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To assess the outcome of surgical treatment for thoracic outlet syndrome (TOS), and to compare the outcome in patients with and without an underlying cervical rib.
a heterogeneous group of 40 patients (33 women, seven men; aged 22-62 years) were evaluated 3 months to 20 years after surgery for suspected neurogenic TOS. Forty nine operations had bee...
Context in source publication
Context 1
... outlet decompression by first thoracic rib resection was performed through an infraclavicular approach in six patients with complications in two: severe but transient shoulder girdle pain in one and bronchitis in the other. Table 3 shows postoperative symptoms. At the neurological follow up assessment patients most often reported a favourable postoperative outcome. ...
Citations
... NTOS is a well-described and rare clinical pathology that results from compression of the C8 and/or T1 (more often) roots or the lower truncus of the brachial plexus by a fibrous band, which may extend from the first rib to the C7 transverse process or cervical rib, if present [11,12]. The most common clinical findings of NTOS are atrophy, weakness and wasting of the thenar and hypothenar muscles [13]. Numbness and loss of sensation are typically seen in the medial forearm area. ...
... NTOS is a well-described and rare clinical pathology that results from compression of the C8 and/or T1 (more often) roots or the lower truncus of the brachial plexus by a fibrous band, which may extend from the first rib to the C7 transverse process or cervical rib, if present [11,12]. The most common clinical findings of NTOS are atrophy, weakness and wasting of the thenar and hypothenar muscles [13]. Numbness and loss of sensation are typically seen in the medial forearm area. ...
In total, 665 of 680 (97%) patients with neurogenic thoracic outlet syndrome (NTOS) improved with conservative treatment. The remaining (3%) patients (15 of 680 patients) did not benefit after 3 months of conservative treatment and were referred for transaxillary first rib resection. We retrospectively compared the preoperative and postoperative (3 months) electromyelography and Quick Disability of Arm, Shoulder and Hands results of operated NTOS patients. Three of the 15 (20%) patients in the surgical cohort were male, with a median age of 25.3 ± 4.16 years, and the other 12 patients (80%) were female with a median age of 31.9 ± 9.48 years. Two of the 15 patients had a cervical rib, 4 of the 15 patients had an extension of the C7 transverse process, and 14 of the 15 patients had a cervical band. These bone and tissue abnormalities were removed in addition to the first rib resection and division of the subclavius muscle and the anterior scalenus and middle scalenus muscles. QuickDASH scores were 1062 preoperatively and 549 postoperatively. The latency of the median F-wave was significantly prolonged on the affected side compared to the unaffected side preoperatively (p = 0.015). There was no remarkable difference in the latency of ulnar F-waves between sides (p = 0.246). The medial antebrachial cutaneous nerve response values increased significantly postoperatively (p < 0.0001). Significant increases in ulnar sensory nerve action potential values amplitude ratio (p < 0.003) and median nerve motor amplitudes (p < 0.0001) were also found postoperatively.
... Urschel [1,2] suggested a representative electrophysiological diagnostic criterion for TOS based on the detection and analysis of the motor nerve conduction velocities of the ulnar nerve at four different points in the upper extremity. However, other scholars criticized this diagnosis criterion based on the lower accuracy of electrophysiological diagnoses compared with clinical diagnoses [3][4][5][6][7]. Somatosensory evoked potentials (SEPs) are part of the electrodiagnosis and exhibit a high specificity but an unsatisfactory sensitively [8][9][10][11]. ...
Introduction:
We sought to investigate the reliability of a new electrodiagnostic method for identifying Electrodiagnosis of Brachial Plexus & Vessel Compression Syndrome (BPVCS) in rats that involves the application of transcranial electrical stimulation motor evoked potentials (TES-MEPs) combined with peripheral nerve stimulation compound muscle action potentials (PNS-CMAPs).
Results:
The latencies of the TES-MEP and PNS-CMAP were initially elongated in the 8-week group. The amplitudes of TES-MEP and PNS-CMAP were initially attenuated in the 16-week group. The isolateral amplitude ratio of the TES-MEP to the PNS-CMAP was apparently decreased, and spontaneous activities emerged at 16 weeks postoperatively.
Materials and methods:
Superior and inferior trunk models of BPVCS were created in 72 male Sprague Dawley (SD) rats that were divided into six experimental groups. The latencies, amplitudes and isolateral amplitude ratios of the TES-MEPs and PNS-CMAPs were recorded at different postoperative intervals.
Conclusions:
Electrophysiological and histological examinations of the rats' compressed brachial plexus nerves were utilized to establish preliminary electrodiagnostic criteria for BPVCS.
... En el SDT neurogénico verdadero en los que ya hay compromiso neurológico significativo, la cirugía estaría indicada como tratamiento inicial, con el propósito de la resección de la primera costilla, costilla cervical, sección de bandas fibrosas, músculos anómalos o alteraciones vasculares, como en nuestro caso, sección de la arteria escapular descendente. En los casos de SDT nerogénico atípico, la indicación quirúrgica es menos precisa y los resultados a largo plazo son menos eficaces 3,5,6,21,22,23,24,25,26 . La arteria escapular descendente(AED), también llamada arteria dorsal de la escápula, tiene su origen en la tercera parte de la arteria subclavia. ...
Resumen El síndrome del desfiladero torácico es una entidad clínica compleja que abarca varias situaciones donde hay compresión del paquete vásculo-nervioso que suministra las extremidades superiores en el canal cervicotorácico. El síndrome se puede dividir en neurogénico y vascular de acuerdo con la estructura comprometida, siendo la primera la más frecuente. Entre las causas descritas están las costillas cervicales, anomalías de la primera costilla, músculos anómalos o hipertrofiados, trauma-tismos y tumores de la región. Describimos el caso de una paciente de 47 años que presenta un cuadro de cervicobraquialgia asociado con parestesias y paresia en la mano izquierda compatible con síndrome del desfiladero torácico en que la causa de la compresión era la arteria escapular descendente. Fue realizada una revisión de la literatura siendo encontrado sólo un caso similar. Palabras clave: Síndrome del desfiladero torácico, plexo braquial, arteria subclavia. Abstract The thoracic outlet syndrome is a complex clinical entity that encompasses several situations where there is compression of the neurovascular bundle that supplies the upper limbs in the cervicothoracic channel. It can be divided in neurogenic and vascular according to the structure committed, the first being the most frequently found. Among the causes described there are cervical ribs, anomalies of the first rib, anomalous or hypertrophied muscles, trauma and tumors of the region. We report the case of a 47 year old patient who presents with a clinical picture of cervicobrachialgia associated with paresthesia and paresis on the left hand compatible with thoracic outlet syndrome in which the cause of compression was the descending scapular artery.We conducted a literature review and found only one similar case. Introducción El síndrome del desfiladero torácico (SDT) es el término usado para des-cribir varias entidades clínicas que causan braquialgias como resultado de la compresión del paquete vasculoner-vioso que suministra las extremidades superiores situadas desde la región cervical hasta la porción proximal del brazo. Según la estructura del paque-te vasculonervioso más afectada, el SDT se subdivide en vascular y neu-rogénico. El SDT neurogénico, debido al compromiso del plexo braquial, es el más frecuente, siendo las causas más habitualmente mencionadas compre-siones por la costilla cervical, anoma-lías de la primera costilla, músculos anómalos o hipertrofiados y bandas fibrosas existentes en el espacio inte-rescalénico 1,2,3,4. Presentamos el caso de una paciente de 47 años con SDT neurogénico causado por la compre
... Ninety-five percent of patients have a neurogenic form, 2% have venous symptoms, and only 1% have clinical arterial compression [5]. The diagnosis of neurogenic TOS is relatively straightforward in the patient with pain and sensory disturbance predominantly in the ulnar forearm and hand, aggravated by use of the affected limb and associated with weakness and wasting of the small hand muscles, a cervical rib on a radiograph, and neurophysiological studies confirming chronic postganglionic axonal loss and excluding focal mononeuropathy [6]. ...
... Weakness and wasting of the small hand muscles are also reported. Neurophysiological studies confirming chronic postganglionic axonal loss, and excluding focal mono-neuropathy [6]. ...
Objectives. To compare the outcome of early surgical intervention versus late surgical treatment in cases of neurogenic thoracic outlet syndrome (NTOS). Design. Prospective study. Settings. Secondary care (Al-Minia University Hospital, Egypt) from 2007 to 2010. Participants. Thirty-five patients of NTOS (25 women and 10 men, aged 20-52 years), were classified into 2 groups. First group (20 patients) was operated within 3 months of the onset and the second group (15 patients) was operated 6 months after physiotherapy. Interventions. All patients were operated via supraclavicular surgical approach. Outcomes Measures. Both groups were evaluated clinically and, neurophysiologically and answered the disabilities of the arm, shoulder, and hand (DASH) questionnaire preoperatively and 6 months after the surgery. Results. Paraesthesia, pain, and sensory nerve action potential (SNAP) of ulnar nerve were significantly improved in group one. Muscle weakness and denervation in electromyography EMG were less frequent in group one. The postoperative DASH score improved in both groups but it was less significant in group two (P < .001 in group 1 and P < .05 in group 2). Conclusions. Surgical treatment of NTOS improves functional disability and stop degeneration of the nerves. Early surgical treatment decreases the occurrence of muscle wasting and denervation of nerves compared to late surgery.
... Previous examinations of patients with symptomatic contralateral NTOS have been limited to isolated case reports, yet we report 21 patients treated with bilateral FRRS for NTOS symptoms. 26,27 We have shown that patients with symptomatic contralateral NTOS were more often engaged in chronic repetitive motion than traumatic events but did not vary significantly from patients with unilateral NTOS symptoms. TOS has been linked to various anatomic abnormalities of the thoracic outlet with a congenital or traumatic basis. ...
Surgical treatment for neurogenic thoracic outlet syndrome does not always yield successful outcomes. The purpose of this study was to describe patients with unresolved, recurrent, and/or contralateral symptoms following first rib resection and scalenectomy (FRRS) and to determine therapies for improving their outcomes.
Data on 161 neurogenic thoracic outlet syndrome patients (182 FRRS procedures) were prospectively collected from 2003 to 2011 and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, interventions, and outcomes were compared between these patients and those with a successful result.
Twenty-three patients (24 FRRS) had unresolved symptoms at a mean of 16.1 ± 14.7 postoperative months. Compared with successes, these patients were older (mean age, 45 vs 38 years; P = .002) and active smokers (33% vs 13%; P = .031), with a longer duration of symptoms (90 vs 48 months; P = .005). They had higher rates of chronic pain syndromes (67% vs 14%; P < .001), neck and/or shoulder comorbidities (58% vs 22%; P < .001), preoperative opioid use (67% vs 31%; P = .001), and preoperative Botox injections (46% vs 20%; P = .009) with less relief (18% vs 64%; P = .014). Sixteen patients had recurrent symptoms at a mean of 12.1 ± 9.7 postoperative months. These patients had more chronic pain syndromes (38%; P = .028) and neck and/or shoulder comorbidities (50%; P = .027), with recurrence secondary to scar tissue (69%; P < .001) and reinjury (31%; P = .002). Postoperative treatments for both groups included physical therapy and local injections, where six unresolved (26%) and 13 recurrent (81%) patients achieved freedom from opioids at the end of the follow-up period. Twenty-one patients had contralateral symptoms and underwent secondary FRRS at a mean of 15.0 months (range, 7-30 months) following primary FRRS. The first operation was successful in 90% of cases.
Patients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer symptom duration. These patients face a more difficult recovery, whereas patients with recurrent symptoms are well managed with physical therapy and Botox injections. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.
... Thoracic outlet syndrome (TOS) refers to compression of the neurovascular structures at the superior aperture of the thorax [17, 20, 35]. Controversies exist concerning its causes, diagnosis, and treatment despite years of intense study of hundreds of patients [6, 7, 11, 21, 30, 32]. Although early investigators concentrated on the vascular manifestations of the disorder [1], more recent investigators think that the neural compression may be the source of many of the complaints [16, 18]. ...
Unlabelled:
The authors' experience with the supraclavicular approach for the treatment of patients with primary thoracic outlet syndrome (TOS) and for patients with recurrent TOS or iatrogenic brachial plexus injury after prior transaxillary first rib resection is presented. The records of 33 patients (34 plexuses) with TOS who presented for evaluation and treatment were analyzed. Of these, 12 (35%) plexuses underwent surgical treatment, and 22 (65%) plexuses were managed non-operatively. The patients who were treated non-operatively and had an adequate follow-up (n = 11) were used as a control group. Of the 12 surgically treated patients, five patients underwent primary surgery; four patients had secondary surgery for recurrent TOS; and three patients had surgery for iatrogenic brachial plexus injury. All patients presented with severe pain, and most of them had neurologic symptoms. All nine (100%) patients who underwent primary surgery (n = 5) and secondary surgery for recurrent TOS (n = 4) demonstrated excellent or good results. On the other hand, six (54%) of the 11 patients from the control group had some benefit from the non-operative treatment. Reoperation in three patients with iatrogenic brachial plexus injury resulted in good result in one case and in fair results in two patients; however, all patients were pain-free. No complications were encountered. Supraclavicular exploration of the brachial plexus enables precise assessment of the contents of the thoracic inlet area. It allows for safe identification and release of all abnormal anatomical structures and complete first rib resection with minimal risk to neurovascular structures. Additionally, this approach allows for the appropriate nerve reconstruction in cases of prior transaxillary iatrogenic plexus injury.
Electronic supplementary material:
The online version of this article (doi:10.1007/s11552-009-9253-0) contains supplementary material, which is available to authorized users.
... 17,18 In our series 77.8% of the patients were positive to TOS manoeuvres. 19 The presence of a pathological EMG has been correlated with a lesser functional prognosis after surgery because of established neuronal damage. 4,18 In our study EMG was carried out on all patients suspected of neurogenic TOS. ...
The aim of this study is to evaluate the functional recovery after Thoracic Outlet Syndrome (TOS) surgery, by the application of Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.
This was a prospective study of all patients operated on for TOS from January 1998 to December 2005. The DASH questionnaire was administered pre- and postoperatively. The scores were analysed according to TOS type, the associated comorbidity and the type of surgery performed. Results were assessed with Wilcoxon Test for continuous variables, and the Fisher Test for categories.
Twenty-three consecutive patients were included in the study, the average age was 37 years (range: 22-54). Fourteen patients presented with venous TOS and 9 with neurogenic TOS. Patients with venous TOS had a preoperative score of 14.9 (SD 18.31) and a postoperative score of 14.8 (SD 15.6) (p>0.05). The preoperative score in patients with neurogenic TOS was 53.96 (SD 15.6) and the postoperative score was 17.8 (SD 15.3) (p=0.01).
DASH questionnaire is a valid and objective test for evaluating the functional state after TOS surgery. Venous TOS is clinically less incapacitating than neurogenic. Surgically decompression of thoracic outlet leads to significant benefit in patients with neurogenic TOS.
... Seltener konsultie ren Patienten einen Arzt aufgrund einer progredienten Handschwäche, wie dies in der Originalarbeit von Gilliat beschrieben wurde. Dies waren die häufigsten Symptome von zwei retrospektiven operativen NTOSSerien (König et al. 2005;Donaghy et al. 1999). Donaghy et al. beurteilen überwiegend nächtliche Sympto me als starkes Argument gegen das Vorliegen eines NTOS. ...
... Dies wurde in zwei klinischen Arbeiten bestätigt (Nord et al. 2008;Plewa und Delinger 1998). In den zwei operierten NTOSSerien wurden die Provokations manöver, auch in Kombination mehrerer Manöver, als nicht genügend spezi fisch beurteilt (König et al. 2005;Donaghy et al. 1999). Beim umstrittenen un spezifischen TOS hingegen können klinisch und elektrodiagnostisch keine pa thologischen Befunde objektiviert werden (Wilbourn 1990). ...
