Decompression For Thoracic Outlet Syndrome Research Articles

Number of Patient Self-Reported Allergies Can Affect Outcomes after Surgical Decompression for Thoracic Outlet Syndrome

Number of Patient Self-Reported Allergies Can Affect Outcomes after Surgical Decompression for Thoracic Outlet Syndrome

Erector Spinae Plane Block versus Continuous Perineural Local Anesthetic Infusion for Postoperative Pain Control After Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A Matched Case-Control Comparison

The purpose of this study was to determine if single injection erector spinae plane blocks are associated with improved pain control, opioid use, numbness, length of stay, or patient satisfaction compared to intraoperatively placed continuous perineural infusion of local anesthetic after decompression of neurogenic thoracic outlet syndrome. This is a retrospective cohort study at a tertiary academic center of eighty patients that underwent supraclavicular decompression for thoracic outlet syndrome between May 2019 and January 2020. Forty consecutive patients treated with single-injection preoperative erector spinae plane blocks were retrospectively compared to 40 age- and gender-matched controls treated with continuous perineural infusion. The primary outcome of mean pain scores was not significantly different between the erector spinae and perineural infusion groups over the three-day study period (4.2-5.3 vs 3.0-5.1 P=0.08). On post-operative day 0, mean pain scores were significantly higher in the erector spinae group (4.2 vs 3.0, P=0.02). While statistically significant, the score was still lower in the erector spinae group on day 0 than on day 1,2, or 3 in either group. Opioid use, nausea, length of stay and patient satisfaction were also similar. Upper extremity numbness was significantly less severe in the erector spinae group (36% vs 73% moderate-extreme, P=0.03) at 6-month follow-up. Seventy-two-hour perineural local anesthetic infusion did not provide superior analgesia compared to preoperative single-injection erector spinae blocks. Furthermore, there was significantly less long-term postoperative numbness associated with erector spinae blocks compared to perineural local anesthetic infusion.

Contemporary Outcomes of Supraclavicular Decompression for Thoracic Outlet Syndrome

The optimal approach to decompression in patients with thoracic outlet syndrome (TOS) is controversial due to a paucity of safety and effectiveness data. We sought to report outcomes of a comprehensive approach to supraclavicular TOS decompression with first rib resection in a contemporary cohort of patients with TOS.

Differences in quality of life outcomes after paraclavicular decompression for thoracic outlet syndrome

BackgroundThoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms. However, little is known about long-term function and quality of life (QoL) from a patient's perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach. MethodsA prospectively maintained database was used to conduct a retrospective review of patients who underwent thoracic outlet decompression between August 2004 and August 2018. We excluded patients without complete follow-up data. Functional outcomes were assessed by the Derkash classification (poor, fair, good, excellent) using contingency table methods, and QoL was assessed by the 12-Item Short Form Health Survey (SF-12) using general linear models. SF-12 was scored by published criteria, and scale-specific and aggregate mental and physical health-related QoL scores were computed. Aggregate QoL scores range from 0 (terrible) to 100 (perfect). Secondary outcomes included mortality, complications, and duration of hospital stay. ResultsWe performed 105 operations for TOS, and 100 patients with complete follow-up data were included in the study. Five patients were lost to follow-up. Median age was 35 (interquartile range, 24-47) years, and 58 (58%) were female. The median duration of hospital stay was 4 (interquartile range, 3-5.5) days. Of these patients, 46 had venous etiology, 8 arterial, 42 neurogenic, and 4 mixed vascular and neurogenic. Good or excellent Derkash results were reported in 77 (77%) patients, 46 of 54 (85%) of those with vascular TOS vs 31 of 46 (67%) of those with neurogenic etiology (P < .036). SF-12 score was obtained in 93 of 100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic TOS (NTOS) reported significantly lower aggregate mental health QoL than patients with vascular-only TOS (57 vs 59; P < .016). This effect persisted across the entire duration of follow-up and was unaffected by time from surgery (regression P for time = .509). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P = .303), and all patients improved linearly with time (0.5 scale unit/y; P < .009). Three patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n = 6), neurapraxia (n = 6), and lymph leak (n = 2) treated with tube thoracostomy. ConclusionsNTOS is associated with significantly worse functional outcome assessed by the Derkash classification. NTOS also demonstrated worse composite mental health QoL, which did not improve over time. In contrast, composite physical health QoL improved linearly with time from surgery regardless of etiology of TOS.

Transaxillary decompression of thoracic outlet syndrome

Transaxillary decompression of thoracic outlet syndrome

Transaxillary decompression of thoracic outlet syndrome: A single-center study

Objective: Transaxillary approach for the surgical management of thoracic outlet syndrome (TOS) has the advantage of minimal manipulation of brachial plexus and lesser perioperative and postoperative complications. We studied the clinical presentation and transaxillary surgical excision of the first rib in TOS at our center. Materials and Methods: All patients with TOS were reviewed for their clinical presentation and outcomes of transaxillary approach for thoracic outlet decompression over a period of 10 years. We evaluated the clinical presentation, surgical details, and postoperative course of all patients who underwent surgery. Results: Sixty-three patients of TOS were studied who underwent decompression through transaxillary approach over a period of 10 years. Nearly 79.4% of the patients had neurological symptoms, whereas 20.6% had arterial symptoms. Almost all patients (98.4%) had a cervical rib. One-fourth of the study population had bilateral cervical ribs. Around 17.46% of the patients presented with acute thromboembolism of the brachial artery and were managed with emergency thromboembolectomy. Postoperative complications encountered were pleural breach (11.11%), wound infection (7.94%), and re-thrombosis (1.59%). Conclusions: Transaxillary resection of the cervical/ first rib has excellent results, with less morbidity. It is efficient in relieving symptoms and gives cosmetically acceptable scar. It is proposed that whenever any patient presents with acute upper-limb ischemia, he/she must be evaluated for cervical rib as a cause of TOS.

Endovascular Reconstruction of Subclavian Artery Aneurysms in Patients with Arterial Thoracic Outlet Syndrome

Subclavian artery aneurysms associated with thoracic outlet syndrome (TOS) have traditionally been managed by open surgical reconstruction. Endovascular subclavian artery reconstruction is novel in the setting of arterial TOS (aTOS). Our objective is to report our results with endovascular subclavian artery reconstruction in aTOS patients over a 10-year period with attention to surgical approach and late results. Patients who underwent stent-graft reconstruction of subclavian artery aneurysms associated with aTOS between 2006 and 2016 were identified in a prospective database. Data collected included age, gender, presentation, surgical details, and outcomes. Over the study period, 869 TOS procedures were performed. Of these, 7 (0.8%) were aTOS related subclavian artery aneurysms managed with stent-graft repair. All presented with upper extremity pain (7) and a majority with limb-threatening ischemia (6). Other significant findings included subclavian artery aneurysm (7), cervical rib (4), and clavicular fracture (3). TOS decompression was accomplished via transaxillary cervical and first rib resection. Stent-graft deployment was performed concurrently with TOS decompression via brachial artery approach. The mean follow-up period was 24.9months (range 1-60). Two patients required reintervention for stent thrombosis (1.5months, 36months) and 1 required balloon angioplasty for in-stent restenosis (24months). Limb salvage was achieved in all patients with no major amputations, no minor amputations, and restoration of normal function in all. Our experience indicates that stent-graft reconstruction of subclavian artery aneurysms associated with aTOS is successful. This procedure was characterized by short surgical times, low blood loss, and no complications. It may be subject to late graft thrombosis or stenosis and requires life-long surveillance.

Thirty-Day Outcomes Following Surgical Decompression of Thoracic Outlet Syndrome.

Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization. The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013. There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays ( P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9). Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.

Supraclavicular Approach on Thoracic Outlet Syndrome

Background: Thoracic Outlet Syndrome (TOS) is a clinical syndrome that refers to abnormal compression of the neurovascular in the neck and axilla with signs and symptoms manifesting in the shoulders, neck, arms, hands and sometimes fingers. It may be underdiagnosed because this syndrome is poorly understood. The compression is primarily neurogenic, vascular, or both. As the number of patients undergoing successful treatment increases, TOS is becoming a common diagnosis. In those patients in whom pain is refractory to conservative care, surgery should be considered. The aim of this study is to evaluate the outcome of a supraclavicular approach to treat the thoracic outlet syndrome patients in Dr. Ramelan Navy Hospital Surabaya.Materials and methods: This study is a case series of 16 patients (10 females and 6 males) of 19-50 years old, who underwent neurovascular compression with the supraclavicular approach. Symptoms were evaluated with medical records based on peri-operative anamnesis and physical examination.Results: The follow-up with 16 patients showed excellent results such as decreasing pain, decreasing sensory or motoric symptoms, and complications like pneumothorax hematothorax, and injury of artery, vein or plexus brachialis were not found.Conclusion: Supraclavicular approach is relatively effective and safe for neurovascular decompression of TOS. Excellent outcomes were observed with a small incision, safe and minimal complications.

Supraclavicular Approach on Thoracic Outlet Syndrome

Background: Thoracic Outlet Syndrome (TOS) is a clinical syndrome that refers to abnormal compression of the neurovascular in the neck and axilla with signs and symptoms manifesting in the shoulders, neck, arms, hands and sometimes fingers. It may be underdiagnosed because this syndrome is poorly understood. The compression is primarily neurogenic, vascular, or both. As the number of patients undergoing successful treatment increases, TOS is becoming a common diagnosis. In those patients in whom pain is refractory to conservative care, surgery should be considered. The aim of this study is to evaluate the outcome of a supraclavicular approach to treat the thoracic outlet syndrome patients in Dr. Ramelan Navy Hospital Surabaya.Materials and methods: This study is a case series of 16 patients (10 females and 6 males) of 19-50 years old, who underwent neurovascular compression with the supraclavicular approach. Symptoms were evaluated with medical records based on peri-operative anamnesis and physical examination.Results: The follow-up with 16 patients showed excellent results such as decreasing pain, decreasing sensory or motoric symptoms, and complications like pneumothorax hematothorax, and injury of artery, vein or plexus brachialis were not found.Conclusion: Supraclavicular approach is relatively effective and safe for neurovascular decompression of TOS. Excellent outcomes were observed with a small incision, safe and minimal complications.

Surgical and functional outcomes after thoracic outlet syndrome decompression via supraclavicular approach: A 10-year single centre experience

Surgical and functional outcomes after thoracic outlet syndrome decompression via supraclavicular approach: A 10-year single centre experience

Surgical and Functional Outcomes After Thoracic Outlet Syndrome Decompression via Supraclavicular Approach: A 10-Year Single Centre Experience

Background: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the region of thoracic outlet. Treatment depends on the variant (venous, arterial, neurological or any combination of these), severity of symptoms and response to the conservative management. The aim was to assess surgical and functional outcomes after surgical decompression using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Methods: A retrospective review of all TOS cases operated in our department between 2002 and 2012. Collected data provided information on patients’ demographics, TOS type, operative findings, complications and follow-up. The pre and post operative DASH questionnaire scores were recorded. Results: Forty four patients (88%) completed pre and post operative DASH questionnaire. Mean age was 42 ± 10.78 years (range 16 - 60) and 37 were women. Twenty seven patients had the combination of neurological and vascular symptoms. The reminder of patients presented with venous TOS (vTOS, n = 5), arterial TOS (aTOS, n = 7) and 3 cases with venous-arterial TOS. There were 40 elective and 4 emergency operations. All operations were performed under the general anaesthesia and via supraclavicular approach. Decompressive procedures consisted of an excision of the cervical (n = 11) or first rib (n = 23), combined cervical and first rib excision (n = 10), scalenectomy (n = 42) and division of soft tissue (n = 24). Post operative complications included wound infection (n = 1), phrenic nerve traction injury (n = 2) and pleural entries (n = 12). There were no brachial plexus or vascular injuries. Mean follow up was 11.7 ± 15.4 months. Mean DASH questionnaire scores improved post operatively across all TOS groups. When DASH scores were analysed according to the TOS type, the most marked post operative improvement was noted in aTOS with mean delta change of 36.99 ± 22.72, followed by vTOS (26.22 ± 16.89) and nTOS (18.64 ± 21.07). These findings were statistically significant with P < 0.05. Thirty nine (78%) patients reported the return of upper limb function. Only 5 patients (nTOS) reported worsening of the limb function. Conclusions: Careful selection of patients with meticulous surgical technique can produce excellent surgical and functional outcomes in all TOS types. doi: http://dx.doi.org/10.4021/jcs152w

Surgical Treatment for Bilateral Thoracic Outlet Syndrome (TOS)

Thoracic outlet syndrome (TOS) is a complex entrapment syndrome of the brachial plexus in the thoracic outlet, specifically at the scalene triangle. Although it presents a controversial topic with regards to nomenclature, symptoms, signs, tests, diagnosis, and treatment, it nevertheless exists as a clinical entity. From 1993 to 2004, 42 highly selected patients were diagnosed with 47 TOS were operated on at Chang Gung Memorial Hospital by the senior author (DCC Chuang). Among them five patients with bilateral TOS underwent surgical intervention on both sides. Routine surgical decompression for TOS, including near total resection of the scalene anterior muscle, first rib and cervical rib if present was performed. All patients achieved a good result with release in symptoms and signs, and an increase in limb or hand muscle strength. Complications due to the operation were minimal. There were no cases of symptoms recurrence during one to ten years of post-operative follow-up. The scalene anterior muscle and dynamic first rib anomalies play an important role in the pathophysiology of TOS. Advances in our understanding, evaluation and diagnosis, and improved surgical technique have lead to more predictable outcome. In conclusion, surgical intervention, even for bilateral TOS, is warranted.

Outcome following surgery for thoracic outlet syndrome

Introduction: the diagnosis of thoracic outlet syndrome (TOS) relies heavily on subjective rather than objective assessment criteria. Subsequently, published results after surgical decompression vary considerably. This study aimed to use a symptom-based patient-directed questionnaire to assess the outcome after decompression for TOS. Methods: sixty patients who underwent decompression procedures were identified from a prospectively maintained vascular database. Patient records were analysed for details regarding initial presentation, investigation, type of procedure used for decompression and management. Outcome questionnaires were sent to all identified patients to give a patient-based outcome measure. Results: eighty-four per cent of patients responded. In 90% of these patients there was an improvement in symptoms post-surgery with a median follow up of 43 months. The results were not influenced by the procedure or approach used. Conclusion: surgery remains an effective tool in the management of TOS. A simple patient-directed questionnaire as used in this study could assist in the standardisation of outcome assessment.Eur J Vasc Endovasc Surg 26, 170-175 (2003)

Surgical treatment of thoracic outlet syndrome: effect and results of surgery

Background Because of the difficulty in diagnosis and different treatment options, debate on thoracic outlet syndrome (TOS) has continued. Our aim is to report our surgical experience. Methods Forty-seven patients with thoracic outlet syndrome were operated on between 1985 and 2000. Mean age was 37.9 years (range, 17 to 58 years); female/male ratio was 41/6. The most frequent symptom was paresthesia (72.3%). Seventeen patients (36%) had bilateral symptoms. Of all, 89.3% (42 cases) were neurologic thoracic outlet syndrome, and 10.7% (five cases) were vascular. Lower plexus (C8-T1/ulnar nerve) compression was present in 36 patients and upper plexus (C5-C7/median nerve) compression in 6 patients. Doppler ultrasonography in 11 patients, angiography in 8, and lymph node scintigraphy in 1 patient were also performed. Main operative indications were persistence of symptoms after conservative therapy and reduced (< 60 m/s) ulnar nerve conduction velocity. Results Fifty-five operations were performed on the 47 patients. First (59.6%) and cervical costae (21.3%) resections were the most frequent operations. Mean ulnar nerve conduction velocity was 54.8 m/s (range, 43 to 68 m/s) preoperatively and 69.4 m/s (range, 47 to 70 m/s) postoperatively ( p < 0.05). The morbidity rate was 17% (8 of 47). No difference was observed between transaxillary and supraclavicular incisions. No brachial plexus injuries occurred. The most frequent cause of morbidity was incisional pain. Two reoperations were performed for recurrences. Follow-up was 4.6 years, and 75% of lower plexus and 50% of upper plexus compressions remained asymptomatic. Severe and long-term pain occurred in 1 patient. Conclusions Surgical decompression for thoracic outlet syndrome is efficient and dependable, but results deteriorate over time.

Surgical management of thoracic outlet syndrome

Abstract Background The role of surgical decompression for thoracic outlet syndrome (TOS) is not clearly established, especially for the neurological (N-TOS) or venous (V-TOS) variants. Reports lack objective diagnostic criteria and follow-up. American series almost exclusively describe N-TOS. In the authors' practice, arterial TOS (A-TOS) is much more common. Patients are treated by a multidisciplinary team and surgery is reserved for those failing to respond to conservative measures. Methods Data regarding assessment, diagnosis (clinical, radiology, electromyography, duplex) are collected prospectively on a database (Paradox). Independent follow-up has categorized surgical results by structured questionnaire. Results Of 129 patients (104 women; median age 37 years), 91 underwent transaxillary first rib resection (50 A-TOS, 31 N-TOS, ten V-TOS), 24 had a supraclavicular scalenectomy (rib resection; all N-TOS) and 14 had a combined procedure (five A-TOS, nine N-TOS). Eleven were reoperations. Early results (6 months) were available for 122 patients. Overall 91 per cent of patients with A-TOS rated the outcome as excellent/good, compared with 72 per cent of those with N-TOS and nine of ten with V-TOS. Life-table analysis confirmed a durable outcome at up to 6 years. Of 30 patients with A-TOS for whom data were complete, postoperative duplex imaging was normal in 28. Conclusion Careful patient selection following a concerted effort at conservative management yields good results. These data are useful for counselling patients who may be facing surgery for this disabling condition.

Neurogenic thoracic outlet decompression: rationale for sparing the first rib

A total of 168 primary supraclavicular decompressions were performed on 146 patients with neurogenic thoracic outlet syndrome. This report compares the results of rib resection (supraclavicular anterior and middle scalenectomy and first rib resection) with rib-sparing (supraclavicular anterior and middle scalenectomy alone) operations. All patients with cervical ribs were excluded. In total, 125 rib resections and 43 rib-sparing procedures were performed between 1983 and 1992 by a single surgeon. The patients were otherwise comparable in symptoms and physical signs. During surgery there was a significantly higher proportion of pleural injury associated with rib resection (59%) than with rib-sparing (40%) procedures. The mean hospital stay was also prolonged by 1 day in patients undergoing rib resection ( P = 0.005). There was no significant difference in early success between the two groups (83% for rib resection, 91% for rib sparing) and no difference in those resuming employment (52% and 63% respectively). Life-table analysis showed that the two groups have similar long-term results (69% and 76% at 2 years). The only important factor determining clinical outcome in primary supraclavicular thoracic outlet syndrome decompression was the duration of symptoms before operation. Some 83% of patients with symptoms less than 2 years had a successful result compared with only 68% in those with symptoms longer than 2 years ( P < 0.05). Spontaneous or post-traumatic neurogenic symptoms responded to operation identically. The theoretical benefit of first rib resection to relieve mechanical compression of the brachial plexus is not evident from this review. Thorough removal of the scalene musculature and other myofascial anomalies, preferably through the supraclavicular approach, leads to less patient morbidity, shortens hospitalization, and is recommended for patients with neurogenic thoracic outlet syndrome requiring operative intervention.