Diagnosis Of Thoracic Outlet Syndrome Research Articles

Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography

BackgroundThoracic 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).MethodsThe 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.ResultsTOS 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%).ConclusionTOS with the lower trunk compression of brachial plexus can be diagnosed accurately and reliably by high-frequency ultrasound.

Anterior Scalene Muscle Block Response Predicts Outcomes Following Thoracic Outlet Decompression.

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. 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. 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. 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.

Thoracic outlet syndrome: a review

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.

Thoracic outlet syndrome in the рediatric and аdolescent рopulations

Thoracic outlet syndrome (TOS) is challenging to diagnose of it`s different etiology and pathophysiology. For now, all the physical examinations and investigations lack sensitivity and/or specificity. Recent efforts have been made to more clearly define a set of diagnostic criteria that will bring consistency to the diagnosis of TOS. Surgical management remains the mainstay of operative treatment for all patients, who have failed conservative therapy, because of it`s low efficiency.This article aims to review the etiology and pathophysiology, clinical presentations, diagnosis, and management of thoracic outlet syndrome.

Botulinum Toxin A, a Better Choice for Skeletal Muscle Block in a Comparative Study With Lidocaine in Rats.

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.

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.

Rehabilitation in Overhead Athletes With Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a clinical diagnosis resulting from the impingement of neurovascular structures between the clavicle and first rib. Effective prevention and nonoperative treatment in high-performance athletes with TOS are not well documented. The objective of reporting this case was to discuss the symptom progression, relevant clinical findings, and rehabilitation of an overhead athlete with diagnosed neurogenic TOS. Numerous rehabilitative techniques may be used to treat an athlete with TOS, with an emphasis on restoring full shoulder mobility, motor control, and normalized scapular mechanics in a throwing athlete, as well as improving functional thoracic range of motion. Modalities such as neuromuscular electrical stimulation and targeted muscle exercises are incorporated in the process. In the case presented, a collegiate-level throwing athlete returned to full participation at her previous level of play within 18 weeks of rehabilitation initiation. This report details the clinical findings and treatment options available to address pathology in an overhead athlete with a diagnosis of TOS. The clinical case example shows techniques that may help guide the clinician in establishing effective nonoperative or postoperative treatments for TOS. Level of EvidenceLevel V, expert opinion.

Thoracic Outlet Syndrome after Minimally Invasive Repair of Pectus Excavatum in a 15-Year-Old Boy: A Case Report

Nuss procedure has become the treatment of choice in pectus excavatum mainly because of the excellent functional and cosmetic results. Despite the good results, several complications have been reported. The aim of this study is to describe a case of thoracic outlet syndrome (TOS) after Nuss procedure and review the management of such rare complication. A 15-year-old boy otherwise healthy was submitted to Nuss procedure, with no perioperative complications. Two-weeks later, the patient complained of right-hand paresthesia, progressive weakness of the right arm and coldness. After imaging and electromyography, TOS diagnosis was established. Removal of the bar was proposed but refused by the patient. Conservative management with rehabilitation exercising and nerve nourishing was initiated. At 7 months, the patient recovered arm and hand function. Abrupt structural changes of thoracic cavity with marked elevation of the upper chest induce nerve and vascular compression arousing a TOS and should be acknowledged as one potential complication of Nuss procedure. Conservative management can be an alternative treatment to bar removal, showing good results on functional recovery in early stages of compression.

1181 Thoracic Outlet Syndrome - A Miss(Ed) Diagnosis-Delayed Diagnosis Of Thoracic Outlet Syndrome Is Common And Leads To Poorer Functional Outcomes

Abstract Thoracic outlet syndrome was first defined by Peet in 1956 as “compression of the neurovascular structures in the interscalene triangle corresponding to the possible etiology of the symptoms”.1 Diagnosis of TOCS still remains controversial due to lack of clear referral pathways and our study aims to create one to prevent adverse treatment outcomes. Method A retrospective audit in a single vascular centre over a 11-year period correlating time of onset of symptoms to delivery of care and post intervention benefits Results Total of 50 patients were analysed during the study. 30 percent of the patients analysed were noted to be referred to a vascular surgeon 3 years post the initial presentation of symptoms. 60 percent were noted to be referred between 6-2.5 years post initial presentation. Remaining 10 percent were noted to be referred in less than 6 years. It was noted that patients belonging to the group Acohort were noted to have recurrence of symptoms, albeit minor post intervention and treatment of TOCS. Whereas recurrence was noted to be nil/ reduced in the patients intervened in less than 2 years from onset of symptoms. Furthermore, the study also noted that more than 50 percent patients with neurogenic/ venous TOCS had a history of preceeding trauma/ shoulder injury and were noted to be not investigated for TOCS. Conclusions Our study lends evidence that delayed diagnosis of thoracic outlet syndrome is common and leads to poorer functional and treatment outcomes. Hence a diagnostic pathway must be proposed and implemented at primary care which caters to diagnosis of TOCS, to avoid delays in delivery of adequate care and treatment.

Robotic first rib resection for thoracic outlet syndrome.

Robotic resection of the “offending portion” of the first rib in patients with thoracic outlet syndrome (TOS) has been associated with excellent results. The results have been due to (I) a better understanding of the pathogenesis of TOS, and (II) the technical advantages of the robotic platform. This article outlines the recent understanding of the pathogenesis of TOS, and reports the experience with robotic resection of the “offending portion” of the first rib in patients with neurogenic and venous TOS. Patients diagnosed with TOS underwent robotic first rib resection. Diagnosis of TOS was made by magnetic resonance angiography (MRA). On a thoracoscopic platform, the robot was used to dissect the “offending portion” of the first rib. A total of 162 patients underwent robotic first rib resection. Eighty-three patients underwent robotic first rib resection for Paget-Schroetter syndrome (PSS) (venous TOS). There were 49 men and 34 women. Mean age was 24±8.5 years. Operative time was 127.6±20.8 minutes. Median hospitalization was 4 days. There were no surgical complications, neurovascular injuries, or mortality. At a median follow-up of 24 months, all patients had an open subclavian vein (SV) for a patency rate of 100%. Seventy-nine patients underwent robotic first rib resection for neurologic symptoms of the upper extremity (neurogenic TOS). There were 29 men and 50 women. Mean age was 34±9.5 years. Operative time was 87.6±10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2–4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with neurogenic symptoms, Quick DASH Scores (mean ± SEM) decreased from 60.3±2.1 preoperatively to 5±2.3 in the immediate postoperative period, and 3.5±1.1 at 6 months (P<0.0001). Immediate relief of symptoms was seen in 71/79 (91%) patients. Persistent paresthesia was seen in 9/79 (9%) immediately postop and 3/79 (3.8%) patients at 6 months. Following the appropriate identification of the “offending portion” of the first rib which results in compression of the SV at its junction with the innominate vein by MRA, robotic resection of the “offending portion” of the first rib allows is associated with excellent results.

Measurement of interscalene space volume in diagnosis of thoracic outlet syndrome: a cadaver study

Background/aimThe aim of this study was to measure the volume of interscalene space in thoracic outlet region on cadavers and radiological images and to analyze the potential value of these measurements in diagnosis and treatment of thoracic outlet syndrome (TOS).Materials and methodsThe dimensions of the anterior interscalene space in 8 formalin-fixed human cadavers were studied by direct measurement and additionally evaluation of the volume of this space were done by using mold and volume calculation formula of square pyramid, due to resembling a pyramid. In the second phase of this study, interscalene space volume was calculated by formula and compared to calculations from computed tomography (CT) sections in 18 TOS and 16 control patients. ResultsThere was a strong correlation between the volume calculated by formula (4.79 ± 2.18 cm3) and by mold (4.84 ± 1.58 cm3), (R = 0.934, p = 0.001) in cadavers. The average volume measured in TOS patients (2.05 ± 0.32 cm3) was significantly smaller than control patients (4.30 ± 1.85 cm3, p < 0.0001). There were excellent or good results in 14 patients whereas in 4 patients who had neurogenic TOS achieved fair results after surgery. In these 4 patients the average volumes of abnormal sides were close to the healthy sides. ConclusionIn our study, volume of interscalene space in TOS patients was statistically smaller than control group. Also, the volume was even smaller in patients with excellent or good results after surgery. In this respect, volumetric measurements from CT sections could be used in diagnosis and treatment selection in TOS patients.

ChartSweep: A HIPAA-compliant Tool to Automate Chart Review for Plastic Surgery Research.

Summary:Retrospective chart review (RCR) is the process of manual patient data review to answer research questions. Large and heterogeneous datasets make the RCR process time-consuming, with potential to introduce errors. The authors therefore designed and developed ChartSweep to expedite the RCR process while remaining faithful to its methodological rigor. ChartSweep is an open-source tool that can be customized for use with any electronic health record system. ChartSweep was developed by the authors to extract information from electronic health records using the Python coding language. As proof-of-concept, the tool was tested in three studies: RCR1—Identification of subjects who underwent radiofrequency ablation in a cohort of patients who had undergone headache surgery (n = 172); RCR2—Identification of patients with a diagnosis of thoracic outlet syndrome in patients who underwent peripheral neuroplasty (n = 806); RCR3—Identification of patients with a history of implant illness or breast implant-associated anaplastic large cell lymphoma in patients who had undergone implant-based breast augmentation or reconstruction (n = 1133). Inter-rater reliability was assessed. ChartSweep reduced the time required to conduct RCR1 by 1315 minutes (21.9 hours), RCR2 by 1664 minutes (27.7 hours), and RCR3 by 2215 minutes (36.9 hours). Inter-rater reliability was uncompromised (k = 1.00). Open-source Python libraries as leveraged by ChartSweep significantly accelerate the RCR process in plastic surgery research. Quality of data review is not compromised. Further analyses with larger, heterogeneous study populations are required to further validate ChartSweep as a research tool.

DIAGNOSTICS OF NERVE IMPULSES TRANSMISSION PATHOLOGY IN PATIENTS WITH SUSPECTED THORACIC OUTLET SYNDROME USING CLINICAL NEUROPHYSIOLOGY TESTS

Introduction Thoracic Outlet Syndrome (TOS) is a group of conditions characterized by compression of the nerves, arteries and veins in the lower neck and upper chest area. On average, six physicians of different specialities need 4.3 years to develop TOS diagnosis. Early detection of changes in transmission of nerve impulses within the brachial plexus may lead to faster and more effective treatment of patients. Aim The aim of the study is to present the scheme of diagnostic tests of clinical neurophysiology contributing to the objective diagnosis of TOS, as well as the positive results of tests in a group of sixteen patients with clinically confirmed pathological symptoms. Material and methods Sixteen patients with clinically diagnosed TOS and sixteen healthy people as a control group aged from 18 to 36 participated in this study. In both groups of subjects, bilateral clinical neurophysiological diagnostics tests were carried out: an examination of the sensory perception with von Frey’s filaments within C4-C8 dermatomes, examination of surface electromyography (sEMG) during maximal contractions when recordings from proximal and distal muscles of the upper extremities were performed, the electroneurographic transmission of nerve impulses in selected nerves of the upper extremities (ENG) and motor evoked potentials recordings induced with the magnetic field (MEP) following oververtebral C5 and C6 stimulation. Results Comparing to studies performed in a control group of healthy volunteers, more than 50% of patients with clinical symptoms of TOS had confirmed abnormalities in the diagnostic tests of clinical neurophysiology, unilaterally or bilaterally. Conclusions In the diagnosis of TOS, sEMG recordings from the distal muscles of upper extremities during maximal contractions after induction of ischemia (“hand-raised test”), ENG segmental examination of nerve impulses transmission in motor fibers after stimulation of the median and ulnar nerves, and MEP examination after oververtebral C5 and C6 stimulation are particularly useful. Confirmation of a relatively high percentage of positive TOS tests in patients requires a greater number of neurophysiological examinations. Keywords: Thoracic Outlet Syndrome, neurophysiological diagnostics, motor evoked potentials

Endoscopic Assisted Transaxially Approach for First Rib Resection in Thoracic Outlet Syndromes

Thoracic outlet syndrome (TOS) is a complex of signs and symptoms resulting from compression of the nerves and vessels supplying the upper limb. Previous articles described that physicians who do not regularly treat patients with TOS may not have an accurate view of this disorder, its treatment, or the possible success rate of treatment. Roos reported that TOS is underdiagnosed. Difficulty in diagnosis of TOS correctly may cause unexplained various symptoms and less objective diagnostic criteria. Moreover, surgical management for TOS remains more challenging. Transaxillary first rib resection is a well-established surgical treatment for patients with symptomatic TOS. However, it does not allow an adequate exposure of the insertion of the scalene muscle to the first rib. Because surgery for TOS involves many complex and intimately related structures, theoretical complications are numerous and may be severe. There were reported complications including brachial plexus dysfunction and fatal subclavian artery or vein injury. Recent articles showed that with the help of the endoscope, more safety and less invasive surgery has been achieved. The purpose of this study is to access the feasibility of endoscopic assisted transaxially approach for first rib resection in TOS. Forty-eight cases of TOS (21 women and 27 men; mean age, 28.1 years; range, 13-57 years) who underwent endoscopic assisted first rib partial resection were reviewed retrospectively. Conventional transaxially approach described by Roos was underwent before identification of the first rib. A 4.0 mm 30°arthroscope was introduced with an additional small port placed anterior latissimus dorsi. The scope allowed for visual identification and confirmation of the first rib and the contents of the thoracic outlet. Endoscopic classification of neurovascular bundle patterns (NVB), that is, alignment of the nerve, artery, and vein were evaluated intraoperatively. In addition, distance between anterior and middle scalene muscle at the edge of the first clavicle was measured. The first rib was transected anteriorly near the costochondral junction and posteriorly as close to the transverse process as possible in a piece by piece fashion under good visualization with great care to avoid injury to the subclavian vein immediately anterior to the anterior scalene muscles. Roos and Wood score and DASH score was obtained postoperatively. Intraoperative endoscopic findings revealed 3 classifications of NVB patterns based on alignment of scalene muscles, nerve, and artery: parallel type (9 cases) in which the artery and nerve travel parallelly; oblique type (24 cases), in which the nerve was behind the artery; vertical type (15 cases), in which the nerve were totally behind the middle scalene muscle or abnormal band. Abnormal NVB patterns (24 oblique and 15 vertical type) were found in 39 cases (81.3%). In many patients, the interscalene distance was narrow (4.9 mm, range 0-13 mm). Of the congenital abnormal fibrous bands that were identified, 26 of 31 selectively were compressing the lower trunk of the brachial plexus. The insertion of the anterior or middle scalene exceeded the scalene tubercle and extended onto the superior surface of the rib in 13 cases and this was through to narrow the interscalene interval. Postoperative clinical findings showed that excellent or good results by Roos score were obtained in 38 cases (79.2%) and fair to poor results were recorded in 10 cases (20.8%). Pre- and postoperative mean DASH scores were, 35.1 (range 2-77) and 19 (0-72), respectively. No major complication was reported except one pneumothorax. Although transaxillary first rib resection is a well-established surgical treatment for patients with symptomatic TOS, this procedure requires meticulous technique with special attention to fine details to achieve the best results with the least complications. Therefore, many physicians may hesitate to diagnose and treatment TOS.

Normal Costoclavicular Distance as a Standard in the Radiological Evaluation of Thoracic Outlet Syndrome in the Costoclavicular Space

The costoclavicular space is a common site of thoracic outlet syndrome. When there is no anatomical alteration, the diagnosis of thoracic outlet syndrome is difficult. Several authors relate costoclavicular distance to symptoms of thoracic outlet syndrome; however, there is no standardized site for measurement of the costoclavicular distance. This study aimed to determine the standard costoclavicular distance at neurovascular bundle crossing points (near the subclavian vein [Measure V] and the subclavian artery/brachial plexus branches [Measure NA]) using high-resolution chest computed tomography (CT) scans and evaluate its variations with respect to age, sex, height, and body mass index. This prospective cross-sectional observational study analyzed 150 of 156 CT scans from consecutive adult patients (72 females and 78 males). Costoclavicular distance was measured at the subclavian vein and brachial plexus/subclavian artery sites, where narrowing of the costoclavicular distance could lead to symptoms of thoracic outlet syndrome. Costoclavicular distance was analyzed with respect to sex, laterality, age group (<50 and ≥50years) and body mass index group (body mass index <25 and ≥25 kg/m2). Measures of V and NA were normally distributed. The measured costoclavicular distances were 1.23cm (±0.40) and 1.24cm (±0.47), respectively. Age (≥50years) and body mass index (≥25kg/m2) increased the costoclavicular distance. Measurements V and NA below the fifth percentile indicated a narrowed costoclavicular distance and a greater chance of developing thoracic outlet syndrome. For young (<50years) and eutrophic patients (body mass index <25 kg/m2), these measurements were 0.46 and 0.44cm, respectively; for young people and body mass index ≥25kg/m2, they were 0.54 and 0.24cm, respectively; for the elderly (≥50years) and eutrophic, they were 0.57 and 0.48cm, respectively; and for the elderly and body mass index≥25kg/m2, they were 0.83 and 0.73cm, respectively. There was no significant difference between measurements V and NA regarding patient laterality, gender, and height. Standardization of costoclavicular distance measurements at neurovascular bundle crossing points (subclavian vein and brachial plexus/subclavian artery) is possible. It may aid the diagnosis and help direct the therapeutic indications for symptomatic patients with thoracic outlet syndrome.

Electrodiagnostic Studies Role in Diagnosis and Management of Thoracic Outlet Syndrome

Introduction: Thoracic outlet syndrome (TOS) is caused by the compressive effect on brachial plexus or subclavian vessels at the thoracic outlet. The symptoms are usually neurologic, arterial or venous or the combination of them. Method: From these patients we chose 70 patients whom underwent surgery (resection of first rib ,with neurolysis with trans axillary approach) and we had the complete data on EMG -NCV and could follow postoperative course and were completely satisfied by the operation and their symptoms was relieved according the quick DASH Questionnaire and thereby the diagnosis of TOS was proved by the result. Result: The electro diagnostic tests of 6 patients (1.5%) were completely normal. The lower trunk symptoms which should be more frequent in TOS was purely present in 7.1%. Fibrillation and fasciculation along the course of ulnar nerve was present in 10% of cases. The middle trunk abnormal motor NCV was the pure pathology in2.9%. Fibrillation and fasciculation along the course of median nerve (abductor policis berevis) 2.4% and for Brachioradialis (radial nerve) NCV was abnormal in 1.8%. Conclusion: To prove this fact, we selected only the patients who were completely satisfied by the operation and their symptoms was relieved according the quick DASH Questionnaire and thereby we were sure that the diagnosis of TOS has been correct. Retrospectively we evaluated the electrodiagnostic findings in these patients.

Traditional medicine treatment for thoracic outlet syndrome: A protocol for systematic review of randomized controlled trials.

Background:Diagnosis of thoracic outlet syndrome (TOS) is challenging; however, proper evaluation and treatment ensure relief from symptoms in most patients. A comprehensive approach to treatment is important, considering the multifactorial etiology of TOS. The objective of this systematic review is to describe the methods for evaluating the effectiveness and safety of acupuncture-based traditional medicine treatments for TOS.Methods:A total of 13 databases will be searched, from their inception to the present date, for studies that have investigated the treatment of TOS. Databases that will be included are MEDLINE, Embase, AMED, Cochrane Library, CINAHL, and 4 Korean, 2 Chinese, and 2 Japanese databases.We will include randomized controlled trials (RCTs) assessing acupuncture-based traditional medicine for the treatment of any type of TOS. All RCTs on traditional medicine with any form of acupuncture will be eligible for inclusion. The methodologic quality of the RCTs will be analyzed using the Cochrane Collaboration tool to assess the risk of bias, and the confidence in the cumulative evidence will be assessed using the grading of recommendations assessment, development, and evaluation instrument.Ethics and dissemination:The results of this systematic review will be published in a peer-reviewed journal and disseminated both electronically and in print. The review will be updated to inform and guide health care practices.Trial registration number:PROSPERO 2020 CRD42020164869

Endoscopic Assisted First Rib Resection for Thoracic Outlet Syndromes in Overhead Throwing Athletes

Objectives:Thoracic outlet syndrome (TOS) is a complex of signs and symptoms resulting from compression of the nerves and vessels supplying the upper limb. Repetitive and cumulative stress of the upper extremity in athletes are associated with TOS. Despite of several previous reports, TOS is incompletely understood, difficult to diagnose, and often poorly managed. Especially, etiology and pathology on throwing athletes with TOS have not been still unknown. Recent articles showed that with the help of the endoscope, more safety and less invasive surgery has been achieved. We consider that intraoperative observations will lead to analyses the pathology of TOS in athletes. The purpose of this retrospective study was to investigate characteristic clinical features, objective imaging, intraoperative findings, and surgical outcomes of patients with TOS in overhead throwing athletes.Methods:This study analyzed 158 cases of TOS (47 women and 111 men) who underwent endoscopic assisted first rib partial resection. Patients were divided into 2 group: athletes (89 patients) and non-athletes (69 patients). The diagnosis of TOS was based on clinical features, plane radiographs, ultrasonography, three-dimensional computed tomography angiography, and MRI. Indications for this surgery included failure of more than 6 months of conservative treatment or evidence on artery interruption on 3D angiography or obvious narrowing of interscalene region on ultrasound. Conventional transaxially approach described by Roos with endoscopic assist was underwent for partial resection of the first rib and decompression of neurovascular bundle. Intraoperative findings involved as follows; Interscalene distance (ISD): the distance between the posterior edge of the anterior scalene and the anterior edge of the middle scalene, Neurovascular bundle (NVB) patterns: based on alignment of the nerve, artery, and vein, following three types; parallel type, oblique type, and vertical type. Evaluation was performed through use of the clinical rating system of Roos’s classification, DASH, intraoperative endoscopic findings, plain radiographs, and ultrasonography. The mean follow-up period was 17.4 (from 6.4 to 42.4) months.Results:We found characteristic clinical features in athletes with TOS compared with non-athletes as follows; younger (16.7 years vs 36.3 years), shorter duration of symptoms (7.8 vs 26.0), and better outcomes (excellent or good percentage in Roos score; 91.0 % vs 73.9 %). Intraoperative findings showed no significant differences of ISD and NVB patterns between athletes and non-athletes. On the other hand, anatomical variation including abnormal bundle was found more frequently in athletes compared with non-athletes (Figure 1, Table1). There were no major complications.Conclusions:In conclusion, endoscopic assisted transaxially approach for first rib resection in TOS provided a superior magnified clear visualization and safely sufficient decompression of neurovascular bundle. The current study showed better clinical outcomes in athletes compared with non-athletes. Several factors including younger, shorter duration of symptoms, and anatomical variation would reflect to the result. The orthopaedic surgeon should be aware of the possibility of TOS in an adolescent who plays an overhead throwing sport. Appropriate surgical indication would provide them superior clinical outcomes.

Abnormal Anatomical Etiology and the Resultant Bilateral Thoracic Outlet Syndrome

The diagnosis of thoracic outlet syndrome (TOS) is challenging and primarily determined by clinical examination. Symptoms such as numbness and tingling in the arms when raised above the head make the rehabilitation process difficult due to the various manifestations of TOS presented to the athletic trainer (AT). An AT should understand the intricate anatomical characteristics of the thoracic outlet and how various TOS presentations may impact treatment. In this clinical commentary, I provide my own insights for understanding TOS from my perspective as a patient and AT. These insights are valuable when making diagnostic, therapeutic, and prognostic clinical decisions.

Intermediate and Long-term Outcomes Following Surgical Decompression of Neurogenic Thoracic Outlet Syndrome in an Adolescent Patient Population.

Background: Although the diagnosis of thoracic outlet syndrome (TOS) is often missed, outcomes from surgical intervention significantly improve patient satisfaction. This article seeks to highlight patient characteristics, intraoperative findings, and both short and long-term outcomes of thoracic outlet decompression in the adolescent population. Methods: A retrospective chart review of patients between the ages of 13 and 21 years with a clinical diagnosis of neurogenic thoracic outlet syndrome (NTOS) who were treated surgically between 2000 and 2015 was performed. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient-reported outcome scores, including Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Cervical Brachial Symptom Questionnaire (CBSQ), and NTOS index, were obtained for a cohort of patients with follow-up ranging from 2 to 15 years. Results: The study population consisted of 54 patients involving 61 extremities. The most common procedures included neurolysis of the supraclavicular brachial plexus (60, 98.4%), anterior scalenectomy (59, 96.7%), and middle scalenectomy (54, 88.5%). First rib resection (FRR) was performed in 28 patients (45.9%). Long-term outcomes were collected for 24 (44%) of 54 patients with an average follow-up of 69.5 months (range, 24-180 months). The average VAS improved from 7.5 preoperatively to 1.8 postoperatively. The average SANE increased from 28.9 preoperatively to 85.4 postoperatively. The average postoperative scores were 11.4 for the QuickDASH, 27.4 for the CBSQ, and 17.2 for the NTOS index. Subgroup analysis of patients having FRR (28, 45.9%) demonstrated no difference in clinical outcome measures compared with patients who did not have FRR. Conclusion: Surgical treatment of NTOS in adolescent patients has favorable intermediate and long-term outcomes.