Recurrent Neurogenic Thoracic Outlet Syndrome Research Articles

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.

Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series.

BACKGROUND:Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge.OBJECTIVE:To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS.METHODS:From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively.RESULTS:The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P < .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P < .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P < .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%.CONCLUSION:Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.

Redo surgery for neurogenic thoracic outlet syndrome is useful

ObjectivesSurgery for neurogenic thoracic outlet syndrome (NTOS) has shown good outcome in numerous case series. However, 5% to 30% of patients will have persistent or recurrent symptoms, caused by incomplete first rib resection, reattachment of residual scalene muscle, fibrous scarring around the brachial plexus, or a wrong NTOS diagnosis. In patients with a sound diagnosis of recurrent or persisting NTOS, not responding to conservative measures, a secondary procedure can be considered. We report the results of redo thoracic outlet decompression surgery through the supraclavicular approach (SC-REDO-TOD) for persistent or recurrent NTOS. MethodsA retrospective review of a prospective database was performed. Every patient referred from September 2016 until January 2020 was eligible for inclusion. In an SC-REDO-TOD, we perform complete (cartilage-cartilage) resection of the first rib, any bony and fibrous anomalies, complete anterior and middle scalenectomy, and complete neurolysis of the brachial plexus (complete anatomical decompression of the brachial plexus). Clinical outcomes were assessed by questionnaires including the Disability of Arm, Shoulder and Hand (DASH), Cervico-Brachial Symptoms Questionnaire (CBSQ), and TOS (thoracic outlet syndrome) Disability scale. ResultsIn total, 45 patients had a SC-REDO-TOD. The median duration of hospital admission after SC-REDO-TOD was 1.41 days (interquartile range, 1.00 day). In total, 30 (66.66%) of 45 patients had recurrent NTOS, and 15 (33.33%) of 45 patients had persisting NTOS. Postoperative complications were seen in eight patients (18.18%). One patient had postoperative complications with permanent impairment (Horner syndrome). Seven patients had postoperative complications with full recovery (three patients had a chylous leakage that was treated with a median-chain triglycerides diet for 6 weeks, three patients had transient phrenic nerve palsy with full recovery <6 weeks, and one patient had a discrete Horner syndrome that resolved in 6 weeks). The median time of follow-up was 19.50 months (interquartile range, 14.00 months) and the response rate to the questionnaires was 91.11% at 6 months and 64.44% at 12 months. We found a positive and statistically significant difference for DASH score, CBSQ score, and TOS Disability Scale score comparing scores for all patients. (DASH score: P < .001; CBSQ score: P < .001; TOS Disability Scale: P < .001). Patients with first rib remnants showed a significant better response (lower DASH, CBSQ and TOS Disability Scale scores) compared with patients without first rib remnants (DASH score: P = .004; CBSQ score: P ≤ .014; TOS Disability Scale: P = .009). ConclusionsSC-REDO-TOD after a previous NTOS surgery shows good results with a low risk of permanent impairment. Patients with NTOS with first rib remnants after primary surgery seem to benefit the most from SC-REDO-TOD surgery.

Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes.

The clinical outcomes of reoperations for recurrent neurogenic thoracic outlet syndrome (NTOS) remain undefined. From 2009 to 2019, 90 patients with recurrent NTOS underwent anatomically complete supraclavicular reoperation after previous operation(s) performed at other institutions using either supraclavicular (Prev-SC = 48), transaxillary (Prev-TA = 31), or multiple/combination (Prev-MC = 11) approaches. Prospectively maintained data were analyzed retrospectively. The mean patient age was 39.9 ± 1.4 years, 72% were female, and the mean interval after previous operation was 4.1 ± 0.6 years. The mean Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 62 ± 2, reflecting substantial preoperative disability. Residual scalene muscle was present in 100% Prev-TA, 79% Prev-SC, and 55% Prev-MC (P < .05). Retained/residual first rib was present in 90% Prev-TA, 75% Prev-SC, and 55% Prev-MC (P < .05). There were no differences in operative time (overall 210 ± 5 minutes), length of hospital stay (4.7 ± 0.2 days), or 30-day readmissions (7%). During follow-up of 5.6 ± 0.3 years, the improvement in QuickDASH scores was 21 ± 2 (36% ± 3%) (P < .01) and patient-rated outcomes were excellent in 10%, good in 36%, fair in 43%, and poor in 11%. Anatomically complete decompression for recurrent NTOS can be safely and effectively accomplished by supraclavicular reoperation, regardless of the type of previous operation. Residual scalene muscle and retained/residual first rib are more frequently encountered after transaxillary operations than after supraclavicular or multiple/combined operations. Supraclavicular reoperation can achieve significant symptom reduction and functional improvement for approximately 90% of patients with recurrent NTOS.

Five Hundred Rib-Sparing Scalenectomies for the Treatment of Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (TOS) is no longer either controversial or disputed, but its optimal surgical management remains unclear. Most thoracic outlet decompression procedures are carried out by first rib resection, usually through a transaxillary route. A retrospective review was conducted of a prospectively maintained TOS database. Patients with neurogenic TOS associated with a cervical rib were excluded from analysis, as were patients with recurrent neurogenic TOS. All study patients satisfied a 5-point clinical diagnostic protocol and experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis by a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All patients completed a shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) preoperatively and at 1 month, 3 months, and 6 months postoperatively; operative success was defined as 50% improvement of 6-month postoperative vs preoperative QuickDASH scores. Between 2011 and 2019, there were 500 consecutive thoracic outlet decompression procedures carried out in 448 patients. Average operative time was 1.15 hours, and hospital length of stay was 1.05 days. Major complications (serious bleeding, permanent nerve injury, infection) occurred in seven patients (1.3%). All but two (99.6%) patients improved symptomatically; using the more rigorous definition of operative success noted before, 452 (90.9%) rib-sparing neurogenic TOS operations were successful. These results suggest that adherence to a rigorous preoperative diagnostic regimen, including scalene block, ensures, at the least, that operation for neurogenic TOS can successfully be restricted to patients actually suffering from the condition; fibrotic, contracted scalene muscles are the cause of neurogenic TOS; the first rib need not be removed for successful surgical treatment of neurogenic TOS; and >90% of patients so treated can expect significant medium-term symptomatic and functional improvement.

VESS21. Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome Is Effective in Achieving Symptomatic and Functional Improvement Following Surgical Decompression

In some patients with neurogenic thoracic outlet syndrome, surgical decompression does not invariably lead to symptom resolution. Symptom persistence or recurrence is debilitating and, yet, tends to be managed conservatively. At our center, reoperative decompression is performed in carefully selected patients with persistent or recurrent symptoms. The purpose of this study was to assess the symptomatic and functional outcomes in patients undergoing reoperation. We performed a retrospective review of patients who required reoperation for thoracic outlet syndrome at our center from January 2009 to December 2017. Sixty-three cases were found and 27 exhibited complete clinical and outcomes data for review. We complied descriptive statistics. Continuous variables are presented as mean ± standard deviation, or median (quartile 1, quartile 3), if skewed. Categorical variables are presented as frequency and percentage. Long term functional outcome was assessed by the 11-item version of the Disability of the Arm, Shoulder, and Hand questionnaire. Twenty-seven patients underwent a reoperative procedure. The majority of patients were female (74%) and Caucasian (96%). Twelve individuals (44%) were elite competitive athletes. The most common index procedure (67%) was a combination first rib resection and scalenectomy with brachial plexus neurolysis. Median age at index procedure was 20 (18, 41). True recurrence occurred in 24 patients (89%) and true persistence occurred in 3 (11%) individuals. Median time to reoperation was 344 days (212, 756 days). The most common reoperative procedure was brachial plexus neurolysis and adhesiolysis with pectoralis minor release (56%). Residual rib resection was required in six patients (22%). The most common intraoperative findings were dense adhesions around the lower plexus and residual compressive scalene attachments. After reoperation, 22 of 27 patients (81%) experienced durable improvement of symptoms, 3 (11%) had complete resolution, and 2 (7%) patients experienced recurrent symptoms after a period of symptomatic improvement. At long-term follow-up (>1 year), the median Disability of the Arm, Shoulder, and Hand score for the 27 patients was 33.6. Despite the complicated nature and limited treatment options for recurrent thoracic outlet syndrome, we demonstrate that reoperation is associated with modest to excellent symptomatic and functional improvement in the majority of cases though some impairment related to residual symptoms may persist.

Remaining or Residual First Ribs Are the Cause of Recurrent Thoracic Outlet Syndrome

Surgical intervention for neurogenic thoracic outlet syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib because of recurrent thoracic outlet syndrome (TOS)-related symptoms. Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004 to 2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board of Johns Hopkins Hospital. Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracic outlet, and exhibited an intact first rib on chest X-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest X-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated. Different precipitating events reaggravated symptoms in 12 patients. Events included car accidents (n = 4), work-related repetitive movements (n = 5), lifting heavy objects (n = 2), and repetitive injury (n = 1). Group 1: Previous scalenectomy (n = 2), brachial plexus lysis alone (n = 2), or both (n = 3). Seven patients (2 men and 5 women; mean age 34 [25-53]) presented with NTOS symptoms due to a remaining first rib at an average of 24 months (range: 2-68) after their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 17 months (range: 1-79), and all the patients improved in the postoperative period. Group 2: Residual rib (n = 8). Eight patients (2 men and 6 women; mean age 39 [24-58]) presented with a residual first rib at an average of 44 months (range: 12-107) after their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Of the 8 patients, 7 presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all the 8 patients, as seen by a chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients, and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months (range: 1-64), and all the patients improved in the postoperative period. Patients who present with recurrent symptoms of TOS need to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for TOS support our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

Recurrent Neurogenic Thoracic Outlet Syndrome Stressing the Importance of Pectoralis Minor Syndrome

Although first described over 60 years ago, neurogenic pectoralis minor syndrome (NPMS) has only recently been noted to be present in over half the patients with a clinical diagnosis of neurogenic thoracic outlet syndrome (NTOS). Similarly, NPMS has also been observed in the majority of patients with recurrent NTOS. This study explores the role of pectoralis minor tenotomy (PMT) in patients with recurrent NTOS. A total of 86 patients with symptoms of recurrent NTOS, who had failed to improve on conservative management, were evaluated by history and physical examination for both NPMS and NTOS. Diagnostic tests included pectoralis minor muscle (PMM) blocks, scalene muscle blocks, and medial antebrachial cutaneous nerve (MAC) measurements. Surgery was either PMT alone or PMT plus brachial plexus decompression (BPD). Follow-up was 1 to 3 years. All patients had multiple symptoms of pain, weakness, and paresthesia. Patients who qualified for PMT alone had slightly fewer symptoms than those who required PMT plus BPD. There was essentially no difference in physical findings between the 2 groups. It was the response to PMM blocks and scalene muscle blocks that determined which of the 2 operations was performed. Pectoralis minor tenotomy alone gave 69% good results in 65 operations, with 8% fair and 23% failures. Pectoralis minor tenotomy plus BPD in 39 operations gave 58% good improvement, 20% fair and 22% failures. All patients with recurrent NTOS should be evaluated clinically for NPMS. If patients complain of pain or tenderness in the anterior chest wall and axilla, a diagnostic PMM block should be performed. A good response to the block suggests that consideration be given to performing PMT alone as it a simple, low-risk outpatient procedure. If unsuccessful, BPD can be performed at a later date. If there is a poor response to the PMM block, BPD is indicated along with PMT, provided there were some symptoms of NPMS.

Observations on the Use of Seprafilm® on the Brachial Plexus in 249 Operations for Neurogenic Thoracic Outlet Syndrome

Seprafilm was initially used successfully as a membrane to reduce abdominal adhesions. Subsequently it was tried in a number of other areas to reduce postoperative scarring. Seprafilm was employed in this study to see if it would reduce postoperative scarring after supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome (NTOS). There were 249 operations for primary NTOS (185) and recurrent NTOS (64). Seprafilm was applied to the nerve roots at the end of each procedure. Diagnosis was established by careful history and extensive physical exam consisting of several provocative maneuvers. Scalene muscle block confirmed the diagnosis. Success rates for primary operations, 1-2 years postoperation were 74% for scalenectomy without first rib resection and 70% for scalenectomy with first rib resection. For reoperations, success rate for scalenectomy and neurolysis after transaxillary rib resection was 78% whereas success rate for neurolysis after supraclavicular scalenectomy was 68%. Seprafilm did not significantly improve overall results compared to our results 15 years ago, although in reoperations there was a trend toward improvement with Seprafilm. Observations in 10 reoperations after use of Seprafilm revealed that there were fewer adhesions between fat pad and nerve roots, making it much easier to find the nerve roots. Recurrence was because of scar formation around individual nerve roots. Seprafilm made reoperations easier by reducing scarring between scalene fat pad and brachial plexus. However, it did not prevent scar tissue forming around the individual nerve roots nor did it significantly lower the failure rate for primary operations. The trend supported the use of Seprafilm in reoperations.

Role of first rib stump length in recurrent neurogenic thoracic outlet syndrome

We read with great interest the article by Ambrad-Chalela et al [1] in which the investigators reported their experience with recurrent neurogenic thoracic outlet syndrome (TOS). They identified just 1 case (6%) in which an incomplete first-rib resection was responsible for the symptom recurrence and stated that incomplete excision of first rib is an occasional cause of TOS recurrence. Conversely, in our experience on 118 patients who had transaxillary first-rib resection for TOS, a long first-rib posterior stump—shown by routine follow-up chest x-ray films—was responsible for TOS recurrence in 20 of 25 cases (80%) [2].

Recurrent neurogenic thoracic outlet syndrome

Background Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience “excellent” or “good” results after thoracic outlet decompression, recurrent symptoms may develop in certain patients. Methods This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed. Results Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had “excellent” or “good” results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these). Conclusions Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.

Recurrent neurogenic thoracic outlet syndrome

Background Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience “excellent” or “good” results after thoracic outlet decompression, recurrent symptoms may develop in certain patients. Methods This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed. Results Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had “excellent” or “good” results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these). Conclusions Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.