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Dellon AL. Comments on the Delphi Study, "Consensus Recommendations for Neurogenic Thoracic Outlet Syndrome From the INTOS Workgroup". Microsurgery 2025; 45:e70053. [PMID: 40095227 DOI: 10.1002/micr.70053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2025] [Revised: 02/08/2025] [Accepted: 03/11/2025] [Indexed: 03/19/2025]
Affiliation(s)
- A Lee Dellon
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Satake H, Nito T, Naganuma Y, Maruyama M, Hanaka N, Uno T, Takagi M. Endoscopically assisted transaxillary release of the scalene muscles for thoracic outlet syndromes: a comparison with or without first rib resection. Gen Thorac Cardiovasc Surg 2024; 72:487-494. [PMID: 38700608 DOI: 10.1007/s11748-024-02031-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/02/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES 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. METHODS We chose two surgeries depending on the patient's TOS condition. If the costoclavicular space was under 12 mm, we selected endoscopically assisted transaxillary first rib resection (EAFRR). If the costoclavicular space was over 12 mm, 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. RESULTS Complete and almost complete relief was achieved in 24 patients (77%), and partial relief was conducted in seven patients (23%) at a mean of 19.7 months 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. CONCLUSIONS 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.
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Affiliation(s)
- Hiroshi Satake
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan.
| | - Toshiya Nito
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Yasushi Naganuma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Masahiro Maruyama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Naomi Hanaka
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iida Nishi, Yamagata, Japan
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Nordback PH, Sebastin SJ, Yong ZZ, Lee EY, Lim AYT. Scapular Elevation Sign - A New Sign in Evaluation of Thoracic Outlet Syndrome. J Hand Surg Asian Pac Vol 2024; 29:231-239. [PMID: 38726493 DOI: 10.1142/s2424835524500255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic).
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Affiliation(s)
- Panu H Nordback
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
- Department of Hand Surgery, Bridge Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Sandeep J Sebastin
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Zachary Z Yong
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Ellen Y Lee
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Aymeric Y T Lim
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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Issa TZ, Lin JS, Herrera F, Mailey B. Trends in the Surgical Management of Thoracic Outlet Syndrome. Hand (N Y) 2024; 19:367-373. [PMID: 36544244 PMCID: PMC11067839 DOI: 10.1177/15589447221141479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Beason AM, Thayer JA, Arras N, Franke JD, Mailey BA. Anterior Scalene Muscle Block Response Predicts Outcomes Following Thoracic Outlet Decompression. Hand (N Y) 2024; 19:361-366. [PMID: 36341588 PMCID: PMC11067833 DOI: 10.1177/15589447221131850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is no definitive objective measure for diagnosis of thoracic outlet syndrome (TOS), and functional capacity testing on standardized rehabilitation exercises before and after an anterior scalene muscle block (ASMB) has the potential to serve as a predictor of response to surgery and to improve diagnostic accuracy in these cases. METHODS Patients evaluated for TOS underwent ASMB as a diagnostic test and were retrospectively reviewed. Functional capacity scores were recorded for patients performing repetitive motion exercises immediately before ASMB, 15 minutes after ASMB, and at a minimum of 6 weeks after thoracic outlet decompression (TOD). The primary outcome of interest was correlation between the pre- to post-ASMB difference and the pre-ASMB to postoperative difference with respect to 3 functional work capacity scores. RESULTS The average change in time-to-fatigue and work product between pre- and post-ASMB of all exercises was an increase of 39.5% and 53.8%, respectively. The greatest pre-ASMB to post-TOD difference was seen for the Extremity Abduction Stress Test with an average improvement of 109.7% and 150.4% for time-to-fatigue and work product, respectively. The degree of percent improvement post-ASMB correlated positively with the degree of percent improvement post-TOD for all exercises with respect to work product and time-to-fatigue. CONCLUSIONS Patient response to ASMB as measured by functional capacity on rehabilitation exercises predicted objective functional outcomes following TOD. Post-ASMB outcomes correlated with post-TOD outcomes. The ASMB can be used to assist in diagnosing TOS and provide a surrogate for expectation in patients considering undergoing neurogenic TOD.
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Affiliation(s)
- Austin M. Beason
- Southern Illinois University School of Medicine, Springfield, USA
| | - Jacob A. Thayer
- Southern Illinois University School of Medicine, Springfield, USA
| | - Norma Arras
- Southern Illinois University School of Medicine, Springfield, USA
| | - Jacob D. Franke
- Southern Illinois University School of Medicine, Springfield, USA
| | - Brian A. Mailey
- Southern Illinois University School of Medicine, Springfield, USA
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6
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Funakoshi T, Furushima K, Miyamoto A, Kusano H, Takahashi T, Inoue A, Shimokobe H. Thoracic outlet syndrome in overhead athletes. JSES Int 2024; 8:620-629. [PMID: 38707577 PMCID: PMC11064620 DOI: 10.1016/j.jseint.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background We aimed to retrospectively compare the clinical outcomes of endoscopy-assisted first-rib resection for thoracic outlet syndrome (TOS) between overhead athletes and nonathletes and investigate the return to same-level sports rate in overhead athletes. Methods We retrospectively reviewed 181 cases with TOS (75 women, 106 men; mean age, 28.4 years; range, 12-57 years) who underwent endoscopy-assisted first-rib resection. We divided into two groups: 79 overhead athletes and 102 nonathletes groups. A transaxillary approach for first-rib resection and neurovascular decompression was performed under magnified visualization. Endoscopic findings related to the neurovascular bundle, interscalene distance, and scalene muscle were evaluated intraoperatively. We assessed the Roos and Disability of the Arm, Shoulder, and Hand scores, return to same-level sports rate, and ball velocity. Results Overhead athletes were significantly more likely to be men, younger, used the dominant side more frequently, and have a larger physique, more shoulder and elbow pain, and shorter symptom duration. The outcomes of the Roos score revealed significant differences in excellent or good results between overhead athletes (91.1%) and nonathletes (62.8%). The two groups significantly differed in preoperative and postoperative Disability of the Arm, Shoulder, and Hand and recovery rate scores (P = .007, < .001, < .001). Conclusion Overhead athletes with TOS were more likely to be men, younger, dominant side more frequently, and have more shoulder and elbow pain, and a shorter symptom duration. Endoscopy-assisted transaxillary first-rib resection and neurolysis provided superior clinical outcomes in overhead athletes with TOS compared with nonathletes and a high return-to-same-level-play rate in sports.
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Affiliation(s)
| | | | | | | | | | - Akira Inoue
- Keiyu Orthopaedic Hospital, Tatebayashi, Japan
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Talutis SD, Ulloa JG, Gelabert HA. The impact of competitive level of high school and collegiate athletes on outcomes of thoracic outlet syndrome. J Vasc Surg 2024; 79:388-396. [PMID: 37931887 DOI: 10.1016/j.jvs.2023.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Thoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes. METHODS This was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P < .05. RESULTS Thirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P = .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P = .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P = 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P = .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P = .15). Operating room time was 90.0 vs 105.3 minutes for HS and CO athletes, respectively (P = .14). Mean length of stay was 2.0 vs 1.9 days for HS and CO athletes (P = .91). Mean follow-up was 6.9 months for HS athletes and 10.5 months for CO athletes (P = .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P = 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P = .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P = .035). CONCLUSIONS Despite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes.
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Affiliation(s)
- Stephanie D Talutis
- Division of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA.
| | - Jesus G Ulloa
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at UCLA, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, CA
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8
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Tiongco RFP, Dellon AL. Histologic evidence of brachial plexus compression sites at the thoracic inlet and variations in formation of the lower trunk in cadavers. Microsurgery 2023; 43:588-596. [PMID: 37042225 DOI: 10.1002/micr.31037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/11/2023] [Accepted: 03/03/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND In thoracic "outlet" syndrome (TOS), pathologic evidence is well documented for vascular but not neurologic compression. We hypothesized that histologic evidence of compression would be identified at sites where the upper trunk was impacted by the anterior scalene muscle and the lower trunk by anatomic anomalies or the first rib. The purpose of this study was to investigate this hypothesis in human cadavers. MATERIALS AND METHODS Twenty-five cadavers' brachial plexuses were dissected and excised. Histologic and descriptive analysis was directed at juncture 1, the upper trunk and anterior scalene muscle, and juncture 2, C8 and T1 nerve roots (lower trunk) with the posterior border of the first rib. Measurements were obtained at the juncture of the T1 nerve root with the C8 nerve root in relationship to the first rib. RESULTS Histologic analysis demonstrated epineurial and perineurial fibrosis, myelin thinning, and Renaut bodies at junctures 1 and 2. Lower trunk formation occurred on or lateral to the first rib in 66% of specimens, with asymmetry in 32% of cadavers. A muscle of Albinus was present in 18% of cadavers. A large dorsal scapular artery coursed through 36% of plexuses with a high, arched subclavian artery. CONCLUSIONS We report histologic changes consistent with chronic compression of the upper and lower plexus in the thoracic inlet at hypothesized sites of brachial plexus compression that may correlate with clinical neck/shoulder (upper trunk) and "ulnar nervelike" (C8-T1/lower trunk) symptoms. Anatomic anomalies identified should alert the surgeon to variations of lower trunk formation at compression sites.
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Affiliation(s)
- Rafael Felix P Tiongco
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Lee Dellon
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Teijink SBJ, Pesser N, Goeteyn J, Barnhoorn RJ, van Sambeek MRHM, van Nuenen BFL, Gelabert HA, Teijink JAW. General Overview and Diagnostic (Imaging) Techniques for Neurogenic Thoracic Outlet Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13091625. [PMID: 37175016 PMCID: PMC10178617 DOI: 10.3390/diagnostics13091625] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Thoracic outlet syndrome is an uncommon and controversial syndrome. Three different diagnoses can be made based on the compressed structure, arterial TOS, venous TOS, and neurogenic TOS, though combinations do exist as well. Diagnosing NTOS is difficult since no specific objective diagnostic modalities exist. This has resulted in a lot of controversy in recent decades. NTOS remains a clinical diagnosis and is mostly diagnosed based on the exclusion of an extensive list of differential diagnoses. To guide the diagnosis and treatment of TOS, a group of experts published the reporting standards for TOS in 2016. However, a consensus was not reached regarding a blueprint for a daily care pathway in this document. Therefore, we constructed a care pathway based on the reporting standards for both the diagnosis and treatment of NTOS patients. This care pathway includes a multidisciplinary approach in which different diagnostic tests and additional imaging techniques are combined to diagnose NTOS or guide patients in their treatment for differential diagnoses. The aim of the present work is to discuss and explain the diagnostic part of this care pathway.
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Affiliation(s)
- Stijn B J Teijink
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Niels Pesser
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Jens Goeteyn
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Renée J Barnhoorn
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- Department of Biomedical Technology, University of Technology Eindhoven, 5612 AJ Eindhoven, The Netherlands
| | - Bart F L van Nuenen
- Department of Neurology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Hugh A Gelabert
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6229 HX Maastricht, The Netherlands
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Sonoo M. [Borderline regions between neurology and psychiatry, focusing particularly on the functional neurological disorders]. Rinsho Shinkeigaku 2023; 63:135-144. [PMID: 36843086 DOI: 10.5692/clinicalneurol.cn-001817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Neurology in Japan did not develop from the separation of neuropsychiatry into neurology and psychiatry, which casts a shadow on the present situation of Japanese neurology. Functional neurological disorder (FND; hysteria) is a typical link between neurology and psychiatry. FND is a common disorder, which has been described from the ancient times and has also been the headstream of neurology. FND is not diagnosed by exclusion or by psychiatric causes, but should be actively diagnosed based on the neurological signs themselves (= positive signs of FND) as early as possible, with minimal ancillary tests. This opinion has been supported by the newest Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Many positive signs have been described. Assessment by a neurologist also becomes a treatment.
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Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine
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Satake H, Honma R, Nito T, Naganuma Y, Shibuya J, Maruyama M, Uno T, Takagi M. Midterm results of endoscopically assisted first rib resection in the zero position for thoracic outlet syndrome. Interact Cardiovasc Thorac Surg 2022; 35:6696242. [PMID: 36094365 PMCID: PMC9536291 DOI: 10.1093/icvts/ivac239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hiroshi Satake
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Ryusuke Honma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Toshiya Nito
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Yasushi Naganuma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Junichiro Shibuya
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Masahiro Maruyama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine , Yamagata, Japan
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12
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Weiss K, Grünert J, Knechtle B. [Please Don't Forget the Neurogenic Thoracic Outlet Syndrome]. PRAXIS 2022; 111:632-638. [PMID: 35975409 DOI: 10.1024/1661-8157/a003870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Please Don't Forget the Neurogenic Thoracic Outlet Syndrome Abstract. We report the case of a 52-year-old patient who was treated for years for headaches, pain in the neck and arms, and sweating. Despite various therapeutic approaches there was no improvement in the symptoms. Further investigations showed a bilateral thoracic outlet syndrome in the status after multiple bilateral rib fractures after a fall from a window at the age of 18. After the operation of a bilateral thoracic outlet syndrome, the headache disappeared almost completely and there was no more sweating.
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Affiliation(s)
- Katja Weiss
- Medbase St. Gallen am Vadianplatz, St. Gallen, Schweiz
| | - Jörg Grünert
- Klinik für Hand-, Plastische und Wiederherstellungschirurgie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Beat Knechtle
- Medbase St. Gallen am Vadianplatz, St. Gallen, Schweiz
- Institut für Hausarztmedizin, Universität Zürich, Zürich, Schweiz
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13
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Reliability and Validity of the Elevated Arm Stress Test in the Diagnosis of Neurogenic Thoracic Outlet Syndrome. J Vasc Surg 2022; 76:814-820. [PMID: 35550394 DOI: 10.1016/j.jvs.2022.03.883] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 03/23/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the test-retest reliability and validity of the elevated arm stress test (EAST) as measured by the duration in a cohort of patients with suspected neurogenic thoracic outlet syndrome (NTOS). DESIGN Retrospective analysis of prospectively collected data METHODS: Patients evaluated for NTOS between January 2017 and September 2018 were identified. Test-retest reliability by the intraclass correlation coefficient (ICC) was determined for duration of the EAST. For the validity analysis, patients were classified in a proven NTOS group or a symptomatic control group without NTOS using the SVS-reporting standards and the outcome of thoracic outlet decompression (TOD) surgery. A receiver operating characteristic (ROC) curve was made for the duration of EAST. The area under the curve (AUC), and positive and negative predictive values were calculated for the EAST. RESULTS In total, 428 patients with suspected NTOS retrospectively analysed. Of these patients, 61 were excluded because no EAST data was available. Another 101 patients were excluded because of inconclusive reporting standards, arterial or venous TOS, or because TOD surgery was not performed or had a negative result. The validity analysis in the remaining 266 patients showed an AUC for the duration of the EAST of 0.62 (95% confidence interval (CI): 0.55-0.69). The positive predictive value of the duration ranged between 65% and 66%, and the negative predictive value between 53% and 58%. For the test-retest reliability analysis, 118 patients were excluded because they performed only one measurement in a 100-day time period. Analysis in the remaining 148 patients showed an ICC value of 0.65 (95% CI: 0.55-0.74) for duration. CONCLUSION The EAST measured by the duration showed a moderate test-retest reliability, but the discriminative value was low in the diagnosis of NTOS. The outcome of the EAST measured by the duration should be used with caution.
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14
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Linnenberg C, Weidner R. Industrial exoskeletons for overhead work: Circumferential pressures on the upper arm caused by the physical human-machine-interface. APPLIED ERGONOMICS 2022; 101:103706. [PMID: 35134687 DOI: 10.1016/j.apergo.2022.103706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 06/14/2023]
Abstract
This study investigated the pressures occurring within the arm human-machine-interfaces (HMI) of four different exoskeletons that support static and dynamic work at or above head level, and the effects of the HMI on neurovascular supply of the upper extremity using an orthopedic provocation maneuver with raised arms with and without the exoskeletons. Decreased time in the provocation maneuver with exoskeletons indicated a negative effect of the HMIs on the vascular and neural supply of the arm. Average pressure in the static situation was 3.2 ± 0.7 kPa and 4.4 ± 0.4 kPa with regular peak values of 6.5 ± 0.5 kPa in the dynamic task. These pressures were significantly higher than the pressure values that guarantee adequate tissue oxygenation. It remains unknown whether the way exoskeletons apply pressure affects vascular and neural supply to the arms, or whether the regular unloading during dynamic activity has a neutralizing effect.
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Affiliation(s)
- Christine Linnenberg
- Institute for Mechatronics, University of Innsbruck, Technikerstraße 13, 6020, Innsbruck, Austria.
| | - Robert Weidner
- Institute for Mechatronics, University of Innsbruck, Technikerstraße 13, 6020, Innsbruck, Austria; Laboratory for Manufacturing Technology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany.
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15
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Chang MC, Kim DH. Essentials of thoracic outlet syndrome: A narrative review. World J Clin Cases 2021; 9:5804-5811. [PMID: 34368299 PMCID: PMC8316950 DOI: 10.12998/wjcc.v9.i21.5804] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
Thoracic outlet syndrome (TOS) is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region. TOS results in pain, numbness, paresthesia, and motor weakness in the affected upper limb. We reviewed the pathophysiology, clinical evaluation, differential diagnoses, and treatment of TOS. TOS is usually classified into three types, neurogenic, venous, and arterial, according to the primarily affected structure. Both true neurogenic and disputed TOS are considered neurogenic TOS. Since identifying the causative lesions is complex, detailed history taking and thorough clinical investigation are needed. Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS. The existence of a disputed TOS remains controversial. Neuromuscular physicians tend to be skeptical about the existence of disputed TOS, but thoracic surgeons argue that disputed TOS is under-diagnosed. Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.
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Affiliation(s)
- Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu 42415, South Korea
| | - Du Hwan Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Chung-Ang University, Seoul 06973, South Korea
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16
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Ohida H, Curuk C, Prescher H, Stegemann E, Bürger T. Thoracic outlet syndrome in a patient with SAPHO syndrome - A case report. Int J Surg Case Rep 2021; 80:105710. [PMID: 33667913 PMCID: PMC7937738 DOI: 10.1016/j.ijscr.2021.105710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Thoracic outlet syndrome (TOS) includes disorders caused by compression of the neurovascular structures in the upper thoracic outlet (Roos and Owens, 1996 [1]; Bürger, 2014; Curuk, 2020 [3]). Depending on the compressed structure, it is categorized into neurological, arterial and venous TOS. SAPHO syndrome (synovitis-acne-pustulosis-hyperostosis-osteitis syndrome) is a rare chronic inflammatory disease of unknown etiology. With its typical involvement of sternoclavicular joint and clavicle, complication due to hyperostosis in this region, leading to thrombosis of the subclavian vein have been reported in some cases of SAPHO syndrome. Between 2015 and 2019 488 patients, suffering from neurological, vascular or combined TOS presented at our department. Depending on clinical and diagnostic results surgical therapy was performed in 175 cases via the transaxillary approach, including complete first rib and/or cervical rib resection, neurolysis of plexus brachialis, thoracic sympathectomy and vascular reconstruction if indicated (Curuk, 2020). During this period, only one single patient presented with SAPHO syndrome with thrombosis of the subclavian vein and neurovascular TOS. CASE PRESENTATION We present a 50-year-old female patient, in line with the SCARE 2020 criteria (Agha et al., 2020 [12]) suffering from extremely rare combination of neurovascular TOS and SAPHO syndrome with thrombosis of the left subclavian vein due to hyperostosis of the left clavicle. CONCLUSION Progressive bone changes associated with SAPHO syndrome can lead to narrowing of the thoracic outlet. Pharmacological therapies to avoid the progression of the hyperostosis of the costoclavicular joint and the clavicle do currently not exist. First rib resection is a therapeutic option to widen the space in the upper thoracic region. Surely, it is a rare condition and more long-term follow-up data are required.
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Affiliation(s)
- H Ohida
- Agaplesion Diakonie Kliniken Kassel gGmbH, Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119 Kassel, Germany.
| | - C Curuk
- Agaplesion Diakonie Kliniken Kassel gGmbH, Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119 Kassel, Germany
| | - H Prescher
- Agaplesion Diakonie Kliniken Kassel gGmbH, Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119 Kassel, Germany
| | - E Stegemann
- Agaplesion Diakonie Kliniken Kassel gGmbH, Department of Angiology and Internal Medicine, Herkulesstraße 34, 34119 Kassel, Germany
| | - Th Bürger
- Agaplesion Diakonie Kliniken Kassel gGmbH, Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119 Kassel, Germany
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17
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Furushima K, Funakoshi T, Kusano H, Miyamoto A, Takahashi T, Horiuchi Y, Itoh Y. Endoscopic-Assisted Transaxillary Approach for First Rib Resection in Thoracic Outlet Syndrome. Arthrosc Sports Med Rehabil 2021; 3:e155-e162. [PMID: 33615259 PMCID: PMC7879182 DOI: 10.1016/j.asmr.2020.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 08/31/2020] [Indexed: 11/03/2022] Open
Abstract
Purpose To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach. Methods We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores. Results We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score. Conclusions An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure. Level of Evidence IV, therapeutic case series.
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Curuk C, Ohida H, Gebauer T, Stegemann E, Buerger T. An isolated double-crush-syndrome in posttraumatic thoracic outlet syndrome - A case report. Int J Surg Case Rep 2020; 75:521-525. [PMID: 33076208 PMCID: PMC7548988 DOI: 10.1016/j.ijscr.2020.09.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/20/2020] [Accepted: 09/20/2020] [Indexed: 01/17/2023] Open
Abstract
Neurovascular compression. Non-standardized treatment. Clinical, apparative tests. Thoracic outlet Syndrome (TOS) includes all disorders caused by compression of all neurovascular Structures in the upper thoracic outlet (Ross and Owners, 1966, Bürger and Arterien, 2014, Sanders and Annest, 2017). The Double-Crush-Syndrome (DBS) defines multilevel lesions along a neurovascular trunk caused by mechanical compression in different areas. Pectoralis-minor-syndrome (PMS) is also classified in the disorders of he upper thoracic outlet and was also known as hyperabductionsyndrome or subcoracoidal-syndrome. Between 2015–2019 our department treatet 488 patients suffering from neurological, vascular or combined TOS. Surgical treatment, depending on clinical and specific diagnostics was performed in 175 cases via transaxillary approach, including cervical rib resection, first rib resection, neurolysis of plexus brachialis, thoracal sympathectomy or vascular reconstruction. In all this year just a single patient with double crush syndrome was present. Case presentation and methods We report a case of a 28-years old female patient, reported in line with the SCARE criteria [13], suffering from neurvascular compression in the upper thoracic outlet after surgically treated clavicula fracture. She developed typical symptomes of a Thoracic Outlet Syndrome. Conclusion Double-Crush-Syndrome in patients with Thoracic Outlet Syndrome are very rare, case reports seldomly exist. The diagnosis requires a specific clinical testing and x-ray radiography. Furthermore dynamic tests like ultrasound and angiography and neurophysiological testing requires a high degree of experience, so the compressed area can be detected. Treatment includes an attempt of best medical and physical therapy, in case of failure a surgical treatment is necessary.
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Affiliation(s)
- C Curuk
- Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119, Kassel, Germany.
| | - H Ohida
- Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119, Kassel, Germany
| | - T Gebauer
- Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119, Kassel, Germany
| | - E Stegemann
- Department of Angiology and Internal Medicine, Herkulesstraße 34, 34119, Kassel, Germany
| | - T Buerger
- Department of Vascular and Endovascular Surgery, Herkulesstraße 34, 34119, Kassel, Germany
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19
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Lee TS, Hines GL. Cerebral Embolic Stroke and Arm Ischemia in a Teenager With Arterial Thoracic Outlet Syndrome: A Case Report. Vasc Endovascular Surg 2019; 41:254-7. [PMID: 17595394 DOI: 10.1177/1538574407299780] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A rare presentation of arterial thoracic outlet syndrome (TOS) is described in a young woman. Arterial TOS caused by a cervical rib produced acute upper extremity ischemia due to subclavian artery aneurysm formation. Clinical presentation also included left hemiparesis caused by right subclavian artery thrombosis and retrograde embolization of thrombus via the common carotid artery to the right middle cerebral artery distribution. Surgical repair of the subclavian artery was performed, but permanent neurologic deficit remained. Acute thrombosis of the right subclavian artery can produce cerebrovascular complication. The assessment of such risk in patients with arterial TOS is warranted and the arterial lesion corrected surgically.
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Affiliation(s)
- Thomas S Lee
- School of Medicine, State University of New York Stony Brook, Stony Brook, NY, USA.
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20
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Nicholson JA, Stirling PHC, Strelzow J, Robinson CM. Dynamic Compression of the Subclavian Artery Secondary to Clavicle Nonunion: A Report of 2 Cases. JBJS Case Connect 2019; 9:e4. [PMID: 30628922 DOI: 10.2106/jbjs.cc.18.00200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe 2 patients with nonunion of the clavicle and dynamic compression of the subclavian artery. In both patients, no structural abnormality of the subclavian vessels was evident at rest; however, with the arm in hyperabduction, arterial occlusion occurred because of the mobility of the fracture and a prominent callus. CONCLUSION This small case series demonstrates an important and, to our knowledge, unreported clinical complication of clavicle fracture nonunion. We believe that this complication is worth considering as a rare but important cause of pain in patients with delayed union or nonunion of the clavicle.
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21
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Nassar NM, Yasaky AZ, Farrag DA, Magdy MM. The value of neuromuscular ultrasound in relation to clinical and electrophysiological testing in the diagnosis of thoracic outlet syndrome. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2018. [DOI: 10.4103/err.err_41_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Munro AI, McPherson GD, Jamieson WE. WITHDRAWN: After a motor vehicle accident is it neurogenic thoracic outlet syndrome or ulnar entrapment syndrome? How to make the correct diagnosis. Am J Surg 2018:S0002-9610(17)31701-4. [PMID: 29627065 DOI: 10.1016/j.amjsurg.2018.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/09/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- A Ian Munro
- British Columbia and University of British Columbia, Vancouver, Canada; PO Box 74723, RPO Connaught, Vancouver, BC V6K 0E4, Canada
| | - G Duncan McPherson
- British Columbia and University of British Columbia, Vancouver, Canada; PO Box 38099, RPO King Edward, Vancouver, BC V5Z 4L9, Canada
| | - Wr Eric Jamieson
- British Columbia and University of British Columbia, Vancouver, Canada; Vancouver Coastal Research Institute, 6th Floor-2635 Laurel Street, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
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Abstract
A subclavicular approach to the first rib for resection in cases of subclavian vein thrombosis or chronic obstruction is described. The steps of the surgical procedure are described. The technique is ideally suited for emergency care of Paget-Schroetter syndrome patients.
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Affiliation(s)
- J. Ernesto Molina
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Minnesota Hospital, Minneapolis, Minnesota
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24
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Youmans CR, Smiley RH. Thoracic Outlet Syndrome With Negative Adson's and Hyperabduction Maneuvers. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857448001400504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The thoracic outlet syndrome is a prevalent entity. Most cases respond to conservative methods of therapy. Surgical decompression, when necessary, is effective in the majority of cases, and morbidity and mortality are low. The diagnosis of thoracic outlet compression syndrome is usually made on the basis of an adequate history and physical examination. Neuroelectric studies are inconsistently helpful. The predominant symptoms are neuro logic, not vascular. Pulse obliteration does indicate some element of anatomic tightness. However, without symptom reproduction, pulse change has no diagnostic relationship to thoracic outlet syndrome. Conversely, the inability to obliterate or diminish the radial pulse in positions of thoracic outlet tightness, when symptoms are reproduced in those positions, has no corre lation to the results of decompression.
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Affiliation(s)
- C. Roger Youmans
- Bay Area Thoracic and Cardiovascular Surgical Association, Clear Lake Hospital, Webster, Texas Memorial Hospital of Galveston County, Texas City, Texas
| | - Robert H. Smiley
- Bay Area Thoracic and Cardiovascular Surgical Association, Clear Lake Hospital, Webster, Texas Memorial Hospital of Galveston County, Texas City, Texas
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25
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Sanders RJ, Monsour JW, Gerber WF. Recurrent Thoracic Outlet Syndrome Following First Rib Resection. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857447901300505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Five years ago, a follow-up study of first rib resections in patients with the thoracic outlet syndrome (TOS) disclosed a recurrence rate of over 15%. Many patients were re-explored supraclavicularly, and in every case the anterior scalene muscle was found reattached to the bed of the first rib. The invariable success of scalenectomy led to a study of this procedure as the first operation for all cases of persistent thoracic outlet syndrome. Most patients with TOS gave a history of neck trauma and had symptoms of paresthesias of the hands and weakness of the arms, as well as neck pains and headaches. The common physical findings were tenderness over the scalene muscles and duplication of symptoms with the arms raised. A scalene muscle block with a local anesthetic was the most useful diagnostic test. The good to excellent long-term results following 239 scalenectomies and 214 first rib resections were almost identical, 68% and 69% respectively, with fair results in 20% and 13% respectively.
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Affiliation(s)
- Richard J. Sanders
- Department of Surgery, General Rose Memorial Hospital, Veterans Administration Hospital, University of Colorado Medical Center, Denver, Colorado
| | - James W. Monsour
- Department of Surgery, General Rose Memorial Hospital, Veterans Administration Hospital, University of Colorado Medical Center, Denver, Colorado
| | - William F. Gerber
- Department of Surgery, General Rose Memorial Hospital, Veterans Administration Hospital, University of Colorado Medical Center, Denver, Colorado
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26
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Martinez NS. Posterior First Rib Resection for Complete Thoracic Outlet Decompression: Evolution, Advantages and New Technical Aspects. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857448201600604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Nestor S. Martinez
- Cardiothoracic, Vascular Surgeon, Cardiothoracic Vascular Service, Little Company of Mary Hospital, Evergreen Park, Ill., Hinsdale Sanitarium and Hospital, Hinsdale, Ill., Edward Hospital, Naperville, Ill
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27
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Munro AI, McPherson GD. The enigma of neurogenic thoracic outlet syndrome following motor vehicle collisions. Can J Surg 2016; 59:276-80. [PMID: 27454840 DOI: 10.1503/cjs.009814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The concept of neurogenic thoracic outlet syndrome (N-TOS) including upper and lower plexus syndromes secondary to soft tissue neck injury after motor vehicle collisions (MVCs) has been contentious. We considered that analysis of objective data from this group of patients could provide insight into this controversial type of N-TOS. METHODS During the 10-year period January 2001 through December 2010 we examined patients who had received a diagnosis of N-TOS following an MVC. We graded the principal diagnosis based on the objective data from our physical examination. RESULTS In total 263 patients received a diagnosis of N-TOS during the study period. At the highest accuracy level of diagnosis there were 56 patients with ulnar entrapment syndrome (UES), 40 with carpal tunnel syndrome (CTS) and 55 with nonorganic disease (NOD), for a total of 151 (57.4%) cases in which the diagnosis of N-TOS was brought into question. The elevated arm stress test (EAST) reproduced the symptoms of UES in 33 of the 56 patients of UES (58.9%) and reproduced the symptoms of CTS in 18 of the 40 patients with CTS (45.0%). CONCLUSION There appears to be a high incidence of misdiagnosis of N-TOS following MVCs. The EAST is not a prime test for N-TOS.
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Affiliation(s)
- A Ian Munro
- From the Department of Surgery, University of British Columbia, Retired (Munro); and the Department of Orthopedics, University of British Columbia, Retired (McPherson)
| | - G Duncan McPherson
- From the Department of Surgery, University of British Columbia, Retired (Munro); and the Department of Orthopedics, University of British Columbia, Retired (McPherson)
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Braun RM, Shah KN, Rechnic M, Doehr S, Woods N. Quantitative Assessment of Scalene Muscle Block for the Diagnosis of Suspected Thoracic Outlet Syndrome. J Hand Surg Am 2015; 40:2255-61. [PMID: 26429586 DOI: 10.1016/j.jhsa.2015.08.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 08/18/2015] [Accepted: 08/18/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To measure changes in upper limb work and power capacity before and after anterior scalene muscle block (ASMB) to suggest thoracic outlet syndrome caused by costoclavicular space compression. METHODS We evaluated 34 patients disabled by symptoms suggesting thoracic outlet syndrome. An ASMB was performed via a supraclavicular injection. The sternocleidomastoid muscle was injected as a control. We captured data obtained from work simulator measurements before and after ASMB. Each patient performed a push-pull test with the forearm at waist level (test 1), an overhead bar push-pull test with the arm elevated (test 2), and the extremity abduction stress test with repetitive hand gripping during static arm elevation (test 3). We measured the work product, time to fatigue, and power generation. Sensory testing was performed after ASMB to rule out improved performance associated with possible sensory nerve block. RESULTS In contrast to sternocleidomastoid injection controls, symptomatic and functional improvement was noted in all patients (n = 34) after ASMB. Work product measurement improved 93%, 108%, and 104% for tests 1, 2, and 3, respectively. Time to fatigue and power output also increased after the block. CONCLUSIONS Temporary symptomatic improvement after ASMB may be anticipated in patients with TOS. This study documents a significant concurrent increase in upper limb motor function after the block. Increased work and power measurements after ASMB may draw diagnostic inference regarding a dynamic change in the scalene muscle and the costoclavicular space associated with symptomatic thoracic outlet syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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29
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Sanders RJ, Annest SJ. Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome. J Vasc Surg 2015; 61:821-5. [DOI: 10.1016/j.jvs.2014.11.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 11/11/2014] [Indexed: 11/29/2022]
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30
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Diagnostic Accuracy of Physician and Self-referred Patients for Thoracic Outlet Syndrome Is Excellent. Ann Vasc Surg 2014; 28:1100-5. [DOI: 10.1016/j.avsg.2013.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 02/01/2023]
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31
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Bilateral first rib resection and scalenectomy is effective for treatment of thoracic outlet syndrome. J Vasc Surg 2014; 60:185-90. [DOI: 10.1016/j.jvs.2014.01.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 01/10/2014] [Accepted: 01/13/2014] [Indexed: 11/18/2022]
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32
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Case report: Thoracic outlet syndrome in an elite archer in full-draw position. Clin Orthop Relat Res 2013; 471:3056-60. [PMID: 23430722 PMCID: PMC3734406 DOI: 10.1007/s11999-013-2865-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/08/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND One possible pathomechanism of thoracic outlet syndrome (TOS) is shoulder abduction and extension inducing backward motion of the clavicle which causes compression on the brachial plexus. This position occurs during the full-draw stage of archery, by drawing and holding the bowstring. CASE DESCRIPTION A 28-year-old elite archer presented with a feeling of weakness and dull shoulder pain, and experienced decreased grip power and hypoesthesia in the ulnar nerve dermatome in the full-draw position. On CT angiography, the cross-sectional area of the subclavian artery in the costoclavicular space decreased to 40% compared with that of the subclavian artery in a noncompressed state. This patient had first rib resection through the supraclavicular approach with a clavicle osteotomy. At 3.5 years postoperatively, the patient maintained his job as a professional coach and did not have any specific complaints when teaching and demonstrating archery skills. LITERATURE REVIEW A literature review revealed numerous causes of TOS, ranging from congenital abnormalities to repetitive postures related to sports activities. The abduction and external rotation (ABER) position (shoulder at 90° abduction and external rotation) has been suggested for detecting TOS and is a documented cause of compression of the brachial plexus and subclavian vessels. We present the case of an archer with TOS association with repeated use of the ABER position. PURPOSE AND CLINICAL RELEVANCE TOS should be suspected when athletes repeatedly use shoulder extension and abduction for their sports if other pathologic conditions can be ruled out.
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Brismée JM, Gilbert K, Isom K, Hall R, Leathers B, Sheppard N, Sawyer S, Sizer P. Rate of False Positive Using the Cyriax Release Test for Thoracic Outlet Syndrome in an Asymptomatic Population. J Man Manip Ther 2013. [DOI: 10.1179/106698104790825374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Lee TY, Cho HM, Kim YJ, Ryu HY. A case of traumatic thoracic outlet syndrome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:412-4. [PMID: 23275926 PMCID: PMC3530728 DOI: 10.5090/kjtcs.2012.45.6.412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 08/03/2012] [Accepted: 08/16/2012] [Indexed: 11/16/2022]
Abstract
Thoracic outlet syndrome (TOS) due to thoracic trauma is a rare disorder. Surgical treatment of TOS is especially rare. We report here a case of traumatic TOS caused by right 1st rib and clavicular fracture after a traffic accident. The patient underwent first rib resection and open reduction with fixation of the clavicle through axillary and supraclavicular incisions.
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Affiliation(s)
- Tae Yeon Lee
- Department of Thoracic and Cardiovascular Surgery, Konyang University College of Medicine, Korea
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35
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Watson L, Pizzari T. Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways. INT J OSTEOPATH MED 2010. [DOI: 10.1016/j.ijosm.2010.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Scali S, Stone D, Bjerke A, Chang C, Rzucidlo E, Goodney P, Walsh D. Long-Term Functional Results for the Surgical Management of Neurogenic Thoracic Outlet Syndrome. Vasc Endovascular Surg 2010; 44:550-5. [DOI: 10.1177/1538574410374658] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To document long-term functional outcomes in patients treated for neurogenic thoracic outlet syndrome (NTOS). Methods: Records of all patients undergoing treatment for NTOS at our center were reviewed. Patient demographics and co-morbidities were recorded. End-points included symptomatic relief, peri-operative adjunctive procedures, functional outcome and employment continuity. Results: From 1988-2008, 26 patients were operated upon for NTOS. Hallmarks of the diagnosis in operated patients included symptom duration less than 1 year and a positive Roos test. Patients receiving disability and those with cervical spine pathology or carpal tunnel syndrome were not considered for surgery. Mean patient age was 39.2 years (range 14-60 years) with a mean follow-up of 104.4 months. Eleven patients (42.3%) engaged in pre-operative physical therapy programs. 7 of 9 patients (26.9%) received adjunctive peri-procedural scalene block with temporary symptom relief. All patients underwent thoracic outlet decompression by either 1st rib resection [18 total: 8 (44%) transaxillary and 10 (66%) supraclavicular)], cervical rib resection [6 (26.1%)] and/or scalenectomy [12 (46.2%)]. Of the 22 patients available for follow-up, six patients (27.3%) have required continued post-operative narcotic analgesics. Sixteen patients (72.7%) returned to work and reported being at an equivalent or better functional outcome than their pre-operative status. Conclusions: Durable long-term functional outcomes can be achieved predicated on a highly selective approach to the surgical management of patients with NTOS. A majority of operated patients will not require adjunctive procedures or chronic narcotic utilization. Patients who undergo surgery can expect to return to work with little or no functional impairment.
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Affiliation(s)
- Salvatore Scali
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA
| | - David Stone
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA,
| | - Aja Bjerke
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA
| | - Catherine Chang
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA
| | - Eva Rzucidlo
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA
| | - Phillip Goodney
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA
| | - Daniel Walsh
- Dartmouth-Hitchcock Medical Center, Section of Vascular Surgery, Lebanon, NH, USA
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Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways. ACTA ACUST UNITED AC 2009; 14:586-95. [PMID: 19744876 DOI: 10.1016/j.math.2009.08.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 07/07/2009] [Accepted: 08/10/2009] [Indexed: 10/20/2022]
Abstract
Thoracic outlet syndrome (TOS) is a challenging condition to diagnose correctly and manage appropriately. This is the result of a number of factors including the multifaceted contribution to the syndrome, the limitations of current clinical diagnostic tests, the insufficient recognition of the sub-types of TOS and the dearth of research into the optimal treatment approach. This masterclass identifies the subtypes of TOS, highlights the possible factors that contribute to the condition and outlines the clinical examination required to diagnose the presence of TOS.
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Affiliation(s)
- L A Watson
- LifeCare Prahran Sports Medicine Centre, 316 Malvern Road, Prahran, VIC 3181, Australia
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Odderson IR, Chun ES, Kolokythas O, Zierler RE. Use of sonography in thoracic outlet syndrome due to a dystonic pectoralis minor. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:1235-1238. [PMID: 19710222 DOI: 10.7863/jum.2009.28.9.1235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE For patients with thoracic outlet syndrome (TOS), it is important to determine the location of the neurovascular compression to achieve effective intervention. METHODS The diagnostic workup for a 39-year-old man with TOS included a selective anesthetic block of the pectoralis minor muscle and duplex sonography before and after the block. RESULTS The subclavian artery peak systolic flow velocity decreased after the block from 208 to 63 cm/s when the arm was in the abduction and external rotation position, indicating a reduction in the severity of focal arterial compression. Also, the arterial diameter increased by 10% after the block (from 0.80 to 0.88 cm). His level of discomfort was reduced from 6 to 2 on a scale of 1 to 10 (66%). CONCLUSIONS The pectoralis minor block resulted in an improvement in subclavian artery blood flow and symptoms and confirmed the diagnosis of pectoralis minor TOS. This suggests that selective anesthetic muscle blocks and duplex sonographic studies may be useful before chemodenervation and surgery.
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Affiliation(s)
- Ib R Odderson
- Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, 98195, USA.
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Zhang Z, Dellon AL. Facial pain and headache associated with brachial plexus compression in the thoracic inlet. Microsurgery 2008; 28:347-50. [PMID: 18561268 DOI: 10.1002/micr.20507] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Among the sources for confusion related to brachial plexus compression in the thoracic inlet are the name for this clinical entity (thoracic outlet syndrome) and the fact that some of its associated symptoms occur outside the upper extremity, such as face and neck pain (FP) and occipital headaches (OH). With the realization that scalenus anticus (SA) contraction is the primary source of brachial plexus compression, it is possible to understand the occurrence of both FP and OH in this syndrome. It was hypothesized that SA contraction compresses the cervical plexus as it exits deep to this muscle. Furthermore, it was hypothesized that tension on the origin of this muscle from the transverse cervical processes causes compression of the occipital nerves. To evaluate this, a consecutive series of 32 patients who had resection of the SA between January 2004 and December 2007 were evaluated to determine prevalence of FP and OH, and the extent to which these symptoms were relieved postoperatively after SA resection. It was found that 25% of the patients had FP and that 50% had OH. Postoperatively, for those patients with neck pain, with or without facial pain, 75% were completely relieved, 18% were partially relieved. OH was completely relieved in 81% and partially relieved in 13% of the patients. In conclusion, symptoms of FP and OH associated with brachial plexus compression is due to cervical plexus compression by SA muscle, and symptoms can be relieved by resection of the SA.
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Affiliation(s)
- Zijie Zhang
- Dellon Institute for Peripheral Nerve Surgery, Baltimore, MD 21218, USA
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Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg 2007; 46:601-4. [PMID: 17826254 DOI: 10.1016/j.jvs.2007.04.050] [Citation(s) in RCA: 267] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 04/18/2007] [Indexed: 01/15/2023]
Abstract
Thoracic outlet syndrome (TOS) is a nonspecific label. When employing it, one should define the type of TOS as arterial TOS, venous TOS, or neurogenic TOS. Each type has different symptoms and physical findings by which the three types can easily be identified. Neurogenic TOS (NTOS) is by far the most common, comprising well over 90% of all TOS patients. Arterial TOS is the least common accounting for no more than 1%. Many patients are erroneously diagnosed as "vascular" TOS, a nonspecific misnomer, whereas they really have NTOS. The Adson Test of noting a radial pulse deficit in provocative positions has been shown to be of no clinical value and should not be relied upon to make the diagnosis of any of the three types. The test is normal in most patients with NTOS and at the same time can be positive in many control volunteers. Arterial TOS is caused by emboli arising from subclavian artery stenosis or aneurysms. Symptoms are those of arterial ischemia and x-rays almost always disclose a cervical rib or anomalous first rib. Venous TOS presents with arm swelling, cyanosis, and pain due to subclavian vein obstruction, with or without thrombosis. Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesia, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds.
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Demirbag D, Unlu E, Ozdemir F, Genchellac H, Temizoz O, Ozdemir H, Demir MK. The Relationship Between Magnetic Resonance Imaging Findings and Postural Maneuver and Physical Examination Tests in Patients With Thoracic Outlet Syndrome: Results of a Double-Blind, Controlled Study. Arch Phys Med Rehabil 2007; 88:844-51. [PMID: 17601463 DOI: 10.1016/j.apmr.2007.03.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate the differences in findings from magnetic resonance imaging (MRI) in the neutral and provocative positions, and to examine the relationship between these differences and the results of physical examination tests in patients with thoracic outlet syndrome (TOS). DESIGN Prospective. SETTING University physical medicine and rehabilitation outpatient and radiology clinics. PARTICIPANTS Twenty-nine patients and 12 healthy controls. All of the patients had positive bilateral TOS stress tests; control group participants were symptom free and had negative TOS stress tests bilaterally. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All participants underwent Adson's test, the Halsted maneuver, and a hyperabduction test. All were evaluated with MRI while in 2 positions: the neutral position (upper extremities adducted) and in a provocative position. Measurements were obtained at the interscalene triangle, at the costoclavicular space, and at the retropectoralis minor space. RESULTS There was a significant difference in MRI findings between the neutral and provocative position in the patients (P<.05), but there were no significant differences in the control group. There was a significant difference in the positional change values in MRI between the patients and the control subjects (P<.05). The difference was found in the minimum costoclavicular distance between patients with a positive Halsted maneuver and a negative Halsted maneuver (P<.05). CONCLUSIONS Our findings indicate that MRI findings in patients in a provocative position are more valuable in the diagnosis of TOS, and these findings are in accord with findings from the physical evaluation tests.
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Affiliation(s)
- Derya Demirbag
- Department of Physical Medicine and Rehabilitation, University of Trakya, Edirne, Turkey
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Cebesoy O. Confirmatory needle placement technique for scalene muscle block in the diagnosis of thoracic outlet syndrome. Tech Hand Up Extrem Surg 2007; 10:197. [PMID: 16974227 DOI: 10.1097/01.bth.0000231967.74041.48] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Scalene muscle block is often performed to assist with the clinical differentiation of primary sources of pain and weakness in the upper limb when the differential diagnosis includes thoracic outlet syndrome. This presentation offers a simple clinical method to assess needle placement in the scalene muscle before an injection of local anesthetic which, if properly placed, weakens the scalene muscle and often leads to temporary relief of symptoms associated with neurovascular compression. An appropriate scalene block response provides assistance with medical decision making.
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Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics 2006; 26:1735-50. [PMID: 17102047 DOI: 10.1148/rg.266055079] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The thoracic outlet includes three compartments (the interscalene triangle, costoclavicular space, and retropectoralis minor space), which extend from the cervical spine and mediastinum to the lower border of the pectoralis minor muscle. Dynamically induced compression of the neural, arterial, or venous structures crossing these compartments leads to thoracic outlet syndrome (TOS). The diagnosis is based on the results of clinical evaluation, particularly if symptoms can be reproduced when various dynamic maneuvers, including elevation of the arm, are undertaken. However, clinical diagnosis is often difficult; thus, the use of imaging is required to demonstrate neurovascular compression and to determine the nature and location of the structure undergoing compression and the structure producing the compression. Cervical plain radiography should be performed first to assess for bone abnormalities and to narrow the differential diagnosis. Computed tomographic (CT) angiography or magnetic resonance (MR) imaging performed in association with postural maneuvers is helpful in analyzing the dynamically induced compression. B-mode and color duplex ultrasonography (US) are good supplementary tools for assessment of vessel compression in association with postural maneuvers, especially in cases with positive clinical features of TOS but negative features of TOS at CT and MR imaging. US may also allow analysis of the brachial plexus. However, MR imaging remains the method of choice when searching for neurologic compression.
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Affiliation(s)
- Xavier Demondion
- Department of Musculoskeletal Radiology, Hôpital Roger Salengro, Bd du Professeur Jules Leclercq, 59037 Lille Cedex, France.
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Abstract
The purpose of this commentary is to describe bilateral anomalous bands of the latissimus dorsi muscle observed in an 81-year-old male embalmed cadaver, and to discuss the possible clinical implications of this anomaly. The musculotendinous bands tautened and compressed the underlying axillary vessels, and the musculocutaneous, median, and ulnar nerves during passive abduction/external rotation of the shoulder. Similar variations found in the latissimus dorsi muscles in this commentary have been reported in the anatomical and surgical literature. These reports include descriptions of the anomalous bands of the latissimus dorsi attaching to the coracoid process, pectoralis major muscle, and fascia of the coracobrachialis muscle. The potential presence of an axillary arch presents several clinical considerations for the physical therapist. The existence of an axillary arch should be considered in patients with signs and symptoms consistent with upper extremity neurovascular compromise similar to thoracic outlet syndrome. Including this variant in the differential diagnostic process may assist physical therapists in the management of patients with signs and symptoms consistent with thoracic outlet syndrome.
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Affiliation(s)
- Russell A Smith
- Physical Therapy Program, University of North Florida, Jacksonville, FL 32224, USA.
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46
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König RW, Kretschmer T, Börm W, Hübner F, Richter HP, Antoniadis G. Neurogenes Thoracic-outlet-Syndrom. DER NERVENARZT 2005; 76:1222, 1224-6, 1230. [PMID: 15864515 DOI: 10.1007/s00115-005-1909-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial entrapment syndromes of the upper extremity. There are two different surgical approaches for its primary surgical treatment: supraclavicular decompression and transaxillary first rib resection. The aim of this study was to evaluate long-term results and surgical risks of the former. METHODS This retrospective long-term study examines a series of 50 supraclavicular decompressions in 45 patients. Follow-up was for at least 24 months. All patients were reexamined regularly in nonstandardized fashion. Finally, each patient underwent a telephone interview with a standardized questionnaire. RESULTS There was a significant deterioration of primary results during follow-up. About 30.0% of cases worsened within 24 months after operation. In the long run, about 80.0% of cases showed improvement of symptoms (26.0% excellent, 36.0% good, 18.0% moderate). The complication rate was 4.0%. CONCLUSION Due to secondary deterioration of treatment during follow-up, only long-term studies are suited for the examination of neurogenic TOS. Results after supraclavicular decompression are satisfactory, and the complication rate is low.
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Affiliation(s)
- R W König
- Neurochirurgische Klinik der Universität Ulm am Bezirkskrankenhaus Günzburg.
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Abstract
Evaluation of the patient with nerve compression and/or nerve injury should include a complete motor and sensory evaluation to establish the level and degree of injury and/or compression. No one test has been accepted as the standard procedure for the evaluation of sensibility. The various sensory tests available for patient assessment will yield different information regarding the integrity of the quickly and slowly adapting sensory receptors. Tests such as provocative maneuvers and sensory thresholds (cutaneous and vibration) will be more sensitive in the evaluation of patients with nerve compression, and other discriminatory measures will yield better functional information in patients with nerve injury.
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Affiliation(s)
- Christine B Novak
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Maxey TS, Reece TB, Ellman PI, Tribble CG, Harthun N, Kron IL, Kern JA. Safety and efficacy of the supraclavicular approach to thoracic outlet decompression. Ann Thorac Surg 2003; 76:396-9; discussion 399-400. [PMID: 12902072 DOI: 10.1016/s0003-4975(03)00531-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) is a clinical diagnosis encountered by both thoracic and vascular surgeons. The goal of surgical therapy involves relieving compression of the neurovascular structures at the superior thoracic aperture. The traditional approach to thoracic outlet decompression has been transaxillary; however more centers are moving toward a more tailored approach through a supraclavicular incision. METHODS The medical records of 67 patients who underwent surgical decompression between 1993 and 2001 for TOS were retrospectively reviewed. Patient demographics and early outcome were assessed through clinic follow-up. RESULTS Seventy-two thoracic outlet decompressions were performed on 67 patients with the diagnosis of TOS. Five patients underwent bilateral thoracic outlet decompression. All operations in this time period were safely accomplished through a supraclavicular approach. The syndromes associated with thoracic outlet compression were neurogenic (n = 59), venous (n = 10), and arterial (n = 3). Forty-six of 72 (63.9%) operations resulted in complete resolution of symptoms, 17 cases (23.6%) had partial resolution, and 9 patients (12.5%) had no resolution. There were no deaths and morbidity was minimal with 6 complications (8.3%). CONCLUSIONS The supraclavicular approach is a safe and effective technique in managing all forms of thoracic outlet compression.
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Affiliation(s)
- Thomas S Maxey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Science Center, Charlottesville, Virginia 22908, USA
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Abstract
The evaluation of patients with nerve injury or nerve compression requires an accurate history and subjective report to determine the tests that are the most useful in providing the essential information. Motor and sensory evaluation is necessary inglobal mixed-nerve injuries, but in cases of nerve compression, tests of provocation give more accurate information for detecting the site of nerve compression. There is no gold standard test in the evaluation of patients with nerve injury or compression; therefore, a battery of valid and reliable sensory and motor tests provides the most complete information to formulate a treatment plan.
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Affiliation(s)
- Christine B Novak
- Division of Plastic and Reconstructive Surgery and Program in Occupational Therapy, Washington University School of Medicine, Suite 17424, East Pavilion, One Barnes-Jewish Hospital Plaza, St Louis, Missouri 63110, USA.
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