Thoracic Outlet Syndrome Research Articles

Utilization and Effectiveness of Pectoralis Minor Tenotomy in the Surgical Management of Neurogenic Thoracic Outlet Syndrome.

Uncertainty exists concerning the optimal utilization and effectiveness of pectoralis minor tenotomy (PMT) in neurogenic thoracic outlet syndrome (NTOS). Between January 2020 and July 2023, 355 patients with NTOS underwent primary surgical treatment. Prospectively collected data were analyzed retrospectively. Overall mean patient age was 35.9 ± 1.9 years, 76% were female, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score at presentation was 60.3 ± 3.2, reflecting substantial disability. Surgical treatment was based on localized tenderness/symptoms to palpation, with 322 (91%) undergoing combined supraclavicular decompression and PMT (SCD + PMT) and 33 (9%) selected for isolated PMT when findings were solely confined to the subcoracoid space. Mean operative time (29 ± 5 vs 164 ± 9 min, P < .01) and hospital stay (0.3 ± 0.1 vs 4.0 ± 0.2 days, P < .01) were both lower after isolated PMT, with no significant differences in postoperative complications or rehospitalization. During follow-up of 26.7 ± 1.5 months, QuickDASH scores declined by 41.2% ± 2.3% (P < .0001) and patient-rated outcomes were excellent in 34%, good in 41%, fair in 22%, and poor in 4%. Fewer patients had poor-rated outcomes after SCD + PMT (2%) than after isolated PMT (19%) (P < .01). Recurrent symptoms requiring supraclavicular reoperation occurred in 16 patients after SCD + PMT (5%) and in 5 patients after isolated PMT (15%) (P < .05). Pectoralis minor tenotomy (PMT) has an important role in surgical treatment of NTOS, mainly as an adjunct in combination with SCD. While highly selected patients can do well after isolated PMT as a short outpatient procedure with rapid recovery, there is a greater potential for poor outcomes and supraclavicular reoperation than after SCD + PMT.

Large Right Subclavian Artery Aneurysm Presenting in a Young Patient.

Subclavian artery aneurysms are extremely rare, accounting for less than 1% all of peripheral aneurysms. They are often due to atherosclerosis or thoracic outlet syndrome and present at an average age of 47years. Here, we present an incidental finding of an 18mm rapidly increasing aneurysm involving the first and second part of the right subclavian artery in a woman in her 20s. To our knowledge, this is the youngest patient presenting with a right subclavian artery aneurysm who underwent surgical resection of the aneurysm with repair using interposition graft and successful re-implantation of the vertebral artery with antegrade flow. This report highlights the multidisciplinary care between vascular, interventional radiology and cardiothoracic teams at our tertiary hospital due to the complex nature of the aneurysm.

Burden of In-Hospital Admissions and Outcomes of Thoracic Outlet Compression Syndrome in the United States From 2010 to 2021

Burden of In-Hospital Admissions and Outcomes of Thoracic Outlet Compression Syndrome in the United States From 2010 to 2021

Technical Adaptation of First Rib Resection by Vats for the Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is not common in the thoracic surgeon´s routine. However, when it is encountered, it is important that the correct diagnosis and treatment is carried out, especially as surgery can be indicated in cases of non-clinical improvement. The goal of the surgery is to release the thoracic outlet constriction structures, which can be performed by several approaches. The innovative VATS surgical technique described here allows better rib exposure, the use of blunt digital dissection, as well as a new device for rib cutting. The technique described here has proven to be feasible, safe and reproducible.

Association of Concave Deformity of the Anterior Scalene on Magnetic Resonance Imaging with Vascular Variant of Neurogenic Thoracic Outlet Syndrome.

Neurogenic thoracic outlet syndrome (NTOS) is a dynamic compression of the brachial plexus. This study aimed to evaluate the correlation between the concave deformity of the posterior edge of the anterior scalene muscle (CDAS) on sagittal T1 with intraoperative findings of vascular compression. The second aim was to define the NTOS vascular subtypes and establish possible treatments. We retrospectively reviewed patients who met the Consortium for Research and Education on Thoracic Outlet Syndrome criteria for NTOS and were operated on after a failed rehabilitation program. Forty-four patients were included; mean age was 29.51 years (range: 13-55 years), and 24 (54.5%) were women. CDAS on sagittal T1 magnetic resonance imaging (MRI) was identified in 20 of 44. Patients were divided into two categories: type A (pure NTOS) (20 of 44); and type B (mixed neurogenic-vascular variants) (24 of 44). Type B was divided into B1, B2, and B3, corresponding to subclavian artery (SCA) compression (seven of 44), subclavian vein compression (SCV) (five of 44), and both SCA and SCV compression (12 of 44), respectively. All patients with B1 had CDAS on MRI T1 sagittal, whereas CDAS was found on 5%, 60%, and 58.3% in types A, B2, and B3, respectively. Intraoperatively, all patients had at least one structural anomaly. Preoperative symptoms of lower or middle-lower brachial plexus trunk compressions were more prominent in patients with the vascular variant (B1: 85%, B2: 83%, and B3: 83%) than the pure NTOS (type A) (40%). NTOS presents as four subtypes: pure neurogenic (A) and vascular (B1, B2, and B3). Preoperative middle/lower trunk symptoms combined with positive upper limb duplex ultrasound of the SCA, SCV, and sagittal MRI show that a CDAS is correlated with the vascular form of NTOS and predicts failure of preoperative rehabilitation program.

The demonstrated step-by-step RATS 1ˢᵗ rib resection has shown to be a safe and effective approach for 1ˢᵗ rib resection in thoracic outlet syndrome.

The demonstrated step-by-step RATS 1ˢᵗ rib resection has shown to be a safe and effective approach for 1ˢᵗ rib resection in thoracic outlet syndrome.

Early Results of Interventions in Patients with Venous Thoracic Outlet Syndrome

To determine the freedom from major complications and the efficacy in the form of technical and clinical success of different interventions in venous thoracic outlet syndrome. Data from three centres regarding patients aged between (18 - 60 years) with symptoms and signs of upper limb venous outflow obstruction was collected and analysed to monitor outcome of different interventions. 23 patients (16 males) with mean age of 35 ± 9.33 years (range 23 - 54 years) were recruited. 17.4% of the patients were thrombotic, 56.5% were non-thrombotic and 26.1% were post-thrombotic. 73.9% had right side presentation with pain and swelling. Two techniques of thrombus removal, two techniques for first rib resection and venoplasty were all used with 100% technical, 87% over all clinical success and no major perioperative complications. The mean follow-up duration was 9.9 months. Interventions in venous thoracic outlet syndrome are both safe and effective in the short and mid-term.

Prevalence of thoracic outlet syndrome among patients visiting physical therapy outpatient department of public sector Tertiary Care Hospitals, Peshawar

The indications and symptoms in the upper extremity brought on by compression of the brachial plexus, subclavian vein, and/or subclavian artery at the thoracic outlet were originally referred to as thoracic outlet syndrome (TOS). The symptoms of neurogenic thoracic outlet syndrome (NTOS) are caused by compression of the brachial plexus roots as they travel through the thoracic outlet. The most typical symptom of thoracic outlet syndrome is neurogenic thoracic outlet syndrome (NTOS). The brachial plexus is compressed and irritated, which causes its symptoms.A cross-sectional study was conducted from March 2023 to June 2023 among patients visiting Physical therapy outpatient department of public sector tertiary care hospitals Peshawar. The DASH questionnaire was distributed to all patients according to inclusion criteria from different hospitals to collect data on the prevalence of thoracic outlet syndrome.The study found that the prevalence of thoracic outlet syndrome was higher in female. The prevalence was higher among female housewives (77.77%) compared to male (63%). Risk factors associated with this pain included improper posture in same position while working, long work durations, repetitive tasks, and restricted neck movements.

Magnetic resonance neurography in the diagnosis of neurological subtypes of thoracic outlet syndrome.

Neurological thoracic outlet syndrome (TOS) can be challenging to diagnose, particularly given its described subtypes of neurogenic TOS (NTOS) and disputed TOS (DTOS) that exhibit variable clinical presentations and etiologies. The diagnostic workup of TOS often includes magnetic resonance neurography (MRN) of the brachial plexus. Specific MRN imaging modifications for TOS evaluation are required to maximize spatial and contrast resolution to increase the conspicuity of nerve segments and their relationships to surrounding osseous structures. Dynamic assessment with arm positioning is used to evaluate outlet narrowing and compression of the plexus. Individual nerve segments are interrogated for their longitudinal and cross-sectional morphologies and signal characteristics. In patients with NTOS, MRN may reveal focal impingement of the C8/T1 nerve roots and/or lower trunk with accompanying abnormal T2-weighted signal hyperintensity. Predisposing anatomical entities include cervical ribs, rib synostoses, hypertrophic callous following clavicular fracture, remnant first thoracic rib from prior incomplete resection, and variable perineural scarring. In comparison, DTOS patients frequently demonstrate signal hyperintensity and enlargement of the mid plexus (trunk and division level), with narrowing of the costoclavicular interval. Following comprehensive diagnostic workup that frequently includes electrodiagnostic testing, patients are directed to different management pathways. Nonsurgical management is considered for all cases of DTOS; all patients with NTOS or DTOS who fail conservative treatment warrant referral for a surgical opinion. If surgery is pursued, MRN can be helpful in preoperative planning.

Factors correlating with positive electrodiagnostic findings for neurogenic thoracic outlet syndrome

IntroductionDiagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report EDX findings in a cohort of patients undergoing surgery for nTOS and also analyse patient related and intraoperative factors associated with positive EDX findings supportive of a diagnosis of NTOS. MethodsBaseline characteristics of patients including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement were gathered and analysed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison. ResultsA total of 30 consecutive patients were included in this study comprising 11 (36.7%) male and 19 (63.3%) female patients, with a mean age of 44.6 ± 17.6 years. When classified by type of nTOS, 22 (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and one (3.3%) patient with type 2 nTOS. In terms of the pattern of nTOS, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P<0.05) were significantly associated with positive EDX findings. ConclusionsEDX assessment, at this point in time, may not be the best modality for diagnosis of nTOS. Interindividual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX.

Thoracic Outlet Syndrome.

Thoracic outlet syndrome is a complex syndrome that manifests with symptoms based on the presumed injury or impairment of the neurovascular structures in the thoracic outlet space with its intricate anatomy and pathophysiology. The thoracic outlet is a specific anatomical region with three distinct anatomical spaces - interscalene triangle, the costoclavicular space, and the retro-pectoralis minor space. Thoracic outlet syndrome is classified into neurogenic, venous, and arterial thoracic outlet syndrome and often poses diagnostic challenge to implicate a specific condition or cause. Many cases of thoracic outlet syndrome can be effectively managed through conservative measures, but patients with refractory symptoms may warrant surgical intervention. Modalities such as intramuscular anesthetic and botulinum toxin injections hold promise as diagnostic, therapeutic, and prognostic procedures. Further research and collaboration are needed to develop algorithms for diagnosis and treatment of thoracic outlet syndrome symptoms. This review aims to explore our understanding of thoracic outlet syndrome, with a focus on current evidence and emerging trends.

Diagnostic and Therapeutic Approach to Thoracic Outlet Syndrome.

Thoracic outlet syndrome (TOS) is a group of symptoms caused by the compression of neurovascular structures of the superior thoracic outlet. The knowledge of its clinical presentation with specific symptoms, as well as proper imaging examinations, ranging from plain radiographs to ultrasound, computed tomography and magnetic resonance imaging, may help achieve a precise diagnosis. Once TOS is recognized, proper treatment may comprise a conservative or a surgical approach.

Comprehensive Endoscopic Brachial Plexus Release for Neurogenic Thoracic Outlet Syndrome Including Suprascapular Nerve Release and Scalenotomy

Thoracic outlet syndrome is characterized by compression of neurovascular structures including the brachial plexus. Endoscopic techniques for brachial plexus neurolysis are emerging as treatment options when properly indicated. This technical note presents an updated comprehensive endoscopic technique for infraclavicular and supraclavicular brachial plexus neurolysis, including release of the suprascapular nerve via the anterior approach and release of the brachial plexus at the level of the interscalene triangle.

Computed Tomography Angiography in Thoracic Outlet Syndrome

Computed Tomography Angiography in Thoracic Outlet Syndrome

Estimation of the prevalence of isolated inter-scalene compression from simultaneous arterial and venous photoplethysmography in patients referred for suspected thoracic outlet syndrome

Objective. In patients with suspected thoracic outlet syndrome (TOS), diagnosing inter-scalene compression could lead to minimally invasive treatments. During photo-plethysmography, completing a 30 s 90° abduction, external rotation (‘surrender’ position) by addition of a 15 s 90° antepulsion ‘prayer’ position, allows quantitative bilateral analysis of both arterial (A-PPG) and venous (V-PPG) results. We aimed at determining the proportion of isolated arterial compression with photo-plethysmography in TOS-suspected patients. Approach. We studied 116 subjects recruited over 4 months (43.3 ± 11.8 years old, 69% females). Fingertip A-PPG and forearm V-PPG were recorded on both sides at 125 Hz and 4 Hz respectively. A-PPG was converted to PPG amplitude and expressed as percentage of resting amplitude (% rest). V-PPG was expressed as percentage of the maximal value (% max) observed during the ‘Surrender-Prayer’ maneuver. Impairment of arterial inflow during the surrender (As+) or prayer (Ap+) phases were defined as a pulse-amplitude either <5% rest, or <25% rest. Incomplete venous emptying during the surrender (Vs+) or prayer (Vp+) phases were defined as V-PPG values either <70% max, or <87% max. Main results. Of the 16 possible associations of encodings, As − Vs − Ap − Vp− was the most frequent observation assumed to be a normal response. Isolated arterial inflow without venous outflow (As + Vs−) impairment in the surrender position was observed in 10.3% (95%CI: 6.7%–15.0%) to 15.1% (95%CI: 10.7%–20.4%) of limbs. Significance. Simultaneous A-PPG and V-PPG can discriminate arterial from venous compression and then potentially inter-scalene from other levels of compressions. As such, it opens new perspectives in evaluation and treatment of TOS.

Management and outcomes of venous thoracic outlet decompression: A transition to the infraclavicular approach

ObjectiveVenous thoracic outlet syndrome (vTOS) is caused by compression of the subclavian vein at the costoclavicular space, which may lead to vein thrombosis. Current treatment includes thoracic outlet decompression with or without venolysis. However, given its relatively low prevalence, the existing literature is limited. Here, we report our single-institution experience in the treatment of vTOS. MethodsWe performed a retrospective review of all patients who underwent rib resection for vTOS at our institution from 2007 to 2022. Demographic, procedural details, and perioperative and long-term outcomes were reviewed. ResultsA total of 76 patients were identified. The mean age was 36 years. Swelling was the most common symptom (93%), followed by pain (6.6%). Ninety percent of patients had associated deep vein thrombosis, with 99% of these patients starting anticoagulation preoperatively. A total of 91% of patients underwent rib resection via the infraclavicular approach, 2% via the paraclavicular approach (due to a neurogenic component), and 7% via the transaxillary approach. Eighty-three percent of patients had endovascular intervention before or at the time of the rib resection, with catheter-directed thrombolysis (87%), followed by angioplasty (71%) and rheolytic thrombectomy (57%) being the most common interventions. The median time from endovascular intervention to rib resection was 14 days, with 25% at the same admission. The median postoperative stay was 3 days (2-5 days). There was no perioperative mortality or nerve injury. Fourteen percent of patients had postoperative complications, with bleeding complications (12%) being the most common. Waiting more than 30 days between initial endovascular intervention and rib resection was not associated with decreased risk of bleeding complications. Patients were seen postoperatively at 1-month (physical examination) and 6-month (duplex) intervals or for any new or recurrent symptoms. Twenty-two percent of our overall patient population underwent reintervention, most commonly angioplasty (21%). At last follow-up, 97% of subclavian veins were patent, and 93% of patients were symptom free. ConclusionsOver the last decade, we have transitioned to an infraclavicular approach for isolated vTOS, with low perioperative morbidity and good patency rates. These results support the adoption of the infraclavicular approach with adjunct endovascular techniques as a safe and efficacious treatment of vTOS.

Consensus Recommendations for Neurogenic Thoracic Outlet Syndrome from the INTOS Workgroup.

There is significant variation in methods used for diagnosis and treatment of neurogenic thoracic outlet syndrome (NTOS). The lack of definitions and criteria for diagnosis as well as controversy in treatment options hampers standardized reporting of outcomes. In the orthopedic and plastic hand surgery literature, there are not standardized guidelines to direct evidence-based practice for hand surgeons relating to NTOS. Hence, expert consensus may provide guidance for clinical practice. An international workgroup of 21 expert hand surgeons with cumulative experience of 5519 NTOS procedures was assembled. The Delphi method was used to arrive at consensus recommendations to guide diagnosis, treatment, surgery, and postoperative management of patients with NTOS. The workgroup achieved majority (greater than 75%) consensus with 17 statements. A modified version of the Society for Vascular Surgery clinical diagnostic criteria is recommended for diagnosis of NTOS. The elevated arm stress test and Tinel sign are recommended as provocative maneuvers. A cervical spine or chest radiograph should be routinely obtained preoperatively. Conservative management should be first line for NTOS, except in patients with significant muscle atrophy or weakness. An anterior supraclavicular approach is recommended for exposure of the supraclavicular brachial plexus, with the necessity for an additional infraclavicular approach or adjunctive surgeries indicated for specific patients. Standardized consensus guidelines help guide management of NTOS by specialized hand surgeons, with an aim toward standardizing criteria for diagnosis and treatment of patients as well as measures and tools used for research and reporting of outcomes.

Challenges and Advances in the Diagnosis and Management of Neurogenic Thoracic Outlet Syndrome: A Comprehensive Review.

Neurogenic thoracic outlet syndrome (nTOS) is caused by brachial plexus compression in the thoracic outlet. It accounts for 85%-95% of thoracic outlet syndrome (TOS) cases, which may also be caused by compression of the subclavian artery and vein. Compression occurs in the interscalene triangle, costoclavicular space or subpectoralis minor space, with congenital anomalies and repetitive overhead activities as contributing factors. Diagnosis is challenging due to overlapping symptoms with other conditions. Patients commonly report pain, numbness, tingling and weakness in the neck, shoulder and arm, exacerbated by arm elevation. Symptoms related to nTOS may manifest in the distribution of the upper (C5-C6), middle (C7) and lower plexus (C8-T1). Although widely used, provocative tests have varying degrees of sensitivity and specificity and may have high false-positive rates, complicating the diagnosis. Patterns on electrodiagnostic studies provide key diagnostic clues, such as reduced sensory response in the medial antebrachial cutaneous nerve and low compound motor action potential in the median nerve. Imaging techniques like magnetic resonance imaging (MRI), alongside procedures like diagnostic and therapeutic anterior scalene blocks, assist in identifying anatomical abnormalities and predicting surgical outcomes. Management of nTOS involves lifestyle changes, physical therapy, medication and botulinum toxin injections for symptomatic relief. Surgical options may include supraclavicular, transaxillary and infraclavicular approaches, each offering specific benefits based on patient anatomy and surgeon expertise. Minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery, enhance exposure and dexterity, leading to better outcomes. Future research should focus on developing precise diagnostic tools, understanding nTOS pathophysiology, standardising diagnostic criteria and surgical approaches, comparing long-term treatment outcomes and exploring preventive measures to improve patient care and quality of life. Level of Evidence: Level V (Therapeutic).

Pediatric thoracic outlet syndrome: a systematic review with metadata.

Thoracic outlet syndrome (TOS) typically considered a condition of the adult population; it is often disregarded in children and adolescents due to its limited recognition within the pediatrics. The current study aims to systematically review and provide insights into TOS among pediatric patients. PubMed, Scopus, Web of Science, and Google Scholar databases were thoroughly searched for English language studies published until March 15th, 2024. The study included those articles focusing on pediatric or adolescent individuals diagnosed with TOS. Data collected from studies encompassed date of publication, number of participants or reported cases, age (years), gender of participants, type of TOS, affected side, type of treatment, surgical approach, bony abnormality, duration of symptoms (months), outcome, and follow-up time duration (months). The current study comprised 33 articles, 21 of which were case reports, 10 of which were case series, and the remaining were cohort studies. In this study, 356 patients were included. Females constituted 234 (65.73%) of the patient population. Among TOS types, neurogenic TOS was found among 201 (56.5%) patients. Sporting-related activity or physical activity was present in 193 (54%) patients, followed by a history of trauma in 27 (7%) patients. Pediatric patients exhibited a higher percentage of vascular TOS than their adult counterparts, with the supraclavicular approach emerging as the preferred treatment method. Sports-related activities were identified as the primary risk factor associated with pediatric TOS.

PREVALENCE OF THORACIC OUTLET SYNDROME IN WORKERS AND PLAYERS OF FAISALABAD

Background of the Study: A neurovascular compression that causes pain and tingling sensation in arms either unilateral or bilateral and aggravates with overhead activities is termed as thoracic outlet syndrome. Symptoms includes discomfort, pain, heaviness and thoracic nerve impingement. It is a form of group of disorders that affects bony, muscular and even fibrous structures. If left untreated TOS can result in devastating functional and structural abnormalities. Methodology: It was a cross sectional observational study. A sample of 195 players and workers was taken from public sector organizations of Faisalabad. Inclusion criteria consisted of participants with 20 years of age or older. Gender was specified to be male only. Players who were actively participating in any sports were included. Laboring staff that were involved in overhead activities were included. Convenience sampling technique was used. Subjects with previously diagnosed traumatic injury and surgery were excluded. Adson maneuver and DASH questionnaire was utilized as data collection procedure. Results: Data was analyzed using SPSS version 21. Independent t test was applied to record prevalence of thoracic outlet syndrome. P-value 0.0001 demonstrates statistically significant prevalence in players and workers. An overall of 59% prevalence was recorded in both workers and players. Conclusions: It is concluded that thoracic outlet syndrome is highly prevalent in both workers and players. Comparison between both populations demonstrates slightly high prevalence in players by 51.8%, as those for workers to be 48.2. It is frequent within age groups of 20-30 in players and 30-50 years in workers.