The impact of competitive level of high school and collegiate athletes on outcomes of thoracic outlet syndrome.

OBJECTIVE: Thoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes. METHODS: This was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P < .05. RESULTS: Thirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P = .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P = .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P = 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P = .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P = .15). Operating room time was 90.0 vs 105.3 minutes for HS and CO athletes, respectively (P = .14). Mean length of stay was 2.0 vs 1.9 days for HS and CO athletes (P = .91). Mean follow-up was 6.9 months for HS athletes and 10.5 months for CO athletes (P = .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P = 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P = .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P = .035). CONCLUSIONS: Despite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes.

Provocative changes in nerve conductions: Fact or fiction?

At times electrodiagnostic medical consultants (EMCs) are asked to perform studies in both a neutral position, and then again after the patient is in a provocative position that exacerbates symptoms, to assess for measurable electrophysiologic changes. While this approach might seem initially appealing, particularly when standard studies are not effective at diagnosis, empiric studies in several conditions have been unimpressive. Studies in median neuropathy at the wrist, thoracic outlet syndrome, piriformis syndrome, and radial tunnel syndrome have failed to demonstrate reproducible changes in nerve conduction studies in positions that exacerbate symptoms. Furthermore, there is lack of a plausible pathophysiologic mechanism for producing both measurable and rapidly reversible electrophysiologic changes after just a few minutes, or less, of compression. Axon loss and demyelination would not be rapidly reversible, and positional changes of 2 min or less (the durations generally studied) would be insufficient to produce measurable nerve ischemia. Last, we have gained a greater appreciation for how much nerves move within limbs with changes in joint position; this movement can lead to misleading changes in nerve conduction studies. It is thus appropriate to conclude that testing nerve conduction in provocative or symptomatic positions adds no value to electrodiagnostic testing.

Botulinum toxin injections for the treatment of neurogenic thoracic outlet syndrome: A systematic review.

Botulinum toxin (BTX) injections into the musculature surrounding the brachial plexus have been examined as a potential treatment for neurogenic thoracic outlet syndrome (nTOS). This systematic review identified 15 publications, of which one was a randomized controlled trial. BTX injections performed with ultrasound or electromyographic guidance, and with the inclusion of the pectoralis minor muscle, in addition to the anterior and/or middle scalenes, tended to provide greater symptom improvement and may predict response to first rib resection. Importantly, most studies were of low quality; thus, the results should be interpreted with caution. Further high-quality studies are needed to confirm these findings.

Under pressure: a head-to-toe review of vascular compression syndromes.

Vascular compression syndromes are a group of conditions resulting from mechanical compression of blood vessels by adjacent structures leading to compromised blood flow and various associated symptoms. They frequently affect young, otherwise healthy individuals and are often underdiagnosed due to their rarity and vague clinical manifestations. Achieving an accurate diagnosis depends on the integration of clinical presentation and imaging findings. Imaging modalities including color doppler ultrasound, computed tomography angiography, magnetic resonance angiography, and catheter-directed digital subtraction angiography are essential for diagnosis and management. Dynamic imaging is crucial in eliciting findings due to the positional nature of many of these syndromes. In this paper, we will present a "head-to-toe" overview of vascular compression syndromes including Vascular Eagle Syndrome, Vascular Thoracic Outlet Syndrome, Quadrilateral Space Syndrome, Hypothenar Hammer Syndrome, Median Arcuate Ligament Syndrome, Renal Artery Entrapment Syndrome, Left Renal Vein Compression/Nutcracker Syndrome, May-Thurner Syndrome, Adductor Canal Syndrome, and Popliteal Artery Entrapment Syndrome. Treatment is variable but typically involves a combination of conservative and surgical management. Surgical approaches focus on decompression of affected neurovascular structures. Endovascular treatment alone is rarely recommended. We aim to equip general radiologists with the knowledge needed to accurately diagnose patients with vascular compression syndromes, allowing for timely treatment.

Patient Self-Reported Allergies and Their Correlation with Thoracic Outlet Syndrome Outcomes.

OBJECTIVES: Thoracic outlet syndrome (TOS) is an uncommon neurovascular disorder that presents as neck and upper extremity pain secondary to brachial plexus trunk or subclavian vasculature compression. The orthopedic literature has correlated patient-reported allergies to postoperative patient-reported outcome (PRO) scores for a variety of surgical procedures. We sought to evaluate patient-reported allergies and PROs following surgical decompression for TOS. METHODS: A chart review was conducted after identifying patients who underwent surgical thoracic outlet decompression by a single surgeon. Patients were contacted and administered five PRO questionnaires via telephone: the QuickDASH Outcome Measure questionnaire (disabilities of the arm, shoulder, and hand [DASH]), the Cervical Brachial Symptom Questionnaire, the Single Assessment Numeric Evaluation, the 12-Item Short Form Survey, and the Numeric Rating Scale (a visual analogue scale). A bivariate analysis of Pearson's correlation coefficient (r) was used to determine the associations of allergies with questionnaires and demographic variables. RESULTS: Of the 393 patients (128 males and 265 females) identified in the study, 75 (24%) responded and completed all of the questionnaires, 18 (24%) males and 57 (76%) females. A significant correlation was found between the number of allergies reported and the QuickDASH Outcome Measure questionnaire (r = 0.375, P < 0.001), the Cervical Brachial Symptom Questionnaire (r = 0.295, P = 0.01), change in the Single Assessment Numeric Evaluation score (r = -0.310, P < 0.01), change in the visual analogue scale (r = 0.244, P = 0.035), sex (r = 0.245, P = 0.034), and the number of medications (r = 0.642, P < 0.001). CONCLUSIONS: The increased frequency of patient-reported allergies is significantly associated with worse PRO scores for women undergoing TOS surgical decompression. Better understanding this association can help physicians counsel patients on expected outcomes.

Neurogenic Thoracic Outlet Syndrome: A Primer for Hand and Peripheral Nerve Surgeons.

Neurogenic thoracic outlet syndrome is a complex condition and is commonly misunderstood. Historically, much of this confusion has been because of its grouping with other diagnoses that have little in common other than anatomic location. Modern understanding emphasizes the role of small unmyelinated C type pain and sympathetic fibers. Diagnosis is primarily clinical, after ruling out other common conditions. Hand therapy is usually the first-line treatment with variable success. Local anesthetic, botulinum toxins, or steroid injections can aid in diagnosis and offer short-term relief. Although surgery can yield reliable results, it is technically challenging, and the preferred surgical approach is a matter of debate. Despite limitations in diagnosis and treatment, recognition and successful treatment of this condition can be highly impactful for the patient.

Thoracic Outlet Syndrome in the Pediatric and Young Adult Population.

PURPOSE: This study aimed to assess both nonsurgical and operative treatment outcomes of pediatric and young adult patients with thoracic outlet syndrome (TOS) at a tertiary care pediatric hospital. METHODS: A retrospective chart review of patients diagnosed with TOS, who were seen between January 2010 and August 2022 at a tertiary care pediatric hospital, was conducted. Collected pre- and postoperative data included symptoms, provocative testing (ie, Roo's, Wright's, and Adson's tests), participation in sports or upper-extremity activities, additional operations, and surgical complications. Assessment of operative treatment efficacy was based on pre- and post-provocative testing, pain, venogram results, alleviation of symptoms, and return to previous activity level 6 months after surgery. RESULTS: Ninety-six patients, (70 females and 26 males) with an average age at onset of 15 ± 4 (4-25) years, met the inclusion criteria for TOS. Among them, 27 had neurogenic TOS, 29 had neurogenic and vasculogenic TOS, 20 had vasculogenic TOS, 19 had Paget-Schroetter Syndrome, and one was asymptomatic. Twenty-six patients were excluded because of less than 6 months of follow-up. Of the remaining 70, 6 (8.6%) patients (4 bilateral and 2 unilateral) underwent nonoperative management with activity modification and physical therapy only, and one was fully discharged because of complete relief of symptoms. Sixty-four (90.1%) patients (45 bilateral and 19 unilateral) underwent surgery. A total of 102 operations were performed. Substantial improvements were observed in provocative maneuvers after surgery. Before surgery, 79.7% were involved in sports or playing musical instruments with repetitive overhead activity, and after surgery, 86.2% of these patients returned to their previous activity level. CONCLUSIONS: Few patients were successfully managed with nonoperative activity modification and physical therapy. In those requiring surgical intervention, first or cervical rib resection with scalenectomy using a supraclavicular approach provided resolution of symptoms with 86.2% of patients being able to return to presymptom sport or activity level. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pediatric thoracic outlet syndrome: a systematic review with metadata.

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

Thoracic Outlet Syndrome.

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

Cross-cultural adaptation of the Thoracic Outlet Syndrome Index for Turkish-speaking patients with thoracic outlet syndrome.

Background/aim: Considering that there is no specifically designed scale to measure quality of life (QoL) and level of functioning among Turkish-speaking patients with thoracic outlet syndrome (TOS), the aim of this study was to adapt the Thoracic Outlet Syndrome Index (TOSI) to the Turkish language (TOSI-TR) and analyze its psychometric properties in patients with TOS. Materials and methods: Thirty-nine patients with symptomatic TOS were included in the study. The participants were assessed using the following measures: the QuickDASH, the Western Ontario Rotator Cuff Index (WORC), and a visual analog scale (VAS). The psychometric properties of the TOSI-TR were examined in terms of test-retest reliability, construct validity, convergent validity, and feasibility. Results: The ICC2,1 of the TOSI-TR was 0.949 (95% CI: 0.903-0.973). The Kaiser-Meyer-Olkin value was found to be 0.716 with a significant result for Bartlett's sphericity test (p < 0.001). The TOSI-TR had a one-factor solution explaining 74.05% of the total variance. There was a significant correlation between TOSI-TR scores and QuickDASH (r = 0.762, p < 0.001), WORC (r =0.794, p < 0.001), and VAS (r = 0.663, p < 0.001) scores. The WORC and VAS scores were significant determinants of the TOSI-TR score, explaining 65.3% of the variance. There were no floor or ceiling effects. Conclusion: The TOSI-TR is a reliable, valid, and feasible questionnaire for the QoL and functional status in Turkish-speaking patients with TOS. We recommend this 15-item scale for optimal assessment in patients with TOS.

Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression.

OBJECTIVES: We aimed to report efficacy, safety, and health-related quality of life (HRQoL) outcomes of a multidisciplinary treatment approach including supraclavicular thoracic outlet decompression among patients with thoracic outlet syndrome (TOS). BACKGROUND: TOS is a challenging condition where controversy remains in diagnosis and treatment, primarily given a lack of data exploring various treatment approaches and associated patient outcomes. METHODS: Patients who underwent unilateral, supraclavicular thoracic outlet decompression, or pectoralis minor tenotomy for neurogenic, venous, or arterial TOS were identified from a prospectively maintained database. Demography, use of preoperative botulinum toxin injection, and participation in multidisciplinary evaluation were measured. The primary endpoints were composite postoperative morbidity and symptomatic improvement compared with baseline. RESULTS: Among 2869 patients evaluated (2007-2021), 1032 underwent surgery, including 864 (83.7%) supraclavicular decompressions and 168 (16.3%) isolated pectoralis minor tenotomies. Predominant TOS subtypes among surgical patients were neurogenic (75.4%) and venous TOS (23.4%). Most patients (92.9%) with nTOS underwent preoperative botulinum toxin injection; 56.3% reported symptomatic improvement. Before surgical consultation, few patients reported participation in physical therapy (10.9%). The median time from first evaluation to surgery was 136 days (interquartile range: 55, 258). Among 864 patients who underwent supraclavicular thoracic outlet decompression, complications occurred in 19.8%; the most common complication was chyle leak (8.3%). Four patients (0.4%) required revisional thoracic outlet decompression. At a median follow-up of 420 days (interquartile range: 150, 937) 93.3% reported symptomatic improvement. CONCLUSION: Based on low composite morbidity, need for very few revisional operations, and high rates of symptomatic improvement, a multidisciplinary treatment approach including primarily supraclavicular thoracic outlet decompression is safe and effective for patients with TOS.

Transthoracic Robotic First and Cervical Rib Resection for Thoracic Outlet Syndrome.

INTRODUCTION: Neurogenic thoracic outlet syndrome (TOS) is a musculoskeletal condition in which the brachial plexus is dynamically compressed within the scalene triangle, an anatomic space bordered by the anterior and middle scalene muscles and the first rib. In some cases, an offending cervical rib is present. Traditional surgical approaches to first rib resection and scalenectomy are limited by exposure, require retraction of neurovascular structures, and result in morbidity. METHODS: We describe a novel transthoracic robotic approach to first/cervical rib resection that overcomes these limitations, and we review its early clinical outcomes. RESULTS: Robotic first rib resection (FRR) is crystallized into 12 distinct steps, each with detailed video commentary, and nuances specific to neurogenic and venous TOS cases are provided. Published data supports decreased surgical morbidity of robotic FRR compared with open cases. CONCLUSIONS: Robotic FRR offers advantages over traditional operative approaches including improved exposure and elimination of retraction of neurovascular structures, which result in improved safety.

Development and validation of a prediction model for outcomes after transaxillary first rib resection for neurogenic thoracic outlet syndrome following strict Society for Vascular Surgery diagnostic criteria.

OBJECTIVE: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS. METHODS: We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation. RESULTS: A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88). CONCLUSIONS: Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.

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

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

Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome).

OBJECTIVE: We assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS). METHODS: We performed a retrospective, single-center review of 266 patients who had undergone primary surgical treatment of VTOS between 2016 and 2022. The clinical outcomes were compared between the patients in four treatment groups determined by intraoperative venography. RESULTS: Of the 266 patients, 132 were male and 134 were female. All patients had a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range, 12-66 years). The timing of clinical presentation was acute (<15 days) for 132 patients (50%), subacute (15-90 days) for 71 (27%), and chronic (>90 days) for 63 patients (24%). Venography with catheter-directed thrombolysis or thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 patients (71%). The median interval between symptom onset and surgery was 78 days. After paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%). However, 26 (10%) had a long chronic AxSCV occlusion with axillary vein inflow insufficient for bypass reconstruction. Patch angioplasty was performed for focal AxSCV stenosis in 55 patients (21%) and bypass graft reconstruction for segmental AxSCV occlusion in 35 (13%). The patients who underwent external venolysis alone (patent or occluded AxSCV; n = 176) had a shorter mean operative time, shorter postoperative length of stay and fewer reoperations and late reinterventions compared with those who underwent AxSCV reconstruction (patch or bypass; n = 90), with no differences in the incidence of overall complications or 30-day readmissions. At a median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling, and only 17 (6%) were receiving anticoagulation treatment; 95% of those with a patent AxSCV at the end of surgery were free of arm swelling vs 69% of those with a long chronic AxSCV occlusion (P < .001). The patients who had undergone CDT at the initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery (30% vs 44%; P = .034) and 60% less likely to have arm swelling at follow-up (5% vs 13%; P < .05) vs those who had not undergone CDT. CONCLUSIONS: Paraclavicular decompression, external venolysis, and selective AxSCV reconstruction determined by intraoperative venography findings can provide successful and durable treatment for >90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt usage of CDT, and even more effective surgical treatment.

When Healing Hands Hurt: Epidemiology of Thoracic Outlet Syndrome Among Physicians.

BACKGROUND: Thoracic outlet syndrome (TOS) is an infrequent condition which results in disability in use of upper extremity. While TOS is often associated with manual labor, industrial workers, and accidents, it has not been reported in a physician (MD) population. Given the investment of time and effort in training to become a MD, the impact of TOS may be devastating. Our objective is to report the presentation and outcome of TOS in MDs. METHODS: A prospectively surgical database was reviewed for MDs who sought care of disabling TOS between 1997 and 2022. Demographic, clinical, outcome and pathological data were reviewed. Outcomes were assessed based on Somatic Pain Scale (SPS), Quick Disabilities of Arm, Shoulder and Hand (DASH) scores, and Derkash scores. Results were also assessed based on return to employment. RESULTS: A total of 19 MDs were identified, from 1,687 TOS cases. The group included 13 (63%) men, 6 (31%) women, average age 45 years (range 27-57). Presentations included 1 (5.3%) arterial TOS (ATOS), 9 (47.4%) venous TOS (VTOS), and 9 (47.4) neurogenic TOS (NTOS). All patients were right-handed, and symptomatic side was dominant hand in 7 (37%) patients. Etiologies included repetitive motion injury, athletic injury, and congenital bony abnormalities. Repetitive motion was associated with 3/9 (33%) NTOS. Significant athletic activities were noted in 12 of 19 (63%) MDs, including 8/9 (89%) VTOS and 4/9 (44%) NTOS. Athletic activities associated with VTOS included triathletes (2), rock climbing (1), long distance swimming (2), and weightlifting (3). Of the 9 NTOS cases, 3 were associated with weightlifting and 1 with skiing. Congenital causes included 1 (5%) abnormal first rib and 1 (5%) cervical rib. Time from symptom onset to consultation varied significantly according to diagnosis: ATOS 6 days, VTOS 97 days, and NTOS 2,335 days (P < 0.05). All underwent first rib resection (FRR), and 4 (4) patients required contralateral FRR. Time from surgery to last follow-up averaged 1,005 days (range: 37-4,535 days). On presentation, 6 patients were work disabled and 13 patients were work restricted. Following surgery, 4 MDs remained work restricted with mild to moderate symptoms. After surgery, standardized outcomes (SPS, Quick DASH, and Derkash score) improved in all metrics. All who were initially disabled returned to work without restriction. Significant non-TOS related comorbidities were present in all who had residual restriction. Return to work was documented in all. CONCLUSIONS: Although it has not been reported, MDs are subject to developing TOS. Causes include repetitive motions, athletic injuries, and congenital bony abnormalities. Surgical decompression is beneficial with significant reduction in pain and disability. MDs are highly motivated and insightful; accordingly, they have a very high probability of successful work resumption, with all returning to their medical positions.

Systematic Review on Botulinum Toxin Injections as Diagnostic or Therapeutic Tool in Thoracic Outlet Syndrome.

BACKGROUND: The optimal diagnostic and treatment algorithm for patients with suspected thoracic outlet syndrome (TOS) remains challenging. Botulinum toxin (BTX) muscle injections have been suggested to shrink muscles in the thoracic outlet reducing neurovascular compression. This systematic review evaluates the diagnostic and therapeutic value of BTX injections in TOS. METHODS: A systematic review of studies reporting BTX as a diagnostic or therapeutic tool in TOS (or pectoralis minor syndrome as TOS subtype) was conducted in PubMed, Embase, and CENTRAL databases on May 26, 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. Primary end point was symptom reduction after primary procedure. Secondary end points were symptom reduction after repeated procedures, the degree of symptom reduction, complications, and duration of clinical effect. RESULTS: Eight studies (1 randomized controlled trial [RCT], 1 prospective cohort study, and 6 retrospective cohort studies) were included reporting 716 procedures in at least 497 patients (at minimum 350 primary and 25 repeated procedures, residual unclear) diagnosed with presumably only neurogenic TOS. Except for the RCT, the methodological quality was fair to poor. All studies were designed on an intention to treat basis, one also investigated BTX as a diagnostic tool to differentiate pectoralis minor syndrome from costoclavicular compression. Reduction of symptoms was reported in 46-63% of primary procedures; no significant difference was found in the RCT. The effect of repeated procedures could not be determined. Degree of symptom reduction was reported by up to 30-42% on the Short-form McGill Pain scale and up to 40 mm on a visual analog scale. Complication rates varied among studies, no major complications were reported. Symptom relief ranged from 1 to 6 months. CONCLUSIONS: Based on limited quality evidence, BTX may provide short-lasting symptom relief in some neurogenic TOS patients but remains overall undecided. The role of BTX for treatment of vascular TOS and as a diagnostic tool in TOS is currently unexploited.

Hybrid Paraclavicular Decompression for Venous Thoracic Outlet Syndrome with Primary Endovascular Reconstruction.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is characterized by severe stenosis and potential thrombosis of the axillary-subclavian vein (effort thrombosis) with significant effects on patient mobility, quality of life, and risks associated with possible anticoagulation. Treatment goals are aimed at symptomatic improvement and freedom from recurrent thrombosis. To date, there exist no clear protocols or recommendations on surgical approach that result in optimal outcomes. We highlight our institution's experience with a systematized, paraclavicular approach with intraoperative balloon angioplasty only, if needed. METHODS: This was a retrospective case series identifying 33 patients that underwent thoracic outlet decompression for vTOS from 2014 to 2021 via paraclavicular approach at Trinity Health Ann Arbor. Demographics, presenting symptoms, perioperative details, and follow-up details describing symptomatic improvement and imaging surveillance were obtained. RESULTS: The average age of our patients was 37 years with the most common presenting symptoms of pain and swelling (91%). The average time from diagnosis to thrombolysis for effort thrombosis was 4 days, with an average time to operative intervention of 46 days. All patients underwent a paraclavicular approach with full first rib resection, anterior and middle scalenectomy, subclavian vein venolysis, and intraoperative venogram. Of these, 20 (61%) underwent endovascular balloon angioplasty, 1 required balloon with stent placement, 13 (39%) required no additional intervention, and no patients required surgical reconstruction of the subclavian-axillary vein. Duplex imaging was used to evaluate recurrence in 26 patients at an average of 6 months postop. Of these, 23 demonstrated complete patency (89%), 1 demonstrated chronic nonocclusive thrombus, and 2 demonstrated chronic occlusive thrombus. Almost all our patients (97%) had moderate or significant improvement of their symptoms. None of our patients required a subsequent operation for recurrence of symptomatic thrombosis. The mode length of anticoagulation use postoperatively was 3 months, with an average use of 4.5 months. CONCLUSIONS: A systematized surgical approach of paraclavicular decompression for venous thoracic outlet syndrome with primary endovascular balloon angioplasty carries minimal morbidity with excellent functional results and symptomatic relief.

Ten-year Experience of Surgical Management of Paget-Schroetter Syndrome.

BACKGROUND: Paget-Schroetter syndrome (PSS) or effort-induced thrombosis is an acute (<14 days) venous thrombosis of the axillosubclavian vein. Early catheter-directed thrombolysis (CDT) is required to improve patency rate and avoid postthrombotic syndrome. This study aimed to report the management of PSS in our center across 10 years and compare it to the established guidelines. METHODS: Some of the selected patients were treated with CDT if the diagnosis of acute vein thrombosis was established 6 weeks after the appearance of the first symptoms and if a vascular surgeon was involved in the care and management of the patient. Patients underwent first rib removal 6 weeks after the CDT. Some patients with primary upper limb venous thrombosis were not immediately referred to a vascular surgeon after the initial diagnosis. They were instead discharged home with the prescription of oral anticoagulation therapy (OAT) alone for at least 3 months. RESULTS: Between 2010 and 2020, 426 first rib removal procedures were performed for 338 patients with thoracic outlet syndrome (TOS) at our center. Among them, 18 (4.2%) patients with PSS were identified. 5 (27.8%) patients underwent CDT. The median duration between first symptoms and thrombolysis was 10 days (range, 1-32). Thirteen (72.2%) patients were discharged home with OAT alone and referred to a vascular surgeon with a median time of 365 days (range, 8-6,422) for TOS diagnosis. Postthrombotic syndrome was noticed in 5 (38%) patients in the OAT group and 1 (20%) patient in the CDT group. CONCLUSIONS: Despite the guidelines being in favor of early CDT in PSS, most patients are discharged home with OAT alone. The study findings demonstrate that better information about this specific complication must be provided to the concerned practitioners who are likely to encounter such patients.

Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget Schroetter Syndrome.

BACKGROUND: Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome- PSS) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT) followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer based upon response. The aim of this study was to evaluate outcomes of this flexible protocol. METHODS: Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. Endpoints included success of TL and eventual clinical outcome. Patients were divided into 2 groups-Group I: TL/PMT + TOD; Group II: medical management/anticoagulation + TOD. RESULTS: PSS was diagnosed in 114 patients; 104 (62 female, mean age 31 years) who underwent TOD were included in the study. Group I: 53 patients underwent TOD after initial TL/PMT (23 at our institution and 30 elsewhere) with success (acute thrombus resolution) in 80% (n = 20) and 72% (n = 24) respectively. Adjunctive balloon-catheter venoplasty was performed in 67%. TL failed to recanalize the occluded SCV in 11% (n = 6). Complete thrombus resolution was seen in 9% (n = 5). Residual chronic thrombus in 79% (n = 42) resulted in median SCV stenosis of 50% (range 10% to 80%). With continued anticoagulation, further thrombus retraction was noted with median 40% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range 2-8 months). Rethrombosis of the SCV occurred in 3 patients 1-3 days postoperatively and was managed with MT/SCV stenting/balloon angioplasty and anticoagulation. Symptomatic relief was achieved in 49/53 (92%) patients at a median follow-up of 14 months. Group II: 51 patients underwent TOD following medical treatment elsewhere with anticoagulation alone for an average 6 months (range 2-18 months) with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (76%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in 4 patients (7%); the indication for TOD being residual symptoms from compression of collateral veins, the median residual stenosis was 70% (range 30-90%). TOD was performed at a median of 6 months after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in 4 patients and stenting in 2. Symptomatic relief was achieved in 46/51 (90%) at a median follow-up of 24 months. CONCLUSIONS: For Paget Schroetter syndrome a management protocol encompassing elective thoracic outlet decompression at a convenient time following thrombolysis is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the subclavian vein and may reduce the need for open venous reconstruction.