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Sun M, Fang L, Tang P, Wang F, Jiang L, Wang T. T1WI Radiomics Analysis of Anterior Scalene Muscle: A Preliminary Application in Neurogenic Thoracic Outlet Syndrome. J Comput Assist Tomogr 2025; 49:486-492. [PMID: 39631432 DOI: 10.1097/rct.0000000000001701] [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: 12/07/2024]
Abstract
AIM This study aimed to analyze the differences in radiomic features of the anterior scalene muscle and evaluate the diagnostic performance of MRI-based radiomics model for neurogenic thoracic outlet syndrome (NTOS). MATERIALS AND METHODS Imaging data of patients with NTOS who underwent preoperative brachial plexus magnetic resonance neurography were collected and were randomly divided into training and test groups. The anterior scalene muscle area was sliced in the T1WI sequence as the region of interest for the extraction of radiomics features. The most significant features were identified using feature selection and dimensionality-reduction methods. Various machine learning algorithms were applied to construct regression models. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC). RESULTS Totally, 267 radiomics features were extracted, of which 57 showed significant differences ( P ≤ 0.05) between the abnormal and normal anterior scalene muscle groups. The least absolute shrinkage and selection operator regression model identified 13 optimal radiomic features with nonzero coefficients for constructing the model. In the training set, the AUROCs of diagnostic models built by different machine learning algorithms, ranked from highest to lowest, were as follows: support vector machine (SVM), 0.953; multilayer perception (MLP), 0.936; logistic regression (LR), 0.926; light gradient boosting machine (LightGBM), 0.906; and K-nearest neighbors (KNN), 0.813. In the testing set, the rankings were as follows: LR, 0.933; SVM, 0.886; KNN, 0.843; LightGBM, 0.824; and MLP, 0.706. CONCLUSIONS NTOS is attributed to anterior scalene muscle abnormalities and exhibits distinct radiomic features. Integrating these features with machine learning can improve traditional manual image interpretation, offering further clarity in NTOS diagnosis.
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Affiliation(s)
| | - Le Fang
- Department of Neurology, China-Japan Union Hospital of Jilin University
| | | | - Fangruyue Wang
- The Third Bethune Hospital of Jilin University, Changchun, China
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Minh HT, Duc NM, Cong NV, Hien MM, Thuy LV, Son NH, Thach TX, Au HD. Imaging features of the brachial plexus in neurogenic thoracic outlet syndrome: A case report. Radiol Case Rep 2025; 20:999-1004. [PMID: 39654566 PMCID: PMC11625319 DOI: 10.1016/j.radcr.2024.10.158] [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] [Received: 06/10/2024] [Revised: 10/28/2024] [Accepted: 10/30/2024] [Indexed: 12/12/2024] Open
Abstract
Neurogenic thoracic outlet syndrome (NTOS) is characterized by the compression of the brachial plexus in the thoracic outlet region, caused by various etiologies. We report a case with clinical symptoms and imaging findings from ultrasound and magnetic resonance imaging (MRI) of NTOS due to an elongated C7 transverse process and a fibrous band of the middle scalene muscle, which was confirmed in decompression surgery.
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Affiliation(s)
- Hoang Tu Minh
- Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh, Vietnam
| | - Nguyen-Van Cong
- Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Ma Mai Hien
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Service d'imagerie diagnostique et interventionnelle, Centre Hospitalier Annecy Genevois, Haute-Savoie, France
| | - Le-Van Thuy
- Department of Neurology, Hanoi Medical University, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Ngo Hai Son
- Department of Maxillofacial - Plastic and Aesthetic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Tran Xuan Thach
- Department of Maxillofacial - Plastic and Aesthetic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Hoang Dinh Au
- Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
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Wu W, Ding Y, Su Y, Wang Y, Liu T, Liu D, Li C, Zheng C, Wang L, Long X. Contrast-enhanced magnetic resonance neurography for diagnosing brachial plexopathy: improved visualization and additional imaging features. Sci Rep 2024; 14:20758. [PMID: 39237747 PMCID: PMC11377534 DOI: 10.1038/s41598-024-71554-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/28/2024] [Indexed: 09/07/2024] Open
Abstract
Contrast-enhanced magnetic resonance neurography (CE-MRN) holds promise for diagnosing brachial plexopathy by enhancing nerve visualization and revealing additional imaging features in various lesions. This study aims to validate CE-MRN's efficacy in improving brachial plexus (BP) imaging across different patient cohorts. Seventy-one subjects, including 19 volunteers and 52 patients with BP compression/entrapment, injury, and neoplasms, underwent both CE-MRN and plain MRN. Two radiologists assessed nerve visibility, with inter-reader agreement evaluated. Quantitative parameters such as signal intensity (SI), contrast-to-noise ratio (CNR), and contrast ratio (CR) of the C7 nerve were measured. Both qualitative scoring and quantitative metrics were compared between CE-MRN and plain MRN within each patient group. Patient classification followed the Neuropathy Score Reporting and Data System (NS-RADS), summarizing additional imaging features for each brachial plexopathy type. Inter-reader agreement for qualitative assessment was strong. CE-MRN significantly enhanced BP visualization and nerve-tissue contrast across all cohorts, particularly in volunteers and patients with injuries. It also uncovered additional imaging features such as hypointense signals in ganglia, compressed nerve sites, and neoplastic enhancements. CE-MRN effectively mitigated muscle edema and vascular contamination, enabling precise classification of BP injuries. Overall, CE-MRN consistently enhances BP visualization and provides valuable imaging features for accurate diagnosis.
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Affiliation(s)
- Wenjun Wu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| | - Yuhong Ding
- Department of Radiology, Yijishan Hospital, Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Yu Su
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
| | - Youzhi Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
| | - Tingting Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
| | - Dingxi Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chungao Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Lixia Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Xi Long
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022, Hubei, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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Pfnür A, Antoniadis G, Wirtz CR, Pedro MT. [Long-Term Outcomes after Surgery of the Neurogenic Thoracic-Outlet Syndrome in Adolescents]. HANDCHIR MIKROCHIR P 2024; 56:32-39. [PMID: 38316411 DOI: 10.1055/a-2234-5066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Neurogenic Thoracic Outlet Syndrome (nTOS) describes a complex of symptoms caused by the compression of neural structures at the upper thoracic outlet. Typical symptoms include pain, numbness and motor weakness of the affected extremity. The incidence of nTOS is 2-3 per 100,000 and is highest between the ages of 25 and 40. There are only a few studies evaluating the surgical outcomes of nTOS in adolescent patients. In particular, there is a lack of long-term data. MATERIALS AND METHODS In a retrospective study of nTOS cases receiving surgical treatment in our clinic between 2002 and 2021, eight patients between 15 and 18 years of age were included. Demographic data, risk factors, clinical symptoms, clinical functional tests, neurophysiological, radiological and intraoperative findings were evaluated. Postoperative data were recorded using a standardised questionnaire. Decompression of the inferior truncus and the C8 and Th1 nerve roots was performed via a supraclavicular approach. RESULTS The average duration of symptoms before surgery was two years. Of the eight patients who underwent surgery, six answered the written questionnaire and could be analysed for the study. The average follow-up was nine years (1-18 years). After surgery, all patients experienced pain reduction; three were pain-free in the long run and five no longer required pain medication. Strength improved in all patients, but two patients still had mild motor deficits. Sensory disturbances were reduced in all patients, but residual hypoesthesia persisted in five. With regard to overhead work, half of the patients had no impairment after surgery. All patients were able to work at the time of the survey. Half of the patients pursued their sports activities without impairment, while mild impairment was reported by the other half. CONCLUSION nTOS in adolescents is a rare compression syndrome. Decompression of the lower parts of the brachial plexus using a supraclavicular approach without resection of the first rib is an adequate treatment. This retrospective study showed that a reduction in pain was achieved in all patients. In some patients, slight sensory and motor disturbances as well as a certain restriction in overhead work persisted. Patients were able to return to sports.
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Affiliation(s)
- Andreas Pfnür
- Neurochirurgie, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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Tolga G, Nilay YÇ, Umut MO, Çağrı TC. Surgical Management of Neurogenic Thoracic Outlet Syndrome: Exploring the Efficacy of the Posterior Intermuscular Approach in Cases Involving Bone Anomalies. Oper Neurosurg (Hagerstown) 2024; 26:133-140. [PMID: 37747340 DOI: 10.1227/ons.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/28/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES This article presents a cohort study focusing on neurogenic thoracic outlet syndrome (NTOS) caused by bone anomalies in the cervicothoracic region, specifically the extraforaminal area and the scalene triangle. Our aim was to contribute to understanding NTOS diagnosis and management, particularly in patients with bone anomalies, and to highlight the potential benefits of the posterior intermuscular approach as a surgical option in this particular patient group. METHODS We retrospectively evaluated the patients who underwent surgery for NTOS with accessory ribs or an elongated cervical vertebrae 7 (C7) transverse process (n = 9). Patients' clinical data, preoperative neurophysiological tests, cervical computed tomography (CT) scans, CT angiography, and postoperative cervical CT scans were reviewed. A single experienced surgeon used the posterior intermuscular approach on all patients. The accessory rib and/or elongated C7 transverse process and fibrous bands were removed; C7, C8, and T1 branches of the plexus were decompressed; and neurolysis was performed. Quality of life, a functional outcome, was measured by using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and pain was measured using visual analog scale scores. RESULTS The mean follow-up time after surgery was 7 months (range: 4-10 months). Before surgery, the mean DASH score was 55.8 ± 5.6. At the 3- and 6-month postoperative evaluations, the mean DASH scores decreased to 15.7 ± 5.8 and 15.4 ± 5.7, respectively. The mean visual analog scale score was 8.2/10 before surgery and decreased to 2.4/10 and 2.1/10 at the 3- and 6-month postoperative evaluations, respectively. All patients experienced good or excellent recovery at the 3- and 6-month postoperative evaluations. CONCLUSION Cervicothoracic extraforaminal area may be the primary site of nerve compression in NTOS, and posterior decompression using the posterior intermuscular approach can provide efficient access to extraforaminal nerve roots.
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Affiliation(s)
- Gediz Tolga
- Department of Neurosurgery, Antalya Training and Research Hospital, Antalya , Turkey
| | - Yalçın Çavuşoğlu Nilay
- Department of Thoracic and Vascular Surgery, Antalya Training and Research Hospital, Antalya , Turkey
| | - Mutlucan Ogün Umut
- Department of Neurosurgery, Antalya Training and Research Hospital, Antalya , Turkey
| | - Türk Cezmi Çağrı
- Department of Neurosurgery, University of Health Sciences, Hamidiye School of Medicine, İstanbul , Turkey
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Szaro P, Suresh R, Molokwu B, Sibala DR, Mendiratta D, Chu A, McGrath A. Magnetic resonance imaging for diagnosis of suspected neurogenic thoracic outlet syndrome-a systematic scoping review. Front Physiol 2023; 14:1198165. [PMID: 37920804 PMCID: PMC10619157 DOI: 10.3389/fphys.2023.1198165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/06/2023] [Indexed: 11/04/2023] Open
Abstract
Background: Neurogenic Thoracic Outlet Syndrome (nTOS) is a rare pathology caused by dynamic conditions or compression of neurovascular structures in the thoracic outlet region. nTOS can be difficult to diagnose due to nonspecific symptoms and magnetic resonance imaging (MRI) techniques are increasingly used to aid the diagnosis and surgical planning. This scoping systematic review explores how MRI is used for diagnosing nTOS and summarizes details of published MRI protocols. Methods: A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in September 2022 to include full-text English papers on MRI and nTOS. Inclusion criteria involved studies describing MRI protocols for the diagnosis of TOS, with a focus on the imaging sequences and protocols. Results: 6289 papers were screened to include 28 papers containing details of MRI protocols. The details of MRI protocols in the analyzed articles were incomplete in all studies. Most authors used 1.5T systems and included T1 and T2-weighted sequences. Most studies applied fat suppression, mainly with STIR. Positioning of the arm differed between studies, including neutral, hyperabducted and abducted and externally rotated positions. Conclusion: Our review highlights a prevalent lack of detailed MRI protocol documentation for brachial plexus. Authors primarily rely on conventional 1.5T systems, employing standard T1 and T2-weighted sequences. The adoption of novel MRI sequences is notably lacking, and fat suppression techniques predominantly adhere to older methods as STIR. There is a clear imperative for authors to provide more comprehensive reporting of the MRI protocols utilized in their studies, ultimately enhancing comparability and clinical applicability. Establishing clear protocol reporting guidelines is crucial to allow for comparison between studies.
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Affiliation(s)
- Pawel Szaro
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rohan Suresh
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Brian Molokwu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Dhiraj Raju Sibala
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Dhruv Mendiratta
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Alice Chu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Rochkind S, Ferraresi S, Denisova N, Garozzo D, Heinen C, Alimehmeti R, Capone C, Barone DG, Zdunczyk A, Pedro MT, Antoniadis G, Kaiser R, Dubuisson A, Pondaag W, Kretschmer T, Rasulic L, Dengler NF. Thoracic Outlet Syndrome Part II: Consensus on the Management of Neurogenic Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery. Neurosurgery 2023; 92:251-257. [PMID: 36542350 DOI: 10.1227/neu.0000000000002232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/31/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons. OBJECTIVE To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community. METHODS The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method. RESULTS Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%. CONCLUSION Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center.
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Affiliation(s)
- Shimon Rochkind
- Division of Peripheral Nerve Reconstruction, Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tela Aviv-Yafo, Israel
| | - Stefano Ferraresi
- Department of Neurosurgery, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Natalia Denisova
- Department of Functional Neurosurgery, Federal Neurosurgical Center, Novosibirsk, Russia
| | - Debora Garozzo
- Department of Neurosurgery, Mediclinic Parkview Hospital, Dubai, UAE
| | - Christian Heinen
- PeripheralNerveUnit Nord, Christliches Krankenhaus Quakenbrück GmbH, Quakenbrück, Germany
| | - Ridvan Alimehmeti
- Department of Neurosurgery at University Hospital Center "Mother Theresa", Tirana, Albania
| | - Crescenzo Capone
- Department of Peripheral Nerve Surgery, Ospedale Civile di Faenza, Local Health Authority of Romagna, Faenza, Italy
| | - Damiano G Barone
- Department of Neurosurgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Anna Zdunczyk
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maria T Pedro
- Peripheral Nerve Unit, Department of Neurosurgery, BKH Günzburg at Ulm UniversityGünzburg, Germany
| | - Gregor Antoniadis
- Peripheral Nerve Unit, Department of Neurosurgery, BKH Günzburg at Ulm UniversityGünzburg, Germany
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Praha 6, Czech Republic
| | | | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, ZA Leiden, Netherlands
| | - Thomas Kretschmer
- Department of Neurosurgery & Neurorestoration, Klinikum Klagenfurt, Klagenfurt am Wörthersee, Austria
| | - Lukas Rasulic
- Department of Neurosurgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nora F Dengler
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Diner C, Mathieu L, Vandendries C, Oberlin C, Belkheyar Z. Elective brachial plexus decompression in neurogenic thoracic outlet syndrome. HAND SURGERY & REHABILITATION 2023; 42:9-14. [PMID: 36574580 DOI: 10.1016/j.hansur.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 11/28/2022]
Abstract
We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- C Diner
- Department of Trauma, Orthopedic and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140 Clamart, France
| | - L Mathieu
- Department of Hand and Upper Extremity Surgery, Edouard Herriot Hospital, 5 Place d'Arsonval, 69003 Lyon, France; Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75005 Paris, France.
| | - C Vandendries
- RMX Center, 80 Avenue Felix Faure, 75015 Paris, France
| | - C Oberlin
- Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 Rue de la Folie Regnault, 75011 Paris, France
| | - Z Belkheyar
- Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 Rue de la Folie Regnault, 75011 Paris, France
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F. Dengler N, T. Pedro M, Kretschmer T, Heinen C, Rosahl SK, Antoniadis G. Neurogenic Thoracic Outlet Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:735-742. [PMID: 35978467 PMCID: PMC9975980 DOI: 10.3238/arztebl.m2022.0296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/01/2022] [Accepted: 07/21/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thoracic outlet syndrome (TOS) refers to a group of disorders in which there is compression of and/or damage to the neurovascular structures at the thoracic outlet, i.e., at the transition from chest to neck. The incidence of neurogenic thoracic outlet syndrome (nTOS) is estimated to be 2-3 / 100 000 / year, with an estimated prevalence of 10 / 100 000. Patients present with upper extremity sensorimotor symptoms that are often related to movement. The aim of the present article is to highlight the clinical presentation patterns of nTOS and to provide an overview of its diagnosis and treatment. METHODS Selective literature search for prospective observational studies and RCTs, including systematic reviews and metaanalyses. RESULTS There is no multicenter randomized controlled trial available on the treatment of nTOS. Prospective observational studies with a hierarchical study design report a positive effect of physiotherapy in 27-59% of cases. After unsuccessful conservative treatment, up to 56-90% benefit from surgical management. Patients with nTOS are more severely affected compared with those with other forms of TOS and benefit less from transaxillary first rib resection. nTOS patients who underwent supraclavicular decompression without rib resection had excellent surgical outcomes in 27%, good outcomes in 36%, acceptable outcomes in 26%, and poor surgical outcomes in 11% of cases. There is no systematic comparison available of the types of surgical management involved. Also, there is currently no uniform classification available for all medical sub-disciplines. Therefore, interpretation, and comparability of the study results are limited. CONCLUSION Although nTOS is the most common form of TOS, studies on its treatment are currently limited in terms of numbers and quality. The type of surgical management varies according to the experience and preference of the surgeon, treating specialty, special anatomic features, and clinical symptoms.
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Affiliation(s)
- Nora F. Dengler
- Department of Neurosurgery, Charité— Universitätsmedizin Berlin,*Charité – Universitätsmedizin Berlin Campus Benjamin Franklin Klinik für Neurochirurgie Hindenburgdamm 30, D-12203 Berlin, Germany
| | - Maria T. Pedro
- District Hospital of Günzburg, Neurosurgical Department of the University of Ulm
| | - Thomas Kretschmer
- Department of Neurosurgery and Neurorestauration, Klinikum Klagenfurt Am Wörthersee, Klagenfurt, Austria
| | - Christian Heinen
- Peripheral Nerve Unit Nord, Christliches Krankenhaus Quakenbrück GmbH, Quakenbrück
| | | | - Gregor Antoniadis
- District Hospital of Günzburg, Neurosurgical Department of the University of Ulm
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Altuwaijri TA. Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome. Medicine (Baltimore) 2022; 101:e30360. [PMID: 36086770 PMCID: PMC10980469 DOI: 10.1097/md.0000000000030360] [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] [Received: 12/02/2021] [Accepted: 07/20/2022] [Indexed: 11/26/2022] Open
Abstract
Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity, specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity, specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%, respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone. The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.
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Affiliation(s)
- Talal A. Altuwaijri
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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11
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Cavanna AC, Giovanis A, Daley A, Feminella R, Chipman R, Onyeukwu V. Thoracic outlet syndrome: a review for the primary care provider. J Osteopath Med 2022; 122:587-599. [PMID: 36018621 DOI: 10.1515/jom-2021-0276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/16/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS. OBJECTIVES This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options. METHODS The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS. RESULTS The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS. CONCLUSIONS The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.
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Affiliation(s)
- Angela C Cavanna
- Department of Clinical Medicine, Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Athina Giovanis
- Department of Osteopathic Manipulative Medicine, Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Alton Daley
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Ryan Feminella
- Touro College of Osteopathic Medicine, Middletown, NY, USA
| | - Ryan Chipman
- Touro College of Osteopathic Medicine, Middletown, NY, USA
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12
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Huang Y, Abad-Santos M, Iyer RS, Monroe EJ, Malone CD. Imaging to intervention: Thoracic outlet syndrome. Clin Imaging 2022; 89:23-36. [PMID: 35689965 DOI: 10.1016/j.clinimag.2022.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/21/2022] [Accepted: 06/06/2022] [Indexed: 11/03/2022]
Abstract
Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.
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Affiliation(s)
- Yijin Huang
- Emory University, Atlanta, GA, United States of America
| | - Matthew Abad-Santos
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Ramesh S Iyer
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Christopher D Malone
- Mallinckrodt Institute of Radiology at Washington University School of Medicine, St. Louis, MO, United States of America.
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13
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Couzan S, Martin JM, Chave É, Le Hello C. Update on the thoracic outlet syndrome and plexus brachial syndrome: Specific clinical examination (for all) and rehabilitation protocol. JOURNAL DE MEDECINE VASCULAIRE 2021; 46:232-240. [PMID: 34862017 DOI: 10.1016/j.jdmv.2021.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 06/13/2023]
Abstract
The diagnosis of uncomplicated forms of thoracobrachial outlet syndrome (TOS) and brachial plexus stretching syndrome (BPSS) is imprecise due to the lack of clear differentiation between dynamic vascular or neurological compression and brachial plexus stretching without vascular compression. After a review of literature, we propose and describe a simple way for clinical assessment of TOS, BPSS or association of both comprising 1 clinical sign and 2 manoeuvres. This clinical assessment can be performed by the medical doctor, the physiotherapist and the surgeon. The clinical diagnosis is essential because it will dictate the rehabilitation treatment. We propose and describe also a rehabilitation protocol comprising 10 phases with modulation of exercises according to clinical form (TOS, BPSS or association) and/or severity of symptoms. The physiotherapist has a capital role and is the guarantor of the effectiveness of the medical treatment. In France, a training is now available thanks to personal continuous development for diagnosis and treatment of TOS and BPSS. This is essential in order to propose an optimal care to patients.
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Affiliation(s)
- Serge Couzan
- Clinique Mutualiste, Saint-Étienne, France; INSERM, U1059 Sainbiose, Université de Lyon, Saint-Étienne, France
| | | | - Éric Chave
- Centre de kinésithérapie, 45b, avenue de la Libération, Saint-Étienne, France
| | - Claire Le Hello
- INSERM, U1059 Sainbiose, Université de Lyon, Saint-Étienne, France; Département de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire, Saint-Étienne, France; Campus Santé et Innovations, Université Jean Monnet, St-Priest-en-Jarez, France.
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14
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Mul K, Pesser N, Vervaart K, Teijink J, van Nuenen B, van Alfen N. Variability in electrodiagnostic findings associated with neurogenic thoracic outlet syndrome. Muscle Nerve 2021; 65:34-42. [PMID: 34378193 PMCID: PMC9292757 DOI: 10.1002/mus.27395] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 01/18/2023]
Abstract
Introduction/Aims Neurogenic thoracic outlet syndrome (NTOS) is a heterogeneous and often disputed entity. An electrodiagnostic pattern of T1 > C8 axon involvement is considered characteristic for the diagnosis of NTOS. However, since the advent of high‐resolution nerve ultrasound (US) imaging, we have encountered several patients with a proven entrapment of the lower brachial plexus who showed a different, variable electrodiagnostic pattern. Methods In this retrospective case series, 14 patients with an NTOS diagnosis with a verified source of compression of the lower brachial plexus and abnormal findings on their electrodiagnostic testing were included. Their medical records were reviewed to obtain clinical, imaging, and electrodiagnostic data. Results Seven patients showed results consistent with the “classic” T1 axon > C8 pattern of involvement. Less typical findings included equally severe involvement of T1 and C8 axons, more severe C8 involvement, pure motor abnormalities, neurogenic changes on needle electromyography in the flexor carpi radialis and biceps brachii muscles, and one patient with an abnormal sensory nerve action potential (SNAP) amplitude for the median sensory response recorded from the third digit. Patients with atypical findings on electrodiagnostic testing underwent nerve imaging more often compared to patients with classic findings (seven of seven patients vs. five of seven respectively), especially nerve ultrasound. Discussion When there is a clinical suspicion of NTOS, an electrodiagnostic finding other than the classic T1 > C8 pattern of involvement does not rule out the diagnosis. High resolution nerve imaging is valuable to diagnose additional patients with this treatable condition. See Editorial on pages 4‐6 in this issue.
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Affiliation(s)
- Karlien Mul
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels Pesser
- Department of Vascular surgery, Catharina Hospital, Eindhoven, The Netherlands.,CAPHRI-Research Center, Maastricht University, Maastricht, The Netherlands
| | - Kimberly Vervaart
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | - Joep Teijink
- Department of Vascular surgery, Catharina Hospital, Eindhoven, The Netherlands.,CAPHRI-Research Center, Maastricht University, Maastricht, The Netherlands
| | - Bart van Nuenen
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nens van Alfen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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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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Yang S, Kwon S, Chang MC. The Usefulness of Diffusion Tensor Tractography in Diagnosing Neuropathic Pain: A Narrative Review. Front Neurosci 2021; 15:591018. [PMID: 33841069 PMCID: PMC8032899 DOI: 10.3389/fnins.2021.591018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Diffusion tensor tractography (DTT) is derived from diffusion tensor imaging. It has allowed visualization and estimation of neural tract injury, which may be associated with the pathogenesis of neuropathic pain (NP). The aim of the present study was to review DTT studies that demonstrated the relationship between neural injuries and NP and to describe the potential use of DTT in the evaluation of neural injuries that are involved in the pathophysiological process of NP. A PubMed search was conducted for articles published until July 3, 2020, which used DTT to investigate the association between neural injuries and NP. The key search phrase for identifying potentially relevant articles was (diffusion tensor tractography AND pain). The following inclusion criteria were applied for article selection: (1) studies involving patients with NP and (2) studies in which DTT was applied for the evaluation of NP. Review articles were excluded. Altogether, 108 potentially relevant articles were identified. After reading the titles and abstracts and assessment of eligibility based on the full-text articles, 46 publications were finally included in our review. The results of the included studies suggested that DTT may be beneficial in identifying the pathophysiological mechanism of NP of various origins including central pain caused by brain injuries, trigeminal neuralgia, sciatica, and some types of headache. Further studies are needed to validate the efficacy of DTT in investigating the pathophysiology of other types of NP.
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Affiliation(s)
- Seoyon Yang
- Department of Rehabilitation Medicine, Ewha Women’s University Seoul Hospital, Ewha Women’s University School of Medicine, Seoul, South Korea
| | - SuYeon Kwon
- Department of Rehabilitation Medicine, Ewha Women’s University Seoul Hospital, Ewha Women’s University School of Medicine, Seoul, South Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
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17
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Manoharan D, Sudhakaran D, Goyal A, Srivastava DN, Ansari MT. Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb. Eur J Radiol 2020; 131:109234. [PMID: 32949858 DOI: 10.1016/j.ejrad.2020.109234] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 06/21/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies. METHODS The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies. RESULTS Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies. CONCLUSION It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.
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Affiliation(s)
- Dinesh Manoharan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Dipin Sudhakaran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Mohd Tahir Ansari
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
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18
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Rubin DI. Brachial and lumbosacral plexopathies: A review. Clin Neurophysiol Pract 2020; 5:173-193. [PMID: 32954064 PMCID: PMC7484503 DOI: 10.1016/j.cnp.2020.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/09/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022] Open
Abstract
Diseases of the brachial and lumbosacral plexus are uncommon and complex. The diagnosis of plexopathies is often challenging for the clinician, both in terms of localizing a patient's symptoms to the plexus as well as determining the etiology. The non-specific clinical features and similar presentations to other root, nerve, and non-neurologic disorders emphasize the importance of a high clinical index of suspicion for a plexopathy and comprehensive clinical evaluation. Various diagnostic tests, including electrodiagnostic (EDX) studies, neuroimaging (including ultrasound, MRI, or PET), serologic studies, and genetic testing, may be used to confirm a plexopathy and assist in identifying the underlying etiology. EDX testing plays an important role in confirming a plexopathy defining the localization, pathophysiology, chronicity, severity, and prognosis. Given the complexity of the plexus anatomy, multiple common and uncommon NCS and an extensive needle examination is often required, and a comprehensive, individualized approach to each patient is necessary. Treatment of plexopathies often focuses on symptomatic management although, depending on the etiology, specific targeted treatments may improve outcome. This article reviews the clinical features, EDX approaches, and evaluation and treatment of brachial and lumbosacral plexopathies.
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Affiliation(s)
- Devon I. Rubin
- Electromyography Laboratory, Mayo Clinic, Jacksonville, FL, USA
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19
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Abstract
Nerve imaging is an important component in the assessment of patients presenting with suspected peripheral nerve pathology. Although magnetic resonance neurography and ultrasound are the most commonly utilized techniques, several promising new modalities are on the horizon. Nerve imaging is useful in localizing the nerve injury, determining the severity, providing prognostic information, helping establish the diagnosis, and helping guide surgical decision making. The focus of this article is imaging of damaged nerves, focusing on nerve injuries and entrapment neuropathies.
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Affiliation(s)
- David A Purger
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Sarada Sakamuri
- Department of Neurology and Neurological Sciences, 213 Quarry Road, MC 5979, Palo Alto, CA 94304, USA
| | - Nicholas F Hug
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Sandip Biswal
- Department of Radiology, Stanford University, 300 Pasteur Drive, S-068B, Stanford, CA 94305, USA
| | - Thomas J Wilson
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, R293, Stanford, CA 94305, USA.
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20
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Al Shakarchi J, Jaipersad A, Morgan R, Pherwani A. Early and Late Outcomes of Surgery for Neurogenic Thoracic Outlet Syndrome in Adolescents. Ann Vasc Surg 2019; 63:332-335. [PMID: 31626925 DOI: 10.1016/j.avsg.2019.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/25/2019] [Accepted: 07/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Neurogenic thoracic outlet syndrome is a condition that is both complex to diagnose and manage successfully. The aim of our study was to present our experience and outcomes of surgical management of thoracic outlet syndrome in adolescents. METHODS We performed a retrospective analysis of a prospectively held database of consecutive adolescents (age 10-19 years) who underwent surgery for neurogenic thoracic outlet syndrome between 2005 and 2017 at our university hospital. RESULTS Fourteen patients were identified (19 operations), with a mean age of 16.5 years (SD: 1.9). All patients had symptomatic relief with surgery with low complication rates (1 pneumothorax). Median hospital stay was 2 days (IQR: 1). There were no early recurrences but 5 late ones which occurred 2, 2.5, 3, 4 and 10 years after surgery (20%). None required a second procedure and were managed successfully with physiotherapy. CONCLUSIONS Surgical intervention for thoracic outlet syndrome in the adolescent population results in excellent outcomes in the short term. However, we found that recurrence of symptoms in this population is common and patients need to be counseled clearly about this prior to surgical intervention. However in our experience these do not require further surgery.
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Affiliation(s)
- Julien Al Shakarchi
- Department of Vascular Surgery, University Hospital of North Midlands, Stoke, UK.
| | - Anthony Jaipersad
- Department of Vascular Surgery, University Hospital of North Midlands, Stoke, UK
| | - Richard Morgan
- Department of Vascular Surgery, University Hospital of North Midlands, Stoke, UK
| | - Arun Pherwani
- Department of Vascular Surgery, University Hospital of North Midlands, Stoke, UK
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21
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Kim SW, Jeong JS, Kim BJ, Choe YH, Yoon YC, Sung DH. Clinical, electrodiagnostic and imaging features of true neurogenic thoracic outlet syndrome: Experience at a tertiary referral center. J Neurol Sci 2019; 404:115-123. [PMID: 31374409 DOI: 10.1016/j.jns.2019.07.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/16/2019] [Accepted: 07/18/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE True neurogenic thoracic outlet syndrome (TN-TOS) is an extremely rare neuromuscular disease. We report clinical, electrodiagnostic and radiologic features of patients with TN-TOS. METHODS Retrospective chart review of patients satisfying criteria was done. Nerve conduction study (NCS) and needle electromyography (EMG) of upper extremity were reviewed. Brachial plexus MRI and computed tomography angiography (CTA) were also reviewed. RESULTS Thirteen TN-TOS patients were identified. The most common neurologic signs were hypesthesia in the medial forearm or ulnar digits and weakness of the abductor pollicis brevis (APB) muscle. In NCS, medial antebrachial cutaneous (MABC) sensory nerve action potential amplitude was decreased in all tested patients. The APB muscle was most commonly involved in EMG. Among radiologic criteria, focal stenosis of subclavian artery in CTA was the most common finding. CONCLUSION We confirmed that TN-TOS is T1 predominant lower roots/trunk brachial plexopathy with clinical and electrodiagnostic features. Radiologic studies may be used to detect structural abnormalities. SIGNIFICANCE As MABC NCS showed abnormal results in all tested patients, it should be added to electrodiagnostic study as screening method. If present, structural abnormalities might be confirmed with radiologic studies.
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Affiliation(s)
- Sun Woong Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Seon Jeong
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Cheol Yoon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Duk Hyun Sung
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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22
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Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB, Brunk AJ, Eng MR, Orhurhu V, Cornett EM, Kaye AD. Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain Ther 2019; 8:5-18. [PMID: 31037504 PMCID: PMC6514035 DOI: 10.1007/s40122-019-0124-2] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 12/22/2022] Open
Abstract
Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Practitioners must consider the pathology of thoracic outlet syndrome in their differential diagnosis for shoulder and upper extremity pain symptoms so that patients are directed appropriately to timely therapeutic interventions. Patients with a definitive etiology who have failed conservative management are ideal candidates for surgical correction. This manuscript will discuss thoracic outlet syndrome, occurrence, physical presentation, clinical implications, diagnosis, and management.
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Affiliation(s)
- Mark R Jones
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA.
| | - Amit Prabhakar
- Division of Critical Care, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA
| | - Jeremy B Green
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Julia B Kendrick
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Andrew J Brunk
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Matthew R Eng
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
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23
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Weaver ML, Hicks CW, Fritz J, Black JH, Lum YW. Local Anesthetic Block of the Anterior Scalene Muscle Increases Muscle Height in Patients With Neurogenic Thoracic Outlet Syndrome. Ann Vasc Surg 2019; 59:28-35. [PMID: 31009716 DOI: 10.1016/j.avsg.2019.01.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 01/06/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Local anesthetic (LA) blocks of the anterior scalene muscle are used to predict which patients with neurogenic thoracic outlet syndrome (TOS) may benefit from surgical decompression. The block is thought to work through both analgesic and muscle relaxation effects, but evidence of the latter is lacking. The aim of our study was to assess the effects of LA blocks on anterior scalene muscle anatomy as captured by magnetic resonance imaging (MRI). METHODS Over a two-year period, a series of patients with neurogenic TOS underwent MRI-guided anterior scalene blocks with an LA. Patients underwent MRI both before injection and 30 minutes after injection. Anterior scalene muscle heights (measured from the superior border of the first rib to the top of C3 vertebrae) before and after injection were compared for the injected side and the noninjected (control) side, both overall and stratified by subjective patient response to injection. RESULTS A total of 54 patients with neurogenic TOS were included. The median age was 39 years (interquartile range, 27-45), 61% were women, and 46% had a history of neck trauma. Forty-five patients (83%) had a favorable response to injection. Overall, there was no significant change in scalene muscle height for either the injected side (preinjection: 90.0 ± 1.2 mm vs. postinjection: 90.7 ± 1.2; P = 0.12) or the control side (preinjection: 89.3 ± 1.4 mm vs. postinjection: 88.9 ± 1.3 mm; P = 0.83). However, when stratified by patient response, those with a positive response had a larger increase in muscle height for the injected side than for the control side (change in baseline: 0.65 ± 0.58 mm vs. -0.53 ± 0.48 mm; P = 0.05). In contrast, nonresponders had no significant change in scalene height for either the injected or control side (change in baseline: 0.59 ± 1.30 mm vs. 0.37 ± 1.07; P = 1.00). Notably, responders had significantly longer anterior scalene muscles at baseline than nonresponders (92.2 ± 1.1 mm vs. 79.5 ± 2.5; P < 0.001). CONCLUSIONS LA blocks of the anterior scalene muscle may provide symptomatic relief in patients with neurogenic TOS by increasing muscle height, although the clinical significance of this small change is unclear. Patients who do not have a response to the block tend to have significantly shorter anterior scalene muscle heights than patients who respond, suggesting an anatomic difference in responders versus nonresponders.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jan Fritz
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
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Wang XT, Yao M, Zhong M, Wang YJ, Shi Q, Cui XJ. Thoracic outlet syndrome in a postoperative cervical spondylotic myelopathy patient: A case report. Medicine (Baltimore) 2019; 98:e14806. [PMID: 30882659 PMCID: PMC6426532 DOI: 10.1097/md.0000000000014806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Thoracic outlet syndrome (TOS) is a rare disease that presents with neurogenic and vascular symptoms similar to those of cervical spondylosis. However, making the diagnosis of TOS can be challenging due to a lack of standardized objective confirmatory tests. PATIENT CONCERNS A 66-year-old man presented with neck, supraclavicular, and right shoulder pain as well as numbness and weakness in the right arm after surgery to correct cervical spondylotic myelopathy (CSM). DIAGNOSIS Magnetic resonance imaging confirmed the diagnosis of CSM. He was diagnosed with TOS based on the manifestations and examination findings. INTERVENTIONS After surgery for CSM, nonoperative management was provided. OUTCOMES The patient reported pain relief and improving sensation in the shoulder and supraclavicular region. LESSONS Based on this case and the reviewed literature, to optimize the diagnosis and treatment of CSM, clinicians should consider preoperative differential diagnosis to preliminarily exclude it.
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Affiliation(s)
- Xiao-Tao Wang
- Department of Traditional Chinese Medicine, Ehu Branch of Xishan People's Hospital, Wuxi, Jiangsu
- Institute of Spine, Longhua Hospital, Shanghai University of Traditional Chinese Medicine
- Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education (Shanghai University of Traditional Chinese Medicine), Shanghai
| | - Min Yao
- Institute of Spine, Longhua Hospital, Shanghai University of Traditional Chinese Medicine
- Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education (Shanghai University of Traditional Chinese Medicine), Shanghai
| | - Ming Zhong
- Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yong-Jun Wang
- Institute of Spine, Longhua Hospital, Shanghai University of Traditional Chinese Medicine
- Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education (Shanghai University of Traditional Chinese Medicine), Shanghai
| | - Qi Shi
- Institute of Spine, Longhua Hospital, Shanghai University of Traditional Chinese Medicine
- Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education (Shanghai University of Traditional Chinese Medicine), Shanghai
| | - Xue-Jun Cui
- Institute of Spine, Longhua Hospital, Shanghai University of Traditional Chinese Medicine
- Key Laboratory of Theory and Therapy of Muscles and Bones, Ministry of Education (Shanghai University of Traditional Chinese Medicine), Shanghai
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Singh V, Kumar A, Bhandari M, Kumar S. Transaxillary decompression of thoracic outlet syndrome: A single-center study. HEART INDIA 2019. [DOI: 10.4103/heartindia.heartindia_16_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Stilwill SE, Mills MK, Hansford BG, Allen H, Mahan M, Moore KR, Hanrahan CJ. Practical Approach and Review of Brachial Plexus Pathology With Operative Correlation: What the Radiologist Needs to Know. Semin Roentgenol 2018; 54:92-112. [PMID: 31128744 DOI: 10.1053/j.ro.2018.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah E Stilwill
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
| | - Megan K Mills
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
| | - Barry G Hansford
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, OR.
| | - Hailey Allen
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
| | - Mark Mahan
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT.
| | - Kevin R Moore
- Intermountain Pediatric Imaging, Primary Children's Hospital, Medical Imaging Department, Salt Lake City, UT.
| | - Christopher J Hanrahan
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
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MR imaging features of presumed retroclavicular and periscapular intermuscular vascular plexi - An observational, anatomic study. Clin Imaging 2018; 52:62-69. [PMID: 29913391 DOI: 10.1016/j.clinimag.2018.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 05/31/2018] [Accepted: 06/07/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe MR imaging features of presumed vascular plexi in the periscapular (PSC) and retroclavicular (RC) locations. MATERIALS/METHODS 443 consecutive MR studies performed as "brachial plexus" protocol (axialT1-W and sagittal STIR) were reviewed for presence, size and characteristics of PSC and RC plexi. RESULTS Presumed PSC and RC vascular plexi were present in 10%. Both plexi more commonly occurred on the left side. Percutaneous biopsy (n = 1) yielded no vascular neoplasm. CONCLUSION RC and PSC vascular plexi are commonly encountered on routine brachial plexus MR imaging and may represent variant vascular networks, as they are frequently found on the contralateral asymptomatic side.
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Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions. Diagnostics (Basel) 2018; 8:diagnostics8010021. [PMID: 29558408 PMCID: PMC5872004 DOI: 10.3390/diagnostics8010021] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/09/2018] [Accepted: 03/15/2018] [Indexed: 12/22/2022] Open
Abstract
The diagnosis of thoracic outlet syndrome (TOS) has long been a controversial and challenging one. Despite common presentations with pain in the neck and upper extremity, there are a host of presenting patterns that can vary within and between the subdivisions of neurogenic, venous, and arterial TOS. Furthermore, there is a plethora of differential diagnoses, from peripheral compressive neuropathies, to intrinsic shoulder pathologies, to pathologies at the cervical spine. Depending on the subdivision of TOS suspected, diagnostic investigations are currently of varying importance, necessitating high dependence on good history taking and clinical examination. Investigations may add weight to a diagnosis suspected on clinical grounds and suggest an optimal management strategy, but in this changing field new developments may alter the role that diagnostic investigations play. In this article, we set out to summarise the diagnostic approach in cases of suspected TOS, including the importance of history taking, clinical examination, and the role of investigations at present, and highlight the developments in this field with respect to all subtypes. In the future, we hope that novel diagnostics may be able to stratify patients according to the exact compressive mechanism and thereby suggest more specific treatments and interventions.
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Gillet R, Teixeira P, Meyer JB, Rauch A, Raymond A, Dap F, Blum A. Dynamic CT angiography for the diagnosis of patients with thoracic outlet syndrome: Correlation with patient symptoms. J Cardiovasc Comput Tomogr 2017; 12:158-165. [PMID: 29233633 DOI: 10.1016/j.jcct.2017.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 11/20/2017] [Accepted: 11/28/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Vasculo-nervous structures serving the upper limbs may be compressed as they pass through three areas: the inter-scalene triangle (IST), the costo-clavicular space (CCS) and the retropectoralis minor space (RMS). The diagnosis of thoracic outlet syndrome (TOS) is essentially clinical, but requires imaging to specify the site of compression, its grade and the existence of predisposing anatomical factors, in order to guide the treatment and eliminate the main differential diagnoses. MATERIAL AND METHODS Images from 141 patients who underwent dynamic CT angiography of the thoracic outlets from June 2008 to January 2015 were analyzed retrospectively. Patients had unilateral or bilateral vascular, neurological, mixed or atypical symptoms. We studied the degree of stenosis of the subclavian artery with the following grading system: 1 (0-<25%), 2 (25-<50%), 3 (50-<75%), 4 (75-100%). The site of stenosis and the presence of underlying anatomical predisposing factors were also taken in account. RESULTS A total of 221 thoracic outlets were analyzed. Symptoms were neurological, mixed, vascular and atypical in 30%, 28%, 13% and 12%, respectively. Among patients with bilateral acquisitions, 38 outlets were asymptomatic; 40% of symptomatic outlets and only 5% of asymptomatic ones had grade 3 or 4 stenosis. 63% of the stenosis were in the CCS and 37% in the IST; 21% had a predisposing anatomical factor most often a costo-clavicular anomaly, associated with significant stenosis in 50% of cases. CONCLUSION Vascular stenosis of more than 50% on dynamic CT angiography is strongly associated with TOS. Predisposing factors were present in 21% of cases, causing significant vascular stenosis in half, underscoring the need for functional evaluation.
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Affiliation(s)
- Romain Gillet
- service d'imagerie GUILLOZ, Hôpital Central, CHU de Nancy, 54000 Nancy, France.
| | - Pedro Teixeira
- service d'imagerie GUILLOZ, Hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Jean-Baptiste Meyer
- service d'imagerie GUILLOZ, Hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Aymeric Rauch
- service d'imagerie GUILLOZ, Hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Ariane Raymond
- service d'imagerie GUILLOZ, Hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - François Dap
- service de chirurgie orthopédique, Centre Chirurgical Emile Gallé, CHU de Nancy, France
| | - Alain Blum
- service d'imagerie GUILLOZ, Hôpital Central, CHU de Nancy, 54000 Nancy, France
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30
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Kuwayama DP, Lund JR, Brantigan CO, Glebova NO. Choosing Surgery for Neurogenic TOS: The Roles of Physical Exam, Physical Therapy, and Imaging. Diagnostics (Basel) 2017. [PMID: 28644402 PMCID: PMC5489957 DOI: 10.3390/diagnostics7020037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Neurogenic thoracic outlet syndrome (nTOS) is characterized by arm and hand pain, paresthesias, and sometimes weakness resulting from compression of the brachial plexus within the thoracic outlet. While it is the most common subtype of TOS, nTOS can be difficult to diagnose. Furthermore, patient selection for surgical treatment can be challenging as symptoms may be vague and ambiguous, and diagnostic studies may be equivocal. Herein, we describe some approaches to aid in identifying patients who would be expected to benefit from surgical intervention for nTOS. We describe the role of physical examination, physical therapy, and imaging in the evaluation and diagnosis of nTOS.
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Affiliation(s)
- David P Kuwayama
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Denver, CO 80045 USA.
| | - Jason R Lund
- Ashbaugh Center for Physical Therapy, Denver, CO 80222, USA.
| | - Charles O Brantigan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Denver, CO 80045 USA.
| | - Natalia O Glebova
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Denver, CO 80045 USA.
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Ave, Room 5409, Mail Stop C 312, Aurora, CO 80045, USA.
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31
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New Diagnostic and Treatment Modalities for Neurogenic Thoracic Outlet Syndrome. Diagnostics (Basel) 2017; 7:diagnostics7020028. [PMID: 28555024 PMCID: PMC5489948 DOI: 10.3390/diagnostics7020028] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/07/2017] [Accepted: 05/24/2017] [Indexed: 11/30/2022] Open
Abstract
Neurogenic thoracic outlet syndrome is a widely recognized, yet controversial, syndrome. The lack of specific objective diagnostic modalities makes diagnosis difficult. This is compounded by a lack of agreed upon definitive criteria to confirm diagnosis. Recent efforts have been made to more clearly define a set of diagnostic criteria that will bring consistency to the diagnosis of neurogenic thoracic syndrome. Additionally, advancements have been made in the quality and techniques of various imaging modalities that may aid in providing more accurate diagnoses. Surgical decompression remains the mainstay of operative treatment; and minimally invasive techniques are currently in development to further minimize the risks of this procedure. Medical management continues to be refined to provide non-operative treatment modalities for certain patients, as well. The aim of the present work is to review these updates in the diagnosis and treatment of neurogenic thoracic outlet syndrome.
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32
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Ferrante MA, Ferrante ND. The thoracic outlet syndromes: Part 1. Overview of the thoracic outlet syndromes and review of true neurogenic thoracic outlet syndrome. Muscle Nerve 2017; 55:782-793. [PMID: 28006844 DOI: 10.1002/mus.25536] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 12/15/2016] [Accepted: 12/15/2016] [Indexed: 01/15/2023]
Abstract
The thoracic outlet syndromes (TOSs) are a group of etiologically and clinically distinct disorders with 1 feature in common: compression of 1 or more neurovascular elements as they traverse the thoracic outlet. The medical literature reflects 5 TOSs: arterial; venous; traumatic neurovascular; true neurogenic; and disputed. Of these, the first 4 demonstrate all of the features expected of a syndrome, whereas disputed TOS does not, causing many experts to doubt its existence altogether. Thus, some categorize disputed TOS as a cervicoscapular pain syndrome rather than as a type of TOS. To better understand these disorders, their distinctions, and the reasoning underlying the categorical change of disputed TOS from a form of TOS to a cervicoscapular pain syndrome, a thorough understanding of the pertinent anatomy, pathology, pathophysiology, and the electrodiagnostic manifestations of their pathophysiologies is required. This review of the TOSs is provided in 2 parts. In this first part we address information pertinent to all 5 TOSs and reviews true neurogenic TOS. In part 2 we review the other 4 TOSs. Muscle Nerve 55: 782-793, 2017.
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Affiliation(s)
- Mark A Ferrante
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Neurophysiology Division, Department of Neurology, Veterans Administration Medical Center, Memphis, Tennessee, USA
| | - Nicole D Ferrante
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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33
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Bottros MM, AuBuchon JD, McLaughlin LN, Altchek DW, Illig KA, Thompson RW. Exercise-Enhanced, Ultrasound-Guided Anterior Scalene Muscle/Pectoralis Minor Muscle Blocks Can Facilitate the Diagnosis of Neurogenic Thoracic Outlet Syndrome in the High-Performance Overhead Athlete. Am J Sports Med 2017; 45:189-194. [PMID: 27664077 DOI: 10.1177/0363546516665801] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Michael M Bottros
- Center for Thoracic Outlet Syndrome, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Pain Management, Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jacob D AuBuchon
- Center for Thoracic Outlet Syndrome, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Pain Management, Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lauren N McLaughlin
- Center for Thoracic Outlet Syndrome, Washington University School of Medicine, St Louis, Missouri, USA.,Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - David W Altchek
- Department of Orthopedic Surgery, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York, USA
| | - Karl A Illig
- Division of Vascular Surgery, University of South Florida, Tampa, Florida, USA
| | - Robert W Thompson
- Center for Thoracic Outlet Syndrome, Washington University School of Medicine, St Louis, Missouri, USA.,Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Nejim B, Alshaikh HN, Arhuidese I, Obeid T, Lum YW, Canner J, Locham SS, Malas M. Perioperative Outcomes of Thoracic Outlet Syndrome Surgical Repair in a Nationally Validated Database. Angiology 2016; 68:502-507. [DOI: 10.1177/0003319716677666] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We evaluated the occurrence of thoracic outlet syndrome (TOS) and 30-day postoperative outcomes. Patients undergoing cervical/first rib resection surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Thoracic outlet syndrome types were then examined. Propensity score matching was performed to account for potential confounders; 1180 patients were explored during the study period, 1007 (85.3%) were of the neurogenic TOS (NTOS), 32 (2.7%) patients had arterial TOS (ATOS), and 141 (12.0%) patients had venous TOS (VTOS). Patients with ATOS were significantly older (median age [interquartile range, IQR]—NTOS: 34 [25-44], ATOS: 49.5 [42.5-57], VTOS: 34 [23-43]; P < .001). Median operating time was significantly longer for patients with ATOS. Median in-hospital stay was also longer for patients with ATOS (median length of in-hospital stay [LOS; IQR]—NTOS: 2 [1-4]; ATOS: 6 [3-7]; and VTOS: 5 [2-7] days; P < .001). Patients with VTOS showed twice longer LOS when compared to NTOS after matching. Presentation and treatment of TOS have been studied extensively at highly experienced centers.
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Affiliation(s)
- Besma Nejim
- Department of Vascular and Endovascular Surgery, Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | - Husain N. Alshaikh
- Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Isibor Arhuidese
- Department of Vascular and Endovascular Surgery, Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | - Tammam Obeid
- Department of Vascular and Endovascular Surgery, Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | - Ying Wei Lum
- Department of Vascular and Endovascular Surgery, Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | - Joseph Canner
- Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Satinderjit S. Locham
- Department of Vascular and Endovascular Surgery, Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | - Mahmoud Malas
- Department of Vascular and Endovascular Surgery, Johns Hopkins Medical Institutes, Baltimore, MD, USA
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Arányi Z, Csillik A, Böhm J, Schelle T. Ultrasonographic Identification of Fibromuscular Bands Associated with Neurogenic Thoracic Outlet Syndrome: The "Wedge-Sickle" Sign. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2357-2366. [PMID: 27444863 DOI: 10.1016/j.ultrasmedbio.2016.06.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 06/06/2023]
Abstract
Thoracic outlet syndrome (TOS) is a disorder characterized by compression of the lower trunk of the brachial plexus, most often in association with anomalous congenital fibromuscular bands in the scalenic region. Early diagnosis is important, because the neurologic deficit associated with TOS may be irreversible. Using high-resolution ultrasound, we investigated 20 consecutive patients with clinical signs suggestive of TOS (all females, average age: 40.4 ± 14.9 y) and 25 control patients. In 19 patients, we identified a hyper-echoic fibromuscular structure at the medial edge of the middle scalene muscle, which indented the lower trunk of the brachial plexus ("wedge-sickle sign"). It was associated with the significant enlargement (p < 0.0001) and hypo-echogenicity of the lower trunk. This novel and distinctive ultrasonographic sign allows pre-surgical identification of anomalous fibromuscular bands causing TOS. It is especially useful in patients without neurologic deficit, in whom the diagnosis may not be as straightforward.
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Affiliation(s)
- Zsuzsanna Arányi
- MTA-SE NAP B Peripheral Nervous System Research Group, Department of Neurology, Semmelweis University, Budapest, Hungary.
| | - Anita Csillik
- MTA-SE NAP B Peripheral Nervous System Research Group, Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Josef Böhm
- Neurologische Praxis, Dr. Friedrich Behse/Dr. Josef Böhm, Berlin, Germany
| | - Thomas Schelle
- Department of Neurology, Städtisches Klinikum Dessau, Dessau-Rosslau, Germany
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Surgical Updates on Thoracic Outlet Syndrome. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0150-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Ali ZS, Pisapia JM, Ma TS, Zager EL, Heuer GG, Khoury V. Ultrasonographic Evaluation of Peripheral Nerves. World Neurosurg 2016; 85:333-9. [DOI: 10.1016/j.wneu.2015.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/03/2015] [Accepted: 10/05/2015] [Indexed: 12/13/2022]
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