Arterial Thoracic Outlet Syndrome Research Articles

Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis.

Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. Cohort study; Level of evidence, 3. All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.

17 years' experience of surgical management of thoracic outlet syndrome at a district general hospital.

Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular structures passing through the thoracic inlet. It is categorised into three subtypes: neurogenic TOS (NTOS), venous TOS (VTOS) and arterial TOS (ATOS). This study evaluates the outcomes of patients who underwent first rib resection (FRR) for TOS during a period of 17 years at a single district general hospital. Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021. A total of 62 FRRs were performed on 51 individual patients. Indications for FRR included 42 NTOS (68%), 6 VTOS (10%) and 14 ATOS (23%). Thirty-four patients (64%) were female and the mean age at time of surgery was 39 years (range 27 to 64 years). Eleven patients (21%) underwent bilateral FRR and seven cases of cervical ribs were observed. The mean time from initial symptoms to diagnosis was 18 months (range 2 to 60 months). Overall, outcomes after surgery were positive across all subtypes of TOS. Based on Derkash's classification, 52 patients (84%) reported excellent/good, 8 (13%) reported fair and 2 (3%) reported poor resolution of symptoms at 6 month follow-up. Complications included four (9%) pneumothorax, two (4%) wound infections, two (4%) haematoma, one (2%) haemothorax, three (5%) phrenic nerve complications and one (2%) brachial neuropraxia. FRR for TOS can be performed safely and effectively in a district general hospital environment with excellent patient clinical outcomes.

Validity of Ultrasound for the Diagnosis of Arterial Thoracic Outlet Syndrome

ObjectiveThoracic outlet syndrome (TOS) is a rare disorder mostly seen in younger individuals. Although patients’ 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. In 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) is a viable alternative to DSA in diagnosing arterial TOS (aTOS). MethodsPatients 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 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. ResultsFifty 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. ConclusionUS 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.

Surgical approaches for thoracic outlet decompression in the treatment of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a controversial and uncommon syndrome. Three different diagnoses can be made based on the compressed structure: arterial TOS, venous TOS, and neurogenic TOS. Diagnosing TOS, especially neurogenic TOS, remains difficult since a single diagnostic tool does not exist. Although this resulted in a lot of confusion, standardization of care and outcome improved daily care practice measures in the last decade. Current treatment algorithms consist of both conservative and surgical treatment approaches, which should be chosen depending on the type of TOS and extend of the complaints. Surgical treatment of TOS is performed via thoracic outlet decompression (TOD). TOD surgery includes complete resection of the first rib (cartilage to cartilage), transection of the scalene muscles and complete neurolysis/venolysis or arteriolysis. Four different approaches can be chosen for TOD surgery: the transaxillary (TA), supraclavicular (SC), paraclavicular (PC), and infraclavicular (IC) approach. The TA, SC, and PC approach can be used for every form of TOS. However, the PC approach is mostly used for treating venous TOS. The IC approach has no role in treating neurogenic or arterial TOS and is only used for venous TOS. Every approach has its own benefits and limitations and literature does not agree on what approach is best. Therefore, the used surgical approach for TOD should be based on the surgeon's preference and experience. The aim of this review is to present an overview of the diagnostic pathway and provide an in-depth description of the surgical approach in each form of TOS.

Cinematic Rendering of Arterial Thoracic Outlet Syndrome from Intraarterial-CTA

Cinematic Rendering of Arterial Thoracic Outlet Syndrome from Intraarterial-CTA

Reverse Flow Thromboembolism From Distal Subclavian Artery Aneurysm Due to Arterial Thoracic Outlet Syndrome and Posterior Circulation Stroke- Role of Dynamic Doppler Imaging.

Arterial thoracic outlet syndrome (aTOS) is the least common among the 3 subtypes of thoracic outlet syndrome and can be the cause of posterior circulation infarction due to thrombus from a secondary thrombosed subclavian-axillary artery aneurysm. Here, we report a case of a 51-year-old man who presented to our institute with sudden onset vertigo, dizziness, vomiting, gait imbalance, and visual field defects immediately after strenuous exercise. Computed tomography angiography revealed bilateral cervical ribs with aneurysmal dilatation of the left distal subclavian and proximal axillary arteries. The computed tomography also revealed subacute infarcts in the bilateral cerebellar hemispheres, as well as in the bilateral occipital lobes. Color Doppler evaluation of the subclavian artery after hyperabduction of the ipsilateral arm revealed a continuous reversal of flow in the subclavian artery, which reached the vertebral ostia. The left cervical rib was resected, aneurysm was repaired, and the patient remained asymptomatic on follow-up. Posterior circulation stroke caused by the ipsilateral thrombosed subclavian artery aneurysm in an adult patient with aTOS due to a complete cervical rib is rare. A high index of suspicion should be present for thoracic outlet syndrome in patients with stroke and upper-limb arterial claudication symptoms. Dynamic Doppler evaluation in such patients can be used to demonstrate the underlying pathomechanism, and definitive surgical treatment can prevent further ischemic episodes. Posterior circulation stroke caused by partially thrombosed distal subclavian and axillary artery aneurysms due to aTOS is rare.

Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression.

We aimed to report efficacy, safety, and health-related quality of life (HRQoL) outcomes of a multidisciplinary treatment approach including supraclavicular thoracic outlet decompression among patients with thoracic outlet syndrome (TOS). TOS is a challenging condition where controversy remains in diagnosis and treatment, primarily given a lack of data exploring various treatment approaches and associated patient outcomes. Patients who underwent unilateral, supraclavicular thoracic outlet decompression, or pectoralis minor tenotomy for neurogenic, venous, or arterial TOS were identified from a prospectively maintained database. Demography, use of preoperative botulinum toxin injection, and participation in multidisciplinary evaluation were measured. The primary endpoints were composite postoperative morbidity and symptomatic improvement compared with baseline. Among 2869 patients evaluated (2007-2021), 1032 underwent surgery, including 864 (83.7%) supraclavicular decompressions and 168 (16.3%) isolated pectoralis minor tenotomies. Predominant TOS subtypes among surgical patients were neurogenic (75.4%) and venous TOS (23.4%). Most patients (92.9%) with nTOS underwent preoperative botulinum toxin injection; 56.3% reported symptomatic improvement. Before surgical consultation, few patients reported participation in physical therapy (10.9%). The median time from first evaluation to surgery was 136 days (interquartile range: 55, 258). Among 864 patients who underwent supraclavicular thoracic outlet decompression, complications occurred in 19.8%; the most common complication was chyle leak (8.3%). Four patients (0.4%) required revisional thoracic outlet decompression. At a median follow-up of 420 days (interquartile range: 150, 937) 93.3% reported symptomatic improvement. Based on low composite morbidity, need for very few revisional operations, and high rates of symptomatic improvement, a multidisciplinary treatment approach including primarily supraclavicular thoracic outlet decompression is safe and effective for patients with TOS.

How I do it. Thoracic outlet syndrome and the transaxillary approach

Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach.

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

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.

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

Thoracic outlet syndrome (TOS) is a rare condition caused by compression of the neurovascular structures within the thoracic outlet. Different classifications of TOS exist depending on the neurovascular structure being compressed: neurogenic, venous, or arterial. Any of these forms can present independently or coexist with one other. TOS symptoms are sometimes precipitated by the presence of boney abnormalities that often require surgical intervention for ultimate resolution. This retrospective review will examine the presentations and outcomes of patients with TOS whose cause was a boney abnormality. A total of 73 patients who underwent thoracic outlet surgery between 2016 and 2021 were retrospectively reviewed via electronic medical records. Twelve (16%) patients demonstrated boney abnormalities on presentation causing their symptoms. The patients with boney abnormalities were analyzed based on venous, arterial, or neurogenic TOS diagnosis. Of the 12 patients with boney abnormalities, 5 were classified as venous TOS, 6 patients as neurogenic TOS, and 1 as arterial TOS. The boney abnormalities were as follows: venous TOS: three clavicular fractures, one nonfused congenital clavicle, and one residual rib; neurogenic TOS: three fractured first ribs, one fractured clavicle, and two cervical ribs; and arterial TOS: fused first and second rib with bilateral cervical ribs and arterial compression. Postoperatively, there were no artery, vein, or nerve injuries. Five patients had a pneumothorax treated over night with a chest tube, and one patient had a superficial wound infection. The median hospital stay was 1day. All patients completed physical therapy after surgery. All patients have symptom resolution at follow-up. Patients with boney abnormalities constitute about one-fifth of patients who can present with all three forms of TOS: neurogenic, arterial, and venous, and some will have more than one of these presentations. Results in patients undergoing surgery with boney abnormalities causing thoracic outlet syndrome are excellent with symptom resolution and without substantial complications.

Functional outcome of arterial thoracic outlet syndrome treatment.

The low prevalence of Arterial Thoracic Outlet Syndrome (ATOS) and diffuse symptomatology have resulted in limited data on optimal treatment strategies and long-term outcome. The aim of this study was to report and evaluate a single center experience with the treatment of ATOS including midterm patient reported outcome. All patients treated for ATOS from 2004 to 2020 were retrospectively identified. Patients were divided into two groups based on presenting symptoms; ATOX group (Acute arterial occlusion with ischemia) and ATOS group (claudication symptoms). Baseline characteristics and treatment details were extracted from electronic patient files. A telephone survey was conducted to collect patients' follow-up data including a functional disability score using the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The primary endpoint of this study was symptom-free survival. Secondary endpoints were median QuickDASH scores during follow-up, postoperative complications and possible re-interventions. A total of 20 patients (mean age 44.6 years, median follow-up 50.5 months) were included and divided into two groups (ATOX N = 9, ATOS N = 11). In the ATOX group, eight patients were primarily treated with catheter directed thrombolysis (CDT; N = 5) or surgical thrombectomy (N = 3). All patients received staged thoracic outlet decompression surgery (TOD). In the ATOS group, 10 patients primarily received TOD and one patient was treated conservatively with physiotherapy. Seven ATOX patients and nine ATOS patients were symptom free at follow-up with a median QuickDASH score of 2.3 (IQR 12.5) and 2.3 (IQR 16.5) respectively. Ten complications occurred in the ATOX group; three bleeding complications, five re-occlusions, one arterial dissection and one occipital infarction. In the ATOS group five complications occurred; one perioperative bleeding complication, three re-occlusions and a stent fracture. Seven vs. five re-interventions were required in the ATOX and ATOS groups respectively. The mid-term self-reported symptom free survival in both the ATOX as well as ATOS group seems acceptable while median QuickDASH scores in both groups indicate a very good functional outcome. This however comes at the cost of treatment related bleeding complications in especially the ATOX group presumably due to thrombolysis, and re-interventions required in almost one out of three patients.

Endovascular Management of Two Uncommon Cases of Acute Upper Limb Ischemia in Young

AbstractAcute upper limb ischemia accounts for less than 5% of all cases of limb ischemia. The etiology in young individuals are usually traumatic. Other non-traumatic causes are rarely seen and here we present two such cases in young, presenting with acute upper limb ischemia. The choice between a surgical or a minimally invasive endovascular approach remains unclear. Endovascular approach to management, although based on expertise, offers good post procedural outcome, comparable to post-surgical outcomes. Here we present two cases of thrombotic occlusion of the upper extremity following trauma and arterial thoracic outlet syndrome respectively managed successfully with endovascular approach.

Think About Klippel–Feil as Causing Neurogenic Thoracic Outlet Syndrome!

A 49-year-old woman presented with bilateral symptomatic neurological and arterial thoracic outlet syndrome. Computed tomography angiography revealed bilateral cervical ribs (black arrows), synostosis with the first right rib (B,*), and a post-stenotic dilatation of the right subclavian artery (A, white arrow). The presence of a supernumerary hemi-vertebra at the cervicothoracic hinge and fused C6 – C7 cervical vertebrae (star) supported the diagnosis of Klippel–Feil syndrome. Transaxillary resection of the cervical and first ribs and scalene muscles was first performed on the right.

When Healing Hands Hurt: Epidemiology of Thoracic Outlet Syndrome Among Physicians

Thoracic outlet syndrome (TOS) is an infrequent condition which results in disability in use of upper extremity. While TOS is often associated with manual labor, industrial workers, and accidents, it has not been reported in a physician (MD) population. Given the investment of time and effort in training to become a MD, the impact of TOS may be devastating. Our objective is to report the presentation and outcome of TOS in MDs. A prospectively surgical database was reviewed for MDs who sought care of disabling TOS between 1997 and 2022. Demographic, clinical, outcome and pathological data were reviewed. Outcomes were assessed based on Somatic Pain Scale (SPS), Quick Disabilities of Arm, Shoulder and Hand (DASH) scores, and Derkash scores. Results were also assessed based on return to employment. A total of 19 MDs were identified, from 1,687 TOS cases. The group included 13 (63%) men, 6 (31%) women, average age 45years (range 27-57). Presentations included 1 (5.3%) arterial TOS (ATOS), 9 (47.4%) venous TOS (VTOS), and 9 (47.4) neurogenic TOS (NTOS). All patients were right-handed, and symptomatic side was dominant hand in 7 (37%) patients. Etiologies included repetitive motion injury, athletic injury, and congenital bony abnormalities. Repetitive motion was associated with 3/9 (33%) NTOS. Significant athletic activities were noted in 12 of 19 (63%) MDs, including 8/9 (89%) VTOS and 4/9 (44%) NTOS. Athletic activities associated with VTOS included triathletes (2), rock climbing (1), long distance swimming (2), and weightlifting (3). Of the 9 NTOS cases, 3 were associated with weightlifting and 1 with skiing. Congenital causes included 1 (5%) abnormal first rib and 1 (5%) cervical rib. Time from symptom onset to consultation varied significantly according to diagnosis: ATOS 6days, VTOS 97days, and NTOS 2,335days (P<0.05). All underwent first rib resection (FRR), and 4 (4) patients required contralateral FRR. Time from surgery to last follow-up averaged 1,005days (range: 37-4,535days). On presentation, 6 patients were work disabled and 13 patients were work restricted. Following surgery, 4 MDs remained work restricted with mild to moderate symptoms. After surgery, standardized outcomes (SPS, Quick DASH, and Derkash score) improved in all metrics. All who were initially disabled returned to work without restriction. Significant non-TOS related comorbidities were present in all who had residual restriction. Return to work was documented in all. Although it has not been reported, MDs are subject to developing TOS. Causes include repetitive motions, athletic injuries, and congenital bony abnormalities. Surgical decompression is beneficial with significant reduction in pain and disability. MDs are highly motivated and insightful; accordingly, they have a very high probability of successful work resumption, with all returning to their medical positions.

Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome.

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.

Arterial thoracic outlet syndrome: a 30-year experience in a high-volume referral center.

The purpose of this study was to assess the clinical presentation and contemporary management of arterial thoracic outlet syndrome (TOS) in high-volume referral center. We conducted a retrospective review of a prospectively maintained database of patients with TOS of any etiology between January 1st 1990 and 2021. Supra-, or combined supra-/infraclavicular approaches have been used for decompression/vascular reconstructions. The group was divided into two equal time periods: period 1 (1990-2006, N.=27) and period 2 (2006-2021, N.=36). Sixty-three consecutive patients underwent surgical treatment due to arterial TOS. Period 2 had more patients who were asymptomatic (N.=16, 44.4% vs. N.=0, 0%, P<0.001) and those presenting with critical hand ischemia (N.=12, 33.3% vs. N.=0, 0%, P=0.01), while acute limb ischemia was more common in period 1 (N.=16, 59.2% vs. N.=5, 13.9%, P<0.001). SA compression without lesion was more common in period 2 (N.=16, 44.4% vs. N.=0, 0%, P<0.001), while SA intimal damage with mural thrombus formation was more common in the period 1 (N.=12, 44.4% vs. N.=1, 2.7%, P<0.001). Decompression as an isolated procedure was performed in 25.4% (N.=16) of all asymptomatic patients, while combined decompressive and vascular procedure in 71.4% (N.=45) of patients. The most common postoperative complication was pneumothorax (N.=7, 11.1%). The supraclavicular approach with its modifications provides adequate decompression and allows also repair or reconstruction of the SA, as well as complete additional revascularization of the upper extremity without the need for further patient repositioning. While treatment methods and early outcomes have not changed significantly over time, there has been a trend towards different clinical and SA pathomorphological presentation.

Poster 119: Outcomes after Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis

Objectives:Determine the performance and return to play (RTP) outcomes for professional baseball players that undergo surgical treatment for thoracic outlet syndrome.Methods:All professional baseball players who underwent surgical treatment of TOS between 2010-2017 were identified using the major league baseball (MLB) HITS (Health and Injury Tracking System) database. Demographic and performance data (pre and post-surgery) for each player was recorded. Standard demographic and return to play outcomes were measured for all players and compared between different types of TOS and league status. Performance variables were analyzed for pitchers and compared to a 1:1 matched set of control pitchers.Results:Overall, 52 players underwent surgery for TOS of which 46 (88%) were pitchers. Neurogenic TOS was the most common and seen in 69% of players. Venous TOS was seen in 29% of players, and a single player had arterial TOS. Following TOS surgery, 79% of players returned to play at the same level (RTSP) and played at least 3 years after surgery. There was no differences in RTSP rate based on the type of TOS. There was no statistically significant difference in RTP and RTSP rates between major and minor league players. In pitchers only, there was a 76% RTSP, which was not different from the natural attrition of control pitchers (p=0.874). Following TOS surgery, pitchers saw a decline in several performance metrics, but not statistically different when compared to the control pitchers. This indicated that the decline in performance following TOS surgery was similar to the decline seen in healthy professional pitchers as they age.Conclusions:The most common type of TOS seen in professional baseball players is neurogenic. The RTSP rate following surgery for TOS in all professional baseball players is 79%. There was no statistically significant difference in ability to RTP based on the type of TOS or league status. Pitchers who underwent surgery for TOS had no significant difference in pitching performance metrics following surgery compared to matched controls. Overall, surgery for thoracic outlet syndrome can help prolong a professional baseball players career and help pitchers maintain their performance over time similar to their peers who have not had surgery for TOS.

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

To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS). This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months). A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases. Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

Combined nerve and vascular ultrasound in thoracic outlet syndrome: A sensitive method in identifying the site of neurovascular compression.

We investigated the diagnostic utility of combined nerve and vascular ultrasound in thoracic outlet syndrome (TOS) in a retrospective cohort study on two sites, involving 167 consecutive patients with the clinical symptoms suggestive of neurogenic and/or vascular TOS, and an age- and sex-matched control group. All patients and control subjects underwent nerve ultrasound of the supraclavicular brachial plexus to look for fibromuscular anomalies / compression of the brachial plexus in the scalenic region, and vascular ultrasound of the infraclavicular subclavian artery with the arm in neutral and abducted position, serving as an indicator for costoclavicular compression of the neurovascular bundle. Based on clinical symptoms, neurogenic TOS (81%) was the most frequent type of TOS, followed by combined neurogenic and arterial TOS (8%). The frequency of abnormal nerve and/or vascular ultrasound findings differed significantly from the control group (P<0.00001). The pooled sensitivity was 48% for nerve ultrasound, 85% for vascular ultrasound, and 94% when combined. Among the findings, the fibromuscular ‘wedge-sickle sign’, indicating compression of the lower trunk in the scalenic region by a congenital fibromuscular anomaly (e.g. Roos ligaments), showed the highest specificity (100%). A bony ‘wedge-sickle sign’ was also delineated, where lower trunk compression is caused by the neck of the 1st rib. As implied by the higher sensitivity of vascular ultrasound, the most common site of compression was the costoclavicular space, but multilevel compression was also frequently observed. In summary, combined nerve and vascular ultrasound is a sensitive and reliable method to support the diagnosis of TOS. It can also identify the site(s) of compression, with obvious therapeutic consequences.

Reliability and validity of the elevated arm stress test in the diagnosis of neurogenic thoracic outlet syndrome

ObjectivesThe objective of this retrospective analysis of prospectively collected data was to assess the test-retest reliability and validity of the elevated arm stress test (EAST) as measured by the duration in a cohort of patients with suspected neurogenic thoracic outlet syndrome (NTOS). MethodsPatients evaluated for NTOS between January 2017 and September 2018 were identified. Test-retest reliability by the intraclass correlation coefficient was determined for duration of the EAST. For the validity analysis, patients were classified in a proven NTOS group or a symptomatic control group without NTOS using the Society for Vascular Surgery reporting standards and the outcome of thoracic outlet decompression surgery. A receiver operating characteristic curve was made for the duration of EAST. The area under the curve, and positive and negative predictive values were calculated for the EAST. ResultsIn total, 428 patients with suspected NTOS were retrospectively analyzed. Of these patients, 61 were excluded because no EAST data was available. Another 101 patients were excluded because of inconclusive reporting standards, arterial or venous TOS, or because thoracic outlet decompression surgery was not performed or had a negative result. The validity analysis in the remaining 266 patients showed an area under the curve for the duration of the EAST of 0.62 (95% confidence interval, 0.55-0.69). The positive predictive value of the duration ranged between 65% and 66%, and the negative predictive value between 53% and 58%. For the test-retest reliability analysis, 118 patients were excluded because they performed only one measurement in a 100-day time period. Analysis in the remaining 148 patients showed an intraclass correlation coefficient value of 0.65 (95% confidence interval, 0.55-0.74) for duration. ConclusionsThe EAST measured by the duration showed a moderate test-retest reliability, but the discriminative value was low in the diagnosis of NTOS. The outcome of the EAST measured by the duration should be used with caution.