Neurogenic Thoracic Outlet Syndrome Patients Research Articles

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

The recurrence or persistence of symptoms after thoracic outlet decompression (TOD) in patients with neurogenic thoracic outlet syndrome (NTOS) is not uncommon. Some authors have shown significantly better clinical outcomes in patients who underwent TOD with exarticulation of the first rib compared to a group who underwent TOD with preservation of the dorsal portion of the first rib. Several other case series have shown significant improvement after redo surgery with removal of the dorsal first rib remnant. This indicates the importance of the dorsal part of the first rib in NTOS. However, radical exarticulation may not always be necessary. In this study, we tried to answer the question of whether there is a morphological difference in the dorsal part of the first rib in NTOS patients that might help in the diagnosis and treatment of NTOS. We used the CT data of 21 NTOS patients who underwent TOD surgery and measured the dorsal part of the first rib, then compared them with a quota sample. We found no difference in the dorsal part of the first rib between NTOS patients and the quota sample in our data. As there was no detectable difference, we were not able to use these data to help decide whether exarticulation is necessary in achieving adequate symptom relief. Therefore, we advocate exarticulation of the first rib when TOD is indicated.

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review.

Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome. Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS. In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

Elective brachial plexus decompression in neurogenic thoracic outlet syndrome

We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6–48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. Level of evidenceIV.

Innominate Vein Stenosis Is Present in Neurogenic Thoracic Outlet Syndrome Patients

It has been established that subclavian and internal jugular vein stenosis is common in patients with neurogenic thoracic outlet syndrome (nTOS). However, a population of nTOS patients with innominate vein stenosis exists that has not been well researched. We compared the demographics and treatment outcomes of nTOS patients with and without innominate vein stenosis.

Duplex Ultrasound Studies Are Neither Necessary or Sufficient for the Diagnosis of Neurogenic Thoracic Outlet Syndrome

Duplex ultrasound (DU) is used in the diagnosis of neurogenic thoracic outlet syndrome (NTOS) to measure compression of the subclavian artery (SCA) which is thought to strengthen the NTOS diagnosis. However, the value of DU in NTOS remains unclear. A retrospective review of a prospectively acquired database from the TOS center of the Catharina Hospital Eindhoven was performed of patients referred between January 2017 and December 2019. Only "proven NTOS" patients, defined as a successful response to thoracic outlet decompression (TOD) surgery based on patient-reported outcomes (NRS pain scale, CBSQ and DASH score) were included to exclude wrongfully diagnosed NTOS patient. The presence of vascular symptoms (defined as discoloration, edema or temperature changes of the hand or fingers), results of provocative maneuvers, and outcome of DU was used for analysis. To assess the link between vascular symptoms and compression on DU, a chi-squared test was performed. Further, we looked for a correlation between vascular symptoms, compression on DU and clinical outcome using a repeated measures analysis of variance (ANOVA). Vascular symptoms were seen in 49 of 133 patients (36.8%). In total, 51 of 133 patients (38.3%) had at least 50% variation in SCA peak systolic velocity (PSV) during DU at the level of SCA stenosis. SCA occlusion was seen in 11 patients (8.3%) during provocative maneuvers. The presence of clinical "arterial symptoms" was not significantly correlated with vascular laboratory findings, neither for alterations in PSV during DU (P=0.245) nor for positional SCA occlusion (P=0.540). No statistically significant correlations between the degree of SCA stenosis and postoperative outcomes, as measured with the DASH, CBSQ, or NRS scale for pain were found (P=0.787). The role of DU in the work-up of NTOS in patients with vascular complaints is questionable. Changes in flow velocities are seen in NTOS patients and do not correlate with "vascular symptoms" or clinical outcome.

A Novel Approach to First-Rib Resection in Neurogenic Thoracic Outlet Syndrome.

Objectives: The treatment for neurogenic thoracic outlet syndrome (NTOS) conventionally involves first-rib resection (FRR) surgery, which is quite challenging to perform, especially for novices, and is often associated with postoperative complications. Herein, we report a new segmental resection approach through piezo surgery that involves using a bone cutter, which can uniquely provide a soft tissue protective effect.Methods: This retrospective study involved the examination of 26 NTOS patients who underwent piezo surgery and another group of 30 patients who underwent FRR using the conventional technique. In the patient group that underwent piezo surgery, the rib was first resected into two pieces using a piezoelectric device and subsequently removed. In the patient group that underwent conventional surgery, the first rib was removed as one piece using a rib cutter and rongeurs.Results: The piezo surgery group had significantly shorter operative time (96.85 ± 14.66 vs. 143.33 ± 25.64 min, P < 0.001) and FRR duration (8.73 ± 2.11 vs. 22.23 ± 6.27 min, P < 0.001) than the conventional group. The posterior stump length of the residual rib was shorter in the piezo surgery group than in the conventional group (0.54 ± 0.19 vs. 0.65 ± 0.15 cm, P < 0.05). There were no significant differences in postoperative complications and scores of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Cervical Brachial Symptom Questionnaire (CBSQ), and the visual analog scale (VAS). Even the TOS index (NTOS Index = [DASH + (0.83 × CBSQ) + (10 × VAS)]/3) and patient self-assessments of both the groups showed no significant differences. Univariate analyses indicated that the type of treatment affected operative time.Conclusion: Our results suggest that piezo surgery is safe, effective, and simple for segmental FRR in NTOS patients. Piezo surgery provides a more thorough FRR without damaging adjacent soft tissues in a relatively short duration and achieves similar functional recovery as conventional techniques. Therefore, piezo surgery can be a promising alternative for FRR during the surgical treatment of NTOS.

Hand Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome.

Neurogenic thoracic outlet syndrome (NTOS) is a chronic painful and disabling condition. Patients complain about upper-limb paresthesia or weakness. Weakness has been considered one of the diagnostic criteria of NTOS, but objective comparisons to healthy controls are lacking. We compared the grip and the key pinch strengths between NTOS patients and healthy controls. Grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. All the patients with NTOS completed a QuickDASH. We included prospectively 85 patients with NTOS, 73% female and 27% male. The mean age was 40.4 ± 9.6. They were compared to 85 healthy subjects, 77.6% female and 22.4% male. Concerning the grip, symptomatic hands of NTOS patients had significantly 30% less strength compared to control hands (p ≤ 0.001), and 19% less strength compared to asymptomatic hands (p = 0.03). Concerning the key pinch, symptomatic hands of patients with NTOS had significantly 19.5% less strength compared to control hands (p ≤ 0.001). Grip and key pinch strengths had a significant correlation with the QuickDASH (r = −0.515 and r = −0.403, respectively; p ≤ 0.001). Patients with NTOS presented an objective hand strength deficit compared to healthy controls. This deficit was significantly correlated to the upper-limb disability. These findings confirm the interest of hand strength evaluation in the diagnostic process of patients with NTOS.

Sonographically guided botulinum toxin injections in patients with neurogenic thoracic outlet syndrome: correlation with surgical outcomes.

We examined the role of botulinum toxin (BTX) injections of anterior scalene (AS) and pectoralis minor (PM) muscles in patients undergoing surgery for neurogenic thoracic outlet syndrome (NTOS). We hypothesized that symptomatic improvement from BTX injections correlates with favorable long-term response to surgery for NTOS. This Health Insurance Portability and Accountability Act compliant study was approved by the institutional review board and prior informed consent requirement was waived. We retrospectively analyzed prospectively acquired data in NTOS patients who underwent sonographically guided chemodenervation of AS and PM using BTX type A followed by scalenectomy and first rib resection. Overall responses to BTX injections and surgery were recorded after each procedure. Statistical analyses were performed to determine correlation between responses to BTX injections and surgery. In 157 patients, 178 BTX injections followed by surgery were identified (114 females; mean age 38 ± 13 years). Responders and non-responders to BTX injections and surgery had similar preoperative symptom duration and age (P > 0.14). Better response to BTX injections correlated positively with better response to surgery (P = 0.003), persisting after adjustment for age, gender, and symptom duration (P = 0.03). A high proportion of responders to BTX injections also responded to surgery (positive predictive value of 99%), and BTX injections showed high specificity (90%). BTX injections were moderately sensitive (66%) and accurate (67%) to determine surgical response and had low negative predictive value (14%). Response to BTX injections correlates positively with long-term surgical outcome in subjects with NTOS, potentially playing an important role in patient management.

Improved functional outcome in NTOS patients following resection of the subclavius muscle with radiological signs of nerve impingement: indication of participation of the subclavius in brachial plexus compression.

Both clinical and radiological reports have suggested that the subclavius, a muscle in the costoclavicular space of the thoracic outlet, participates in neurogenic thoracic outlet syndrome (NTOS) in some instances, especially during movements narrowing the costoclavicular space. Magnetic resonance imaging can identify subclavius muscles with signs of nerve impingement, yet the impact of the subclavius in such situations remains unclear. Therefore, the authors investigated whether dividing or sparing the subclavius characterized by nerve impingement on MRI would affect surgical outcomes. In this retrospective nonrandomized study, authors analyzed all NTOS patients with a subclavius muscle characterized by nerve impingement on MRI (loss of normal fat planes surrounding the brachial plexus) in the period between March 2010 and November 2016. Patients were divided into two groups: the sparing group, in which patients had undergone conventional supraclavicular scalenectomy and first rib resection (FRR), and the dividing group, in which patients had undergone scalenectomy, FRR, and subclavius dividing using a modified supraclavicular incision. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, a shoulder range of motion subscale (DASH items 6, 12-15, and 19) concerning overhead activities that can significantly narrow the costoclavicular space, postoperative MRI studies, and patient self-assessments were used to assess surgical outcomes. Univariate and multivariate analyses were conducted to identify independent factors associated with subscale scores. From a total of 261 patients screened, 71 were eligible for study inclusion. Compared with the sparing group (33 patients), the dividing group (38 patients) had similar postoperative DASH scores and self-assessments but better subscale scores (9.50 ± 2.76 vs 11.94 ± 2.87, p = 0.0005). Postoperative MRI on hyperabduction showed that the brachial plexus became surrounded by normal fat tissue in the costoclavicular space in the diving group but still had signs of impingement from the untreated subclavius muscle in the sparing group. This observation agreed with a better functional recovery in terms of overhead activities in the dividing group, which was reflected by better subscale scores. Multivariate analyses indicated that the type of treatment and symptom duration prior to surgery influenced the subscale scores independently. This study revealed that an untreated radiological nerve-compressing subclavius muscle could lead to a relatively lower degree of recovery in the ability to perform overhead activities for NTOS patients postoperatively, suggesting that such subclavius muscles may participate in positional brachial plexus compression during movements narrowing the costoclavicular space. Dividing the muscles could decompress the costoclavicular space more effectively and may lead to better functional recovery.

Surgical outcomes of neurogenic thoracic outlet syndrome based on electrodiagnostic tests and QuickDASH scores

In total, 665 of 680 (97%) patients with neurogenic thoracic outlet syndrome (NTOS) improved with conservative treatment. The remaining (3%) patients (15 of 680 patients) did not benefit after 3 months of conservative treatment and were referred for transaxillary first rib resection. We retrospectively compared the preoperative and postoperative (3 months) electromyelography and Quick Disability of Arm, Shoulder and Hands results of operated NTOS patients. Three of the 15 (20%) patients in the surgical cohort were male, with a median age of 25.3 ± 4.16 years, and the other 12 patients (80%) were female with a median age of 31.9 ± 9.48 years. Two of the 15 patients had a cervical rib, 4 of the 15 patients had an extension of the C7 transverse process, and 14 of the 15 patients had a cervical band. These bone and tissue abnormalities were removed in addition to the first rib resection and division of the subclavius muscle and the anterior scalenus and middle scalenus muscles. QuickDASH scores were 1062 preoperatively and 549 postoperatively. The latency of the median F-wave was significantly prolonged on the affected side compared to the unaffected side preoperatively (p = 0.015). There was no remarkable difference in the latency of ulnar F-waves between sides (p = 0.246). The medial antebrachial cutaneous nerve response values increased significantly postoperatively (p < 0.0001). Significant increases in ulnar sensory nerve action potential values amplitude ratio (p < 0.003) and median nerve motor amplitudes (p < 0.0001) were also found postoperatively.

Diagnosing neurogenic thoracic outlet syndrome with the triple stimulation technique

ObjectiveWe assessed the diagnostic value of triple stimulation technique (TST) in eight patients with neurogenic thoracic outlet syndrome (TOS) by revealing the conduction block of the proximal lower trunk of the brachial plexus and locating the compression site. MethodsEight patients fulfilling the conventional criteria of the lower-trunk neurogenic TOS were enrolled in our study. TST along with the central motor-conduction time was evaluated. The parameters including the TST amplitude ratio and the TST area ratio were compared between patients and controls. ResultsThe amplitude ratio was significantly lower in the patient group than in the control group (patients: 0.518±0.113; control: 0.954±0.020, P<0.01), so was the area ratio (patients: 0.453±0.194; control group: 0.955±0.192, P<0.01). No significant difference of central motor-conduction time (CMCT) was seen between the patient group and the control group (patients: 6.62±0.36ms; control: 6.54±0.36ms; P=0.528). Surgical procedures proved the compression of the lower trunk in all patients. ConclusionOur results indicated that there was conduction block besides axon loss in neurogenic TOS patients, and the conduction block was located between the nerve root emerging site and the supraclavicular stimulation site. SignificanceWe first applied TST in diagnosing neurogenic TOS, and we showed that the patient’s TST ratio was significantly lower than normal. Combined with clinical manifestations, TOS can be more precisely diagnosed.

Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy

First rib resection and scalenectomy (FRRS) has been shown to improve short-term quality of life (QOL) in the treatment of neurogenic thoracic outlet syndrome (NTOS). Long-term benefits are not well studied but are believed to decrease over time. Our objective was to evaluate long-term NTOS outcomes using validated QOL instruments. We identified 162 NTOS patients aged ≥18 years treated by FRRS from 2003 to 2010 after they had not responded to conservative management. The patients were mailed three surveys to assess QOL (Short-Form 12 [SF-12], Brief Pain Inventory [BPI], and Cervical Brachial Symptom Questionnaire [CBSQ]), with five total outcomes measures including the SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS), BPI severity, BPI interference, and CBSQ score. Demographic and clinical data were extracted from patient records. Each FRRS was categorized based on postoperative clinical assessment as successful, failed, or leading to recurrent symptoms. Survey yield was 53.7% (n= 87) with mean follow-up of 44.7 months (range, 12.4-91.9 months). There was no significant difference in QOL scores associated with long-term compared with short-term follow-up. Significantly poorer scores on all instruments were associated with comorbid chronic pain syndromes, opioid use, and unfavorable clinical assessment (P< .05). Significantly poorer scores on select instruments were associated with smoking (BPI both; P< .02), age ≥40 years (SF-12 PCS, BPI interference, CBSQ; P< .03), neck and/or shoulder disease (SF-12 both, BPI both; P< .01), postoperative injections (BPI both, CBSQ; P< .05), and complications (SF-12 PCS, CBSQ; P< .05). A positive preoperative scalene block was not significantly associated with long-term QOL scores. The QOL after FRRS shows no significant difference with longer follow-up. Clinical assessment reflects patient-reported outcomes and can gauge postoperative improvement. Patient factors, particularly comorbidities and opioid use, are more predictive of long-term QOL than is preoperative scalene block and should also be considered when selecting patients for surgical intervention.

Management of unresolved, recurrent, and/or contralateral neurogenic symptoms in patients following first rib resection and scalenectomy

Surgical treatment for neurogenic thoracic outlet syndrome does not always yield successful outcomes. The purpose of this study was to describe patients with unresolved, recurrent, and/or contralateral symptoms following first rib resection and scalenectomy (FRRS) and to determine therapies for improving their outcomes. Data on 161 neurogenic thoracic outlet syndrome patients (182 FRRS procedures) were prospectively collected from 2003 to 2011 and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, interventions, and outcomes were compared between these patients and those with a successful result. Twenty-three patients (24 FRRS) had unresolved symptoms at a mean of 16.1 ± 14.7 postoperative months. Compared with successes, these patients were older (mean age, 45 vs 38 years; P = .002) and active smokers (33% vs 13%; P = .031), with a longer duration of symptoms (90 vs 48 months; P = .005). They had higher rates of chronic pain syndromes (67% vs 14%; P < .001), neck and/or shoulder comorbidities (58% vs 22%; P < .001), preoperative opioid use (67% vs 31%; P = .001), and preoperative Botox injections (46% vs 20%; P = .009) with less relief (18% vs 64%; P = .014). Sixteen patients had recurrent symptoms at a mean of 12.1 ± 9.7 postoperative months. These patients had more chronic pain syndromes (38%; P = .028) and neck and/or shoulder comorbidities (50%; P = .027), with recurrence secondary to scar tissue (69%; P < .001) and reinjury (31%; P = .002). Postoperative treatments for both groups included physical therapy and local injections, where six unresolved (26%) and 13 recurrent (81%) patients achieved freedom from opioids at the end of the follow-up period. Twenty-one patients had contralateral symptoms and underwent secondary FRRS at a mean of 15.0 months (range, 7-30 months) following primary FRRS. The first operation was successful in 90% of cases. Patients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer symptom duration. These patients face a more difficult recovery, whereas patients with recurrent symptoms are well managed with physical therapy and Botox injections. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.

The Radiologic Relationship of the Shoulder Girdle to the Thorax as an Aid in Diagnosing Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (NTOS) is produced by compression of the brachial plexus in the thoracic outlet. The lower position of the shoulder girdle relative to the upper thorax may be related to NTOS. We investigated this hypothesis using plain cervical radiographs. We conducted this case-control study using plain cervical anteroposterior and lateral radiographs in 63 NTOS patients and 126 carpal tunnel syndrome patients who were matched for age and sex. To estimate the position of the shoulder girdle relative to the upper thorax, we analyzed the level of the clavicle using 2 parameters: the number of vertebrae visible in a lateral radiograph and the number of vertebrae above the line connecting both sternal ends of the clavicles in an anteroposterior radiograph. The number of vertebrae visible in a lateral radiograph was the parameter for the level of the lateral part of the clavicle relative to the upper thorax, whereas we used the number of vertebrae above the line connecting both sternal ends of the clavicles in an anteroposterior radiograph to determine the level of the medial part of the clavicle. Both parameters were greater in the NTOS group than in the control group, which suggests that the level of the shoulder girdle was lower in the NTOS group than in the control group. In addition, the risk of NTOS was increased in patients with lower shoulder girdle position. The lower placement of the shoulder girdle relative to the upper thorax was related to NTOS. Physicians may be able to estimate the position of the shoulder girdle using plain cervical radiographs when NTOS is clinically suspected. Diagnostic IV.

Somatoform disorders in non-specific neurogenic thoracic outlet syndrome patients

Somatoform disorders in non-specific neurogenic thoracic outlet syndrome patients

Medial Antebrachial Cutaneous Nerve Measurements to Diagnose Neurogenic Thoracic Outlet Syndrome

A reliable objective test is still needed to confirm the diagnosis of neurogenic thoracic outlet syndrome (NTOS). Over the past 20 years, it has been suggested that responses to medial antebrachial cutaneous nerve (MAC) and C8 nerve root stimulation could be used for this purpose. Herein, we explore this thesis. A clinical diagnosis of NTOS was established in 41 patients, all of whom underwent surgical decompression. Preoperatively, all patients were studied with MAC sensory neural action potential (SNAP) determinations and C8 nerve root stimulation. Controls were 19 asymptomatic, healthy volunteers. MAC sensory latency on 79 control sides was 1.5-2.4 msec, while latency in 41 symptomatic patients ranged 2.2-2.8 msec. Latency of 2.5 or greater was noted in 30 patients (specificity 99%, sensitivity 73%), confirming a diagnosis of NTOS, while the remaining 11 (27%) fell into the borderline zone of 2.2-2.4 msec. The latency difference between right and left sides in controls was 0-0.2 msec in 17 (89%), while in NTOS patients 31 had a difference of 0.3 msec or more (sensitivity 89%, specificity 63%). Amplitudes of 10 muV or more occurred in 77 of 79 control sides, whereas the amplitude was under 10 muV in 28 patients (specificity 97%, sensitivity 68%). Amplitude ratios between right and left sides in controls were 1.7 or less. Ratios of 2.0 or more were measured in 25 patients (specificity 100%, sensitivity 61%). Using the four diagnostic criteria (latency over 2.4 msec, latency difference between sides of 0.3 or more, amplitude under 10 muV, and amplitude ratios of 2.0 or more), 40 of the 41 patients had at least one of the four diagnostic criteria, 23 patients (56%) had three or four positive criteria, and 12 (29%) had two. C8 nerve root stimulation responses were below normal (56 M/sec) in 54%. MAC measurement is a fairly reliable technique for confirming the diagnosis of NTOS. Latency determination appeared to be a slightly more consistent measurement in this study, but amplitude and C8 nerve root stimulation were also helpful. A combination of these techniques seems to be the most reliable approach.

Reported In-Hospital Complications following Rib Resections for Neurogenic Thoracic Outlet Syndrome

While brachial plexus injury has been described as the most common complication following thoracic outlet syndrome (TOS) operation and case series have been reported, the exact incidence rate has not been described. We conducted a retrospective analysis of 5 years (1999-2003) of the Nationwide Inpatient Sample database. Neurogenic TOS patients, rib resections, brachial plexus injuries, and vascular injuries are identified by ICD-9 diagnosis codes or procedure codes. A total of 2,016 TOS operations were identified, ranging 317-468 per year, in this database. Mean age was 37.3 years, with 1,409 (70.2%) women and 1,270 (63.0%) Caucasians. These patients were treated in a total of 392 hospitals, with an average volume of 1.03 cases per hospital per year (range 0-114). Their mean hospital length of stay was 2.51 days (median 2), with a mean total hospital charge of $16,160 in inflation-adjusted year 2005 dollars (median $11,824). The majority (1,421, or 70.5%) was treated at a teaching hospital. There were 12 brachial plexus injuries (0.60%) and 35 vascular injuries (1.74%). The rate of vascular injuries was significantly lower among teaching hospitals (1.34% vs. 2.69%, P = 0.03) and in women (1.35% vs. 2.67%, P = 0.03). Vascular injury patients had significantly longer lengths of stay (7.7 vs. 2.4 days, P < 0.001) and higher total hospital charges ($53,373 vs. $15,507, P < 0.001), while no such difference was observed among brachial plexus injury patients. On hospital discharge, brachial plexus injury following rib resection for TOS occurs in <1% of cases, while vascular injuries occur in 1-2% of cases. The low complication rates suggest that the operation can be performed safely in all patients, especially at teaching hospitals, which had significantly lower rates of vascular injuries, shorter hospital lengths of stay, and lower hospital charges. The low incidence rates of these traditional clinical measures of outcome in TOS patients suggest that the appropriate measure for TOS patient outcome would be patient-reported quality of life or functional outcomes.

Thoracic Outlet Syndrome: Part II. Management and Outcomes of 133 Operative Neurogenic Thoracic Outlet Syndrome Cases

Neurogenic thoracic outlet syndrome (NTOS) is the most common variant of thoracic outlet syndrome. This article presents a 25-year experience of management of 133 operative NTOS patients, at the Louisiana State University Health Sciences Center, which have been divided into 2 subcategories of “disputed NTOS” or “true NTOS.” The clinical presentations, results of neurologic examinations, radiologic evaluations, operative procedures, intraoperative findings, and nerve action potential results and outcomes of the management are evaluated.

胸郭出口症候群の診断基準―神経性を中心に―

Thoracic outlet syndrome (TOS) can be a painful, debilitating condition for patients with neck-shoulder-arm symptoms and for physicians because of unawareness of accurate diagnosis. The aim of this study was to confirm more accurate diagnostic criteria, leading some authors to neurogenic TOS. Neurogenic TOS patients were studied with use of previous diagnostic tests (Morley, Wright or Roos test), and the results were compared with normal values. Physical examination of TOS patients revealed sensory deficit of the fourth or fifth finger and they complained of aggravated pain or symptoms when sleeping on their back or upon waking in the morning. On their radiographs, the lowest level of cervical spine demonstrated inferior margin of the T1 vertebral body in the neutral-lateral position. The ratio of patients with cervical kyphotic malalignment was higher. In addition, the lateral end on the clavicle of TOS patients mostly revealed the posterior side of the T1 vertebral body, while normal cases showed the anterior side of vertebra. These findings will significantly contribute to providing appropriate diagnosis for neurogenic TOS.

Neurogenic thoracic outlet syndrome in whiplash injury.

A prospective study of 110 patients was carried out to determine the pathogenic significance of trauma to the upper body in the development of neural compressive irritation at the thoracic outlet. Twenty-nine patients were reviewed as cervical strain injuries (N group), 25 patients as probable neurogenic thoracic outlet syndrome (NTOS) (PT group), 39 patients as definite NTOS (T group), and 17 patients as NTOS associated with cervical disc disease (CD-T group). The time lapse between accident and diagnosis and the duration of treatment were significantly longer in T patients or CD-T patients than those in the N group. Radiography of NTOS patients also showed a higher percentage of cervical spine-length/height ratio. Traumatic NTOS would suggest two types related to direct damage of scalene muscles that included some physical aspects of cervical disc disease. Pathogenesis provided a key to the resolution of more complex posttraumatic problems of whiplash injury.