Surgery For Thoracic Outlet Syndrome Research Articles

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

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

Endoscopically assisted transaxillary release of the scalene muscles for thoracic outlet syndromes: a comparison with or without first rib resection.

There are several surgical techniques for thoracic outlet syndrome (TOS). However, there have been no reports of endoscopically assisted transaxillary release of the anterior and middle scalene muscles (EATRS), leaving the first rib intact for TOS. We hypothesized that EATRS would achieve a good Quick Disability of the Arm, Shoulder and Hand score. This study aims to present our experience with a new technique for TOS using endoscopy. We chose two surgeries depending on the patient's TOS condition. If the costoclavicular space was under 12mm, we selected endoscopically assisted transaxillary first rib resection (EAFRR). If the costoclavicular space was over 12mm, we selected EATRS. Between January 2021 and December 2022, 31 consecutive surgeries for TOS were performed in our institution. Twenty-five patients underwent EAFRR, and six (19%) underwent EATRS. Since July 2022, EAFRR has been performed under differential lung ventilation. Complete and almost complete relief was achieved in 24 patients (77%), and partial relief was conducted in seven patients (23%) at a mean of 19.7months after surgery. The symptoms improved in all cases. Intraoperative pneumothorax did not occur, and no other complications were observed. Both EAFRR and EATRS were effective and safe surgeries for TOS. Operative time was significantly shorter in EATRS than in EAFRR. We first report EATRS surgery for TOS. EATRS is indicated for patients whose costoclavicular space is preserved before surgery. Good surgical results were obtained after surgery for this indication.

Nerve entrapment complicating neurogenic thoracic outlet syndrome surgery: A 10-year retrospective study

Neurogenic thoracic outlet syndrome results from compression of the brachial plexus. The symptoms are mainly pain, upper-limb weakness and paresthesia. Management always starts with a rehabilitation program, but failure of rehabilitation may necessitate surgery. In practice, we observed that several patients developed secondary distal nerve entrapment in the months following surgery, with no preoperative compression. We aimed to assess the occurrence of distal nerve entrapment after surgery for neurogenic thoracic outlet syndrome in a retrospective cohort study. Seventy-four patients were included; 82% females; mean age, 39.4 ± 9.4 years. There were 36.5% with high intensity and 63.5% with low to moderate intensity work. Eighteen (24.3%) developed secondary upper-limb entrapment at 10.6 ± 5.8 months after surgery. Sixteen had a single entrapment and 2 had two different entrapments. In 10 cases (50%) the ulnar nerve was involved at the elbow, in 7 (35.0%) the radial nerve at the radial tunnel, and in 3 (15.0%) the median nerve. No differences were found between patients with and without secondary nerve entrapment in gender (p = 0.51), mean age (p = 0.44), symptom duration (p = 0.92) or work intensity (p = 0.26). Further studies are needed to confirm these results and to shed light on the underlying mechanisms.

Erector Spinae versus Surgically Placed Pain Catheters for Thoracic Outlet Decompression

Perioperative care after surgery for thoracic outlet syndrome (TOS) involves multimodal pain control. Pain catheters with bupivacaine infusion are a modality to minimize perioperative narcotic use. Our study aims to compare surgically placed pain catheters (SP) with erector spinae pain catheters (ESP) placed by the anesthesia pain service. Retrospective review of a prospectively maintained surgical TOS database identified patients undergoing transaxillary first rib resection (FRR) who had either SP or ESP placed for pain control. Patients were matched for age and gender. Data collected included demographics, operative details, and perioperative pain medication use. Narcotic pain medication doses were converted to milligram morphine equivalents (MME) for comparison between groups. Pain medications were collected for several time points: intraoperatively, for each post-operative day (POD), and for the entire hospital stay. Eighty-eight total patients were selected for comparison: 44 patients in the SP and ESP groups. Patients in each group did not differ with regards to age, BMI, gender, diagnosis, or comorbidities. There were no differences in preoperative narcotic use, preoperative pain score, or QuickDASH score. All patients underwent FRR. Concurrent cervical rib resection was performed in 6.8% SP and 6.8% ESP patients (p=1.00), pectoralis minor tenotomy in 34.1% SP and 29.5% ESP patients (p=0.65), and venogram in 31.8% SP and 31.8% ESP patients (p=1.00). Mean OR time was 90.0 minutes in SP and 105.3 minute in ESP cases (p=0.15). Mean length of stay was 1.9 days for SP and 1.8 days for ESP patients (p=0.56). There were no significant differences in intraoperative narcotics dosing in MME (SC: 22.1 vs ESP: 25.3, p=0.018). On POD 0, there were no differences in total narcotics dosing (MME) (SC: 112.0 vs ESP: 100.7, p=0.59), or in the use of acetaminophen, NSAIDS, or muscle relaxants. A similar trend in narcotics dosing was observed on POD 1 (SP: 58.6 vs ESP: 69.7, p=0.43), and POD 2 (SP: 23.5 vs ESP: 71.3, p=0.23). On POD 1, there was a higher percentage of SP patients taking NSAIDs (63.6% vs 40.9%, p=0.024), however, this difference was not observed on POD 2. There were no differences in acetaminophen or muscle relaxant use on POD 1 or 2. Total hospital stay MME was similar between groups (SC: 215.9 vs ESP: 250.9, p=0.23) CONCLUSION: Pain catheters with bupivacaine infusions are helpful adjuncts in postoperative pain control after FRR for TOS. This study compares SP to ESP, and demonstrates no difference in narcotics use between SP and ESP groups. SC should be used for pain control in facilities which do not have an anesthesia pain service available for ESP placement.

Adolescent athletes can get back in the game after surgery for thoracic outlet syndrome: Presented at the scientific session of the Seventy-fifth Society for Vascular Surgery Annual Meeting, Boston, MA, June 14-17, 2022.

Adolescent athletes can get back in the game after surgery for thoracic outlet syndrome: Presented at the scientific session of the Seventy-fifth Society for Vascular Surgery Annual Meeting, Boston, MA, June 14-17, 2022.

Trends in the Surgical Management of Thoracic Outlet Syndrome.

The operative treatment for thoracic outlet syndrome (TOS) varies in the United States. This may be due to differences in specialty training of the provider. We sought to identify which procedures are primarily performed by specialty, identify patient characteristics presenting for different neurogenic TOS surgical interventions, and describe the safety of TOS surgery. Patients treated for neurogenic TOS between 2016 and 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient characteristics, surgeon details, intraoperative variables, and complication outcomes were abstracted. Patient cohorts were stratified by type of operative intervention and by treating specialty. Transthoracic first rib resection was the most common procedure performed for TOS relief (46.1%), followed by division of the scalene muscles with rib resection (23.9%) and brachial plexus exploration with decompression (19.4%). Vascular surgeons performed 87% of TOS repairs. Thirty-day complication rate was 3.5%. Addition of scalenectomy to first rib resection was common and resulted in increased operative time but did not increase early complication rate or readmission rate. Patient characteristics and dispositions are similar between the various TOS operative approaches. All major surgical treatments for TOS have low complication rates. Transthoracic first rib resection performed by vascular surgeons remains the most common surgical treatment for patients with TOS in the United States. Despite neurogenic symptoms representing most cases, less than 10% of operations are performed by peripheral nerve specialists, highlighting a potential need for greater incorporation of TOS release into peripheral nerve practices.

Adolescent athletes can get back in the game after surgery for thoracic outlet syndrome

ObjectiveWe compared the functional outcomes among adolescent athletes with venous thoracic outlet syndrome (VTOS) and neurogenic TOS (NTOS) after thoracic outlet decompression. MethodsWe performed a single-institution retrospective review of a prospective database of adolescent athletes (aged 13-19 years) from June 1, 1996 to December 31, 2021 who had undergone operative decompression for TOS. The demographic data, preoperative symptoms, operative details, and postoperative outcomes were compared. The primary outcome was the postoperative return to sport. The secondary outcomes included symptom resolution and assessment of the somatic pain scale, QuickDASH, and Derkash scores. The Fisher exact test and t test were used to evaluate the categorical and continuous variables, respectively. A logistic regression model was constructed to adjust for the influence of preoperative factors and return to sport. ResultsA total of 60 patients (40.0% with VTOS and 60.0% with NTOS) were included. The average age of the VTOS patients was 17.2 years vs 16.6 years for the NTOS patients (P = .265). The NTOS patients were more likely to be female (88.9% vs 62.5%; P = .024). The NTOS patients had more frequently presented with pain (97.2% vs 70.8%; P = .005), paresthesia (94.4% vs 29.1%; P = .021), and weakness (67.7% vs 12.5%; P = .004) but had less often reported swelling (25.0% vs 95.8%; P < .001). At presentation, the NTOS patients had also reported a longer symptom duration (17.7 months vs 3.1 months; P < .001). Transaxillary first rib resection with subtotal scalenectomy was performed for 100% of the VTOS patients and 94.4% of the NTOS patients undergoing cervical rib resection (2.8%) or scalenectomy alone (2.8%). Additionally, 11.1% of the NTOS patients had undergone combined first rib resection and cervical rib resection. For the VTOS patients, postoperative venography showed patent subclavian veins in 27.8%. In addition, 44.4% had required venoplasty, 16.8% had required thrombolysis, and 11% were chronically occluded. No significant differences were found in blood loss, operative time, or length of stay between the groups. No surgical complications occurred. The average follow-up was 6.3 months. Significant differences were found between the VTOS and NTOS groups for the pre- and postoperative somatic pain scale, QuickDASH, and Derkash scores. Complete symptom resolution had occurred in 83.3% of the VTOS and 75% of the NTOS patients (P = .074). No statistically significant difference in the return to sport was observed between the two groups (VTOS, 94.4%; vs NTOS, 73.9%; P = .123). Of the NTOS patients, 10.0% had had other concomitant injuries and 5.0% had had medical conditions that had precluded their return to sport. Logistic regression found no significant relationship between the preoperative somatic pain scale score, QuickDASH score, or duration of symptoms and the return to sport. ConclusionsAdolescent athletes with VTOS and NTOS can have good functional outcomes, and most will be able to return to sport after surgery. Greater initial symptom severity and concomitant injuries were observed in adolescents with NTOS. Of those who had not returned to sport postoperatively, three of seven had had unrelated health issues that had prevented their return to sport.

Midterm results of endoscopically assisted first rib resection in the zero position for thoracic outlet syndrome

OBJECTIVESWe have hypothesized that an endoscopically assisted transaxillary approach in the zero position would be able to improve visualization and allow safe surgery for thoracic outlet syndrome.METHODSWe performed surgery only for patients with certain objective findings, including blood flow disruption, low blood flow and accelerated blood flow in the subclavian artery demonstrated using Doppler sonography, narrowing of the scalene interval width between the anterior and middle interscalene muscles (interscalene base) or costoclavicular space demonstrated using Duplex ultrasonography or computed tomography angiography. The present study included 45 consecutive patients (50 limbs) who underwent endoscopic transaxillary first rib resection with scalenotomy and brachial plexus neurolysis. We assessed the intraoperative parameters, including the interscalene base, blood loss, operation time, patient satisfaction, preoperative and postoperative Quick Disability of the Arm, Shoulder and Hand and complications.RESULTSThe mean intraoperatively measured interscalene base width was 6.4 mm. All patients showed improvement after surgery. The outcome was excellent in 40% of cases, good in 48%, fair in 12% and poor in none. Pneumothorax was present in 6%. There were no other complications and no recurrences. Among patients who had been followed up for at least 2 years, the Quick Disability of the Arm, Shoulder and Hand score was significantly improved (42 before surgery vs 12 at final follow-up), especially in athletes relative to non-athletes (0.2 vs 16). The present approach achieved complete relief in 43% of cases overall (91% in athletes and 16% in non-athletes).CONCLUSIONSEndoscopically assisted transaxillary first rib resection and brachial plexus neurolysis in the zero position are useful and safe for thoracic outlet syndrome, especially in athletes.

Presentation, management and outcome of surgically managed pediatric thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a rare disorder involving compression of the brachial plexus, subclavian artery, and subclavian vein. There is a paucity of data for this pathology's surgical treatment within pediatrics. The objective of this study is to explore the presentation, management, and outcome of pediatric TOS. A retrospective chart review was conducted for 44 patients at a single institution undergoing surgery for TOS. Data was collected on demographics, pre- and postoperative factors, and outcomes. Forty-four patients underwent 50 surgeries (8 bilaterally). The average age was 15.5years with 72% female. The most common symptoms were numbness (72%) and pain (66%), with a normal exam in 58%. The average symptom duration prior to surgery was 35.2months. A supraclavicular approach was performed in all patients, with anterior scalene section(90%), rib resection (72%), neurolysis (92%), and intraoperative EMG (84%) commonly used. Two patients had a lymphatic leak. All patients reported subjective improvement of preoperative symptoms of numbness (26%), pain (22%), and weakness (6%). Differences between vTOS (n = 9) and nTOS (n = 35) included higher preop swelling (p < 0.012), decreased symptom duration (p < 0.022), higher venogram usage (p < 0.0030), and higher preoperative thrombolytics/angioplasty (p < 0.001) in vTOS compared to nTOS. A comparison of soft tissue and soft tissue with bone decompression did not reveal any outcome differences. Pediatric TOS benefits from a multidisciplinary approach, showing good outcomes in postoperative symptom resolution. In our cohort, a supraclavicular approach provided an effective window for decompression with a low complication rate.

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

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

Subclavian Artery Flow Dynamics Evaluated by Analytical Intraoperative Indocyanine Green Videoangiography During Surgical Treatment of Thoracic Outlet Syndrome: A Case Series.

Indocyanine green (ICG) videoangiography is rarely used during the surgical treatment of thoracic outlet syndrome (TOS). To evaluate subclavian artery (SA) flow dynamics using the analytical ICG videoangiography during TOS surgeries. We examined patients with neurogenic TOS who received surgical treatment and whose SA blood flow at the interscalene space was evaluated using ICG videoangiography equipped with an analytical function (FLOW800). Anterior scalenectomy with or without middle scalenectomy and first rib resection were conducted for decompression of the brachial plexus. ICG videoangiography was performed before and after decompression of the brachial plexus. After acquisition of grayscale and color-coded maps, a region of interest was placed in the SA to obtain time-intensity diagrams. Maximum intensity (MI), rise time (RT), and blood flow index (BFi) were calculated from the diagram, in arbitrary intensity (AI) units. We compared values before and after decompression. Comparisons of the three parameters before and after decompression were assessed statistically using the paired t-tests and Wilcoxon signed-rank test. We evaluated nine procedures in consecutively presenting patients. The observed mean values of MI, RT, and BFi before decompression were 174.1 ± 61.5 AI, 5.2 ± 1.1 s, and 35.2 ± 13.5 AI/s, respectively, and the observed mean values of MI, RT, and BFi after decompression were 299.3 ± 167.4 AI, 6.6 ± 0.8 s, and 44.6 ± 28.3 AI/s, respectively. These parameters showed higher values after decompression than before decompression, and the increase in MI and RT was statistically significant (P < .05). ICG videoangiography allows semiquantitative evaluation of hemodynamic changes during TOS surgery. A marked decrease in the velocity of SA flow was observed after decompression.

The effects of major depression disorder on neurogenic thoracic outlet syndrome surgery outcomes.

Thoracic outlet syndrome (TOS) is a group of disorders caused by impingement of the neurovascular structures at the thoracic outlet. Neurogenic TOS (nTOS), which is thought to be caused by a compression of the brachial plexus, accounts for more than 90% of the cases. Although treatment for nTOS is successful through physiotherapy and/or surgical decompression, little is known about the impact of psychosocial factors, namely, major depressive disorder (MDD), on postoperative outcomes such as non-routine discharge (NRD). Here, we assess whether MDD predicts the type of discharge following nTOS surgical intervention. A retrospective analysis of the National Inpatient Sample database from the years 2005-2018 was performed. Using the International Classification of Diseases Clinical Modification, Ninth and Tenth revisions, patients who underwent a surgical intervention for nTOS were identified. Our primary outcome was to investigate the effects of MDD on nTOS patient disposition status after surgical management; secondary outcomes included analysis of total hospital charges and length of stay. NRD was defined as anything beyond discharge home without healthcare services. Univariate and multivariable logistic regression analyses were conducted to assess MDD and other potential independent predictors of NRD and prolonged hospital stay (> 2days) following surgical intervention. A total of 6099 patients were identified: 596 (9.77%) patients with MDD and 5503 (90.23%) without MDD. On average, patients with MDD were older (39.6 ± 12.0years vs. 36.0 ± 13.0years; p < 0.001), female (80.7% vs. 63.5%; p < 0.001), white (89.6% vs. 85.6%; p = 0.030), and on Medicare (9.6% vs 5.2%; p < 0.001). Univariate and multivariable logistic regression models identified MDD as an independent risk factor associated with a higher risk of NRD (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI], 1.0-2.2). Additionally, chronic kidney disease (aOR, 2.60; 95% CI, 1.2-5.4), postoperative complications (aOR, 1.87; 95% CI, 1.2-2.9), and Medicare (aOR, 2.95; 95% CI, 1.9-4.7) were statistically significant predictors for higher risk of NRD. However, MDD was not associated with prolonged hospital stay (aOR, 1.00; 95% CI, 0.8-1.2) or higher median of total charges (MDD group: $27,867 vs. non-MDD group: $28,123; p = 0.799). Comorbid MDD was strongly associated with higher NRD rates following nTOS surgical intervention. MDD had no significant impact on length of hospital stay or total hospital charges. Additional prospective research is necessary in order to better evaluate the impact of MDD in patients with nTOS.

Development and evolution of a robotic surgical technique for the treatment of thoracic outlet syndrome

ObjectiveWe describe the development and evolution of a surgical technique that uses the robotic da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) for the transaxillary approach to repair the disabling thoracic outlet syndrome (TOS). We report our patient outcomes associated with the use of this robotic technique. MethodsWe present a retrospective review and analysis of data collected from a 16-year experience of a single surgeon using a robotic surgical system and technique for TOS surgery. From the initial design of an endoscope attached to a microvideo camera in 1982 to the adoption of the monorobotic arm with integrated voice in 1998, the main objective of the transaxillary approach has always been to improve visualization of congenital cervical anomalies of the scalene muscles. From February 2003 to December 2018, we performed 412 transaxillary decompression procedures using the robotic da Vinci Surgical System. The surgical procedure has been described in further detail and includes the following steps: (1) positioning of the patient into a lateral decubitus position and using a monoarm retractor; (2) creation of a mini-incision in the axillary area and creation and maintenance of the subpectoral anatomic working space; (3) placement of endoscopic ports and engagement of the robotic instrumentation; (4) dissection of extrapleural and intrapleural soft tissue; (5) creation of the “floater” first rib; (6) excision of the cervical bands and first rib; and (7) placement of thoracostomy tubes for drainage and closure of the incisions. ResultsNone of the patients died, and no patient experienced permanent neurovascular damage of the extremity. Of the 306 patients, 22 (5% of 441 operations) experienced complications. One patient developed postoperative scarring that required a redo operation with a robotic-assisted transaxillary approach. ConclusionsWith its three-dimensional visual magnification of the anatomic area, the endoscopic robotic-assisted transaxillary approach offers safe and effective management of disabling TOS symptoms. The endoscope facilitates observation of the cervical bands and the mechanism (pathogenesis) of the neurovascular compression that causes TOS, thereby allowing complete excision of the first rib, cervical bands, and scalene muscle. We sought to develop and perfect this robotic approach. The present study was not intended to be a comparative study to nonrobotic TOS surgery.

Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States

Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial, given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher versus lower volume centers. The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm (arterial [aTOS]), subclavian deep vein thrombosis (venous [vTOS]), or brachial plexus lesions (neurogenic [nTOS]). Basic descriptive statistics, nonparametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher and lower volume hospitals, respectively. There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010 and 2015 (89.2% nTOS, 9.9% vTOS, and 0.9% aTOS) with annual case volume increasing significantly over time (P=0.03). Higher volume centers (≥10 cases per year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma, or lymphatic leak) rates (adjusted odds ratio [OR] 0.71 [95% confidence interval 0.52-0.98]; P=0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 [0.20-2.43]; P=0.56) or vascular injuries/graft complications (aOR 0.71 [0.0.33-1.54]; P=0.39). Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (P=0.03). However, vTOS and aTOS had >2.5 times the odds of major complication compared with nTOS (OR 2.68 [1.88-3.82] and aOR 4.26 [1.78-10.17]; P<0.001), and ∼10 times the odds of a vascular complication (aOR 10.37 [5.33-20.19] and aOR 12.93 [3.54-47.37]; P<0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (P<0.001). Total hospital charges were on average higher when surgery was performed in lower volume centers (<10 cases per year) compared with higher volume centers (mean $65,634 [standard deviation 98,796] vs. $45,850 [59,285]; P<0.001). The annual number of TOS operations has increased in the United States from 2010 to 2015, whereas complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher volume centers delivered higher value care: less or similar operative morbidity with lower total hospital charges.

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.

Contemporary Practices and Complications Of Surgery For Thoracic Outlet Syndrome In The United States

Contemporary Practices and Complications Of Surgery For Thoracic Outlet Syndrome In The United States

Validity and internal consistency of the thoracic outlet syndrome index for patients with thoracic outlet syndrome

No validated scales exist specifically for measuring quality of life (QoL) and functioning level in patients with thoracic outlet syndrome (TOS). This cross-sectional survey examined whether some items adopted from validated QoL scales could be suitable for patients with TOS. To find an optimal thoracic outlet syndrome index (TOSI), a panel of 14 specialists experienced in treating TOS independently evaluated the relevance of 19 items adopted from scales used in other upper-extremity syndromes. After undergoing surgery for TOS, 52 patients rated the relevance of those items found by experts to be relevant. Content validity was measured by a content validity index, content validity ratio, and modified κ. The internal consistency of 15 retained items was assessed with the Cronbachα, and its construct validity was assessed by an exploratory factor analysis. Of the 19 items, 15 were considered relevant for TOS by the panelists, with an overall test content validity index of 0.93. The internal consistency of these 15 items was excellent. The exploratory factor analysis accompanied by a parallel analysis confirmed the uni-dimensionality of the TOSI. All 15 items that the panelists considered relevant were also items that the patients marked with scores over 7 points on an 11-point scale of relevance. The internally consistent, face- and content-valid TOSI scale is proposed for use in evaluating specifically the QoL in TOS patients, as well as improving future longitudinal studies comparing functioning before and after interventions or spontaneous recovery in TOS patients.

Information for authors and editorial policies

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IF13. Arterial Thoracic Outlet Syndrome: Outcomes of Direct Repair of Subclavian Artery Aneurysms

Arterial complications of thoracic outlet syndrome (TOS) are rare (<1%). Surgery involves decompression of thoracic outlet, repair of subclavian aneurysm, and often embolectomy. Most published series have reported interposition graft for repair of subclavian aneurysm. The objective of this study was to evaluate the long-term results of decompression and direct repair of subclavian artery aneurysm in arterial TOS. This was a retrospective review of a prospectively maintained database. All patients who underwent surgery for arterial TOS from January 2001 to April 2017 were included. Patients’ demographics, presentation, treatment, and outcomes were reviewed. Direct repair of subclavian artery aneurysm included longitudinal arteriotomy, intimectomy, and tailoring. There were 62 operations performed on 53 patients for arterial TOS. Mean age at presentation was 35.62 years (range, 13-65 years). The female to male ratio was 1.65:1.0. There were 12 patients with bilateral arterial TOS, although all presented with unilateral symptoms. Three patients presented with acute limb ischemia. The remaining patients had delayed presentation (range, 30 days-2 years), including neck pain and swelling (7), upper limb claudication (33), rest pain and digital cyanosis (5), and stroke (1). The cause of arterial TOS was complete cervical rib in 50 (94%) patients (12 bilateral), incomplete first rib in 2 (4%) patients, and compression with scalenus anticus in 1 (2%) patient. All 12 asymptomatic TOS patients showed arterial compression, and 3 patients refused surgery for the asymptomatic limb. Surgery included thoracic outlet decompression by anterior scalenotomy (62), excision of cervical rib (59), and excision of first rib (3). Of the 62 operations (89%), 55 included direct repair of subclavian aneurysm: longitudinal arteriotomy, intimectomy, and aneurysmorrhaphy; 2, resection and end-to-end anastomosis; and 2, interposition grafts. Trans-subclavian embolectomy was done in 47 and transbrachial in 27 patients. Early complications included hemothorax requiring chest drain (one), lymph leak (one), phrenic nerve paresis (one), and brachial neurapraxia (two). Mean follow-up was 2 years (range, 6 months-5 years); 13 patients were lost to follow-up after 6 months. Follow-up is at regular intervals clinically and with duplex ultrasound scan. Residual ischemia (asymptomatic) is present in 12 of 53 patients (23%). One patient has persistent neuralgia. Asymptomatic dilation of directly repaired subclavian artery was identified in one patient at 18 months of follow-up, and he is under surveillance. Direct repair of subclavian artery aneurysm in arterial TOS patients can be performed safely. Recurrent dilation is rare and can be managed conservatively.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs

ObjectiveThe transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. MethodsWe reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. ResultsBetween 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). ConclusionsThis series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.