, USA
| | - Jason L Zaremski
- Department of Physical Medicine & Rehabilitation, Department of Orthopaedic Surgery & Sports Medicine, University of Florida Health Orthopaedics and Sports Medicine Institute, Gainesville, Florida, USA
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Kato N, Terao T, Ishii T, Saito E, Hirokawa Y, Michishita S, Sasaki Y, Tani S, Murayama Y. Subclavian Artery Flow Dynamics Evaluated by Analytical Intraoperative Indocyanine Green Videoangiography During Surgical Treatment of Thoracic Outlet Syndrome: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:115-122. [PMID: 34989707 DOI: 10.1227/ons.0000000000000077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Indocyanine green (ICG) videoangiography is rarely used during the surgical treatment of thoracic outlet syndrome (TOS). OBJECTIVE To evaluate subclavian artery (SA) flow dynamics using the analytical ICG videoangiography during TOS surgeries. METHODS We examined patients with neurogenic TOS who received surgical treatment and whose SA blood flow at the interscalene space was evaluated using ICG videoangiography equipped with an analytical function (FLOW800). Anterior scalenectomy with or without middle scalenectomy and first rib resection were conducted for decompression of the brachial plexus. ICG videoangiography was performed before and after decompression of the brachial plexus. After acquisition of grayscale and color-coded maps, a region of interest was placed in the SA to obtain time-intensity diagrams. Maximum intensity (MI), rise time (RT), and blood flow index (BFi) were calculated from the diagram, in arbitrary intensity (AI) units. We compared values before and after decompression. Comparisons of the three parameters before and after decompression were assessed statistically using the paired t-tests and Wilcoxon signed-rank test. RESULTS We evaluated nine procedures in consecutively presenting patients. The observed mean values of MI, RT, and BFi before decompression were 174.1 ± 61.5 AI, 5.2 ± 1.1 s, and 35.2 ± 13.5 AI/s, respectively, and the observed mean values of MI, RT, and BFi after decompression were 299.3 ± 167.4 AI, 6.6 ± 0.8 s, and 44.6 ± 28.3 AI/s, respectively. These parameters showed higher values after decompression than before decompression, and the increase in MI and RT was statistically significant (P < .05). CONCLUSION ICG videoangiography allows semiquantitative evaluation of hemodynamic changes during TOS surgery. A marked decrease in the velocity of SA flow was observed after decompression.
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Affiliation(s)
- Naoki Kato
- Department of Neurosurgery, Atsugi City Hospital, Kanagawa, Japan.,Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Tohru Terao
- Department of Neurosurgery, Atsugi City Hospital, Kanagawa, Japan
| | - Takuya Ishii
- Department of Neurosurgery, Atsugi City Hospital, Kanagawa, Japan.,Department of Neurosurgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Emiko Saito
- Department of Neurosurgery, Atsugi City Hospital, Kanagawa, Japan
| | - Yusuke Hirokawa
- Department of Neurosurgery, Atsugi City Hospital, Kanagawa, Japan
| | | | - Yuichi Sasaki
- Department of Neurosurgery, Atsugi City Hospital, Kanagawa, Japan.,Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Satoshi Tani
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
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Heye T, Timbang MR, Greiten L, Richter G. Congenital cervical rib causing thoracic outlet syndrome. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2021.102126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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41
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Ansuategui-Vicente M, Tapia-Lopez Y, Cases-Perez C, Ibarra-Sanchez G, Gutierrez AG, Gonzalez-Fajardo JA. Treatment of Thoracic Outlet Syndrome Complications Assisted with a Cerebral Embolism Protection Device. Methodist Debakey Cardiovasc J 2022; 18:108-112. [PMID: 36313530 PMCID: PMC9562785 DOI: 10.14797/mdcvj.1103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023] Open
Abstract
We report a case of a stroke and upper limb ischemia in a 27-year-old female secondary to a right cervical rib and retrograde thromboembolization. Follow-up showed complete patency of the vessels after thrombectomy and internal carotid artery stenting followed by transbrachial embolectomy performed with a cerebral protection device. The cervical rib was surgically removed to prevent additional events.
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Specialty Mediated 30-Day Complications in First Rib Resection for Thoracic Outlet Syndrome. J Surg Res 2021; 268:214-220. [PMID: 34365078 PMCID: PMC9843605 DOI: 10.1016/j.jss.2021.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/03/2021] [Accepted: 06/07/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) takes on heterogenous upper extremity manifestations depending on whether the artery, vein or brachial plexus is primarily compressed. As a result of these variable vascular and neurogenic symptoms, these patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work we examine the association of surgeon specialty with short-term outcomes following first rib resection (FRRS) for TOS. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, 3,070 patients were identified who underwent FRRS for TOS between 2006-2017. The primary outcomes of the study were 30-d complications, including postoperative hemorrhage requiring transfusion, wound complications, pneumothorax and deep venous thrombosis. Arterial, venous, and neurogenic TOS were distinguished with ICD-9 and 10 codes while patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and ICD data. RESULTS Most FRRS were performed by vascular surgeons (87.9%), general (6.9%) and thoracic surgeons (4.4%). The relative distribution of vascular TOS between the specialties was not significantly different, with non-vascular surgeons performing an equivalent amount of FRRS for arterial (1.1% versus 2.4%) and venous TOS (8.6% versus 9.1%, both P> 0.05). Patients who underwent FRRS with non-vascular surgeons experienced more frequent perioperative transfusions (3.2% versus 1.2%, P = 0.001) and wound infections (1.9% versus 0.8%, P= 0.04). On multivariable regression, patients undergoing FRRS for venous TOS were more likely to require blood transfusion (odds ratios:3.63, 95% CI 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRRS had a 40% longer operative time (incidence rate ratios:1.42, 95% CI 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratios:9.87, 95% CI 2.28-42.68). CONCLUSIONS The significantly increased operative times and transfusion requirements associated with specialties who uncommonly perform FRRS suggest the role of surgeon experience and volume in this procedure may play more of a role than specialty training. These data also suggest that vascular TOS carries unique risks that should be kept in mind when performing FRRS.
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Lim C, Kavousi Y, Lum YW, Christo PJ. Evaluation and Management of Neurogenic Thoracic Outlet Syndrome with an Overview of Surgical Approaches: A Comprehensive Review. J Pain Res 2021; 14:3085-3095. [PMID: 34675637 PMCID: PMC8502052 DOI: 10.2147/jpr.s282578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/03/2021] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Christine Lim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yasaman Kavousi
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Warrick A, Davis B. Neurogenic Thoracic Outlet Syndrome in Athletes - Nonsurgical Treatment Options. Curr Sports Med Rep 2021; 20:319-326. [PMID: 34099610 DOI: 10.1249/jsr.0000000000000854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Neurogenic thoracic outlet syndrome (NTOS) is an etiologically and clinically diverse disorder caused by compression of the brachial plexus traversing the thoracic outlet. Athletes who perform repetitive overhead activities are at risk of developing NTOS with sport-specific symptoms. This article reviews the controversial NTOS nomenclature, common sites of anatomic compression, and red flag symptoms that require immediate intervention. It also reviews the congenital, traumatic, and functional etiologies of NTOS, with a discussion of the differential diagnosis, diagnostic criteria, and workup for NTOS. Nonsurgical treatment is highlighted with an emphasis on thoracic outlet syndrome-specific physical therapy and updates on injection options and ultrasound guided hydrodissection. This article compares nonsurgical versus surgical functional outcome data with an emphasis on athletes with NTOS. Functional assessment tools and performance metrics for athletes are reviewed, as well as return to sport considerations.
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Affiliation(s)
- Alexandra Warrick
- Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, Sacramento, CA
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45
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Dukan R, Petroni G, Muller GP, Silvera J, Masmejean EH. Rare Case of Dynamic Thoracic Outlet Syndrome Resolved by an Isolated Subclavius Posticus Muscle Resection: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00072. [PMID: 34766925 DOI: 10.2106/jbjs.cc.20.00668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Ruben Dukan
- Hand, Upper Limb, and Peripheral Nerve Surgery Service, Georges-Pompidou European Hospital (HEGP), Paris, France
| | - Gautier Petroni
- Hand, Upper Limb, and Peripheral Nerve Surgery Service, Georges-Pompidou European Hospital (HEGP), Paris, France
| | | | | | - Emmanuel H Masmejean
- Hand, Upper Limb, and Peripheral Nerve Surgery Service, Georges-Pompidou European Hospital (HEGP), Paris, France.,Clinique Blomet (Research Unit), Paris, France.,University of Paris-Medical School, Paris, France
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46
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Gibson TW, Carson L. Acute Thoracic Outlet Syndrome Associated with Congenital Pseudarthrosis of the First Rib: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00052. [PMID: 34329202 DOI: 10.2106/jbjs.cc.20.00594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 15-year-old right-hand-dominant adolescent girl presented with a nondisplaced first rib fracture and evidence of mesoacromion. She reported radiating numbness, pain, temperature change, and paresthesia in her left arm. An MRI revealed a first rib fracture along with brachial plexus and scalene musculature inflammation. Follow-up radiographs demonstrated bilateral rib anomalies during routine comparison views. CONCLUSION Congenital pseudarthrosis of the first rib occurs but is not well documented in the literature. This case report describes a case of congenital bilateral first rib pseudarthrosis with associated thoracic outlet syndrome symptoms in a competitive female softball athlete.
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Affiliation(s)
- T Whitney Gibson
- Department of Pediatric Orthopaedics, Shriners Hospitals for Children-Greenville, Greenville, South Carolina
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Chang MC, Kim DH. Essentials of thoracic outlet syndrome: A narrative review. World J Clin Cases 2021; 9:5804-5811. [PMID: 34368299 PMCID: PMC8316950 DOI: 10.12998/wjcc.v9.i21.5804] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
Thoracic outlet syndrome (TOS) is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region. TOS results in pain, numbness, paresthesia, and motor weakness in the affected upper limb. We reviewed the pathophysiology, clinical evaluation, differential diagnoses, and treatment of TOS. TOS is usually classified into three types, neurogenic, venous, and arterial, according to the primarily affected structure. Both true neurogenic and disputed TOS are considered neurogenic TOS. Since identifying the causative lesions is complex, detailed history taking and thorough clinical investigation are needed. Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS. The existence of a disputed TOS remains controversial. Neuromuscular physicians tend to be skeptical about the existence of disputed TOS, but thoracic surgeons argue that disputed TOS is under-diagnosed. Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.
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Affiliation(s)
- Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu 42415, South Korea
| | - Du Hwan Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Chung-Ang University, Seoul 06973, South Korea
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Parnes N, Dunn JC, Perrine J, Scanaliato JP. Development of Parsonage-Turner Syndrome After Interscalene Brachial Plexus Block Including 10-Year Follow-up: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00015. [PMID: 34242207 DOI: 10.2106/jbjs.cc.21.00113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
CASE A 22-year-old female patient demonstrated physical examination findings of Parsonage-Turner syndrome (PTS) 5 days after left shoulder arthroscopic surgery with interscalene brachial plexus block. The diagnosis was confirmed with electrodiagnostic testing 2 weeks after surgery. Symptoms resolved spontaneously within 2 years with full return-to-preinjury sport and job activity. These outcomes were maintained at the 10-year follow-up. CONCLUSIONS PTS should be considered in the differential diagnoses for any postsurgical neurological variations after upper extremity surgery under regional anesthesia.
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Affiliation(s)
- Nata Parnes
- Department of Orthopaedic Surgery and Rehabilitation, Carthage Area Hospital, Carthage, New York
| | - John C Dunn
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas
| | - Jeff Perrine
- Department of Orthopaedic Surgery and Rehabilitation, Carthage Area Hospital, Carthage, New York
| | - John P Scanaliato
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas
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Garrison JC, Hannon JP, Conway JE. Differences in Passive Shoulder Range of Motion Between Baseball Players With Neurogenic Thoracic Outlet Syndrome and Matched Healthy Controls. Orthop J Sports Med 2021; 9:23259671211000764. [PMID: 33997065 PMCID: PMC8072852 DOI: 10.1177/23259671211000764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Neurogenic thoracic outlet syndrome (nTOS) is becoming more recognized as a diagnosis in the throwing athlete. Currently, there is limited information on the clinical presentation and development of nTOS in baseball players. Purpose: To compare passive shoulder range of motion (ROM) and anatomic humeral retrotorsion (HRT) of baseball players diagnosed with nTOS with a group of healthy, matched controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 53 adolescent baseball players diagnosed with nTOS (age, 17.2 ± 2.3 years; height, 180.9 ± 10.1 cm; weight, 80.0 ± 13.3 kg) were compared with 53 healthy baseball players (age, 17.2 ± 2.4 years; height, 183.9 ± 9.0 cm; weight, 83.8 ± 11.5 kg). Participants were measured for shoulder internal rotation (IR) and external rotation (ER) ROM and HRT. All measurements were taken bilaterally, and the differences (throwing to nonthrowing arm) were used to calculate mean values for glenohumeral internal rotation difference, glenohumeral external rotation difference (GERD), total rotational motion difference (TRMdiff), and anatomic humeral retrotorsion difference. Group comparisons were made between the nTOS and control players using multivariate analysis of variance, and descriptive comparisons were made with independent t tests. Results: There were no significant differences between groups in age, height, weight, or years of experience. Players in the nTOS group had significantly less throwing arm ER compared with controls (103.4° ± 10.4° vs 109.6° ± 7.5°, respectively; P = .001) and GERD (3.0° ± 9.2° vs 8.8° ± 9.2°, respectively; P = .002). TRMdiff was significantly greater in nTOS (–11.1° ± 11.1°) than in controls (–3.7° ± 9.4°) (P < .001). Conclusion: In the current study, adolescent baseball players diagnosed with nTOS were evaluated with shoulder ROM differences when compared with a matched healthy cohort. A loss of throwing arm ER appeared to be the main factor behind shoulder ROM changes in the nTOS group.
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50
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Bishop L, Bartlett M. Doppler waveform analysis during provocative manoeuvres in the assessment for arterial thoracic outlet syndrome results in high false-positive rates; a cross-sectional study. JRSM Cardiovasc Dis 2021; 10:20480040211006571. [PMID: 33868673 PMCID: PMC8020236 DOI: 10.1177/20480040211006571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/05/2021] [Accepted: 03/07/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Lily Bishop
- Department of Vascular Studies, Royal Free London NHS Foundation Trust, London, UK
| | - Matthew Bartlett
- Department of Surgery & Interventional Medicine, University College London, London, UK
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