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.

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.

Vascular thoracic outlet syndrome: Registry of 30-years of patient's outcomes at King Saud University Medical City, Riyadh, Saudi Arabia.

OBJECTIVES: To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS). METHODS: This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months). RESULTS: A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases. CONCLUSION: Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache.

BACKGROUND: Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies. METHODS: One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data. RESULTS: The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups. CONCLUSIONS: The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.

Epidemiology of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) describes a complex disease process with three anatomic variations each with their own individual characteristics. Understanding the prevalence, diagnosis, and treatment of TOS is challenging for many providers. For this reason, the establishment of comprehensive care models and expert leadership by dedicated vascular surgeons with TOS experience has been invaluable.

The Incidence of Thoracic Outlet Syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) refers to a constellation of compressive problems that occur at the thoracic outlet. TOS has been recognized since the 19th century, and the "modern" era of treatment, especially for neurogenic TOS, dates from at least the 1970s. Despite this, however, the incidence and prevalence of these syndromes are almost completely unknown. To attempt to answer this fundamental question, we established a prospective database of all patients who presented to our clinic with a diagnosis of potential TOS, as described below. METHODS: We established a database of all patients referred to our clinic from July 1, 2014 to May 2018. All subjective data, the tentative diagnosis, and plan at the time of the office visit were prospectively recorded. For patients with neurogenic TOS (NTOS), a standardized workup sheet was used based on the Society for Vascular Surgery's recently published reporting standards document. For patients with venous TOS (VTOS), diagnosis was made by clinical examination and ultrasound, and for those with arterial TOS (ATOS), by clinical examination, ultrasound, and cross-sectional imaging when needed. RESULTS: From July 1, 2014, to May 1, 2018, 526 patients were referred to our institution with a diagnosis of possible TOS. Of these, 432 (82%) were referred with symptoms suggestive of NTOS, 84 (16%) with symptoms suggestive of VTOS, and 10 (2%) with findings and/or symptoms suggestive of ATOS. NTOS: After evaluation as per the algorithm previously mentioned, 234 patients (54%) were judged high suspicion for NTOS, 126 (30%) moderate suspicion, and 72 (17%) low suspicion; 360 (83%) of those originally referred were felt to potentially have NTOS. Of the 84 patients with VTOS, 25 (30%) presented with acute Paget-Schroetter syndrome, 41 (48%) with subacute or chronic occlusion, and 18 (21%) with McCleery's syndrome. Finally, 8 of the 10 limbs had true ATOS; of these, 6 (75%) underwent decompression and repair and 2 (25%) endovascular intervention only. Based on referral assumptions and population density in our area, the incidence of NTOS seems to be between 2 and 3 cases per 100,000 people per year and that of VTOS between 0.5 and 1 per 100,000 people per year, ATOS being sporadic. The ratio of those with decent suspicion for NTOS and VTOS, respectively, is about 80:20, whereas that of those undergoing surgical decompression is about 75:25. CONCLUSIONS: The rates of NTOS and VTOS, as aforementioned, are approximately 25 and 8 per year in a metropolitan area of 1,000,000, respectively. Although a rare disease, these numbers are not insignificant, although are much lower than prior estimates.

How Common Is Thoracic Outlet Syndrome?

The incidence of neurogenic thoracic outlet syndrome is completely unknown, and has been wildly overestimated in the past. Based on a prospectively maintained database at our academic Thoracic Outlet Center, we estimate the yearly incidence of neurogenic and venous thoracic outlet syndrome to be approximately 3 and 1 per 100,000 population, respectively. The ratio of neurogenic to venous thoracic outlet syndrome seems to be approximately 80:20 based on presentation, and 75:25 based on operative correction. These data will help to understand the impact of these disorders, and perhaps help to guide resource management.

Traditional medicine treatment for thoracic outlet syndrome: A protocol for systematic review of randomized controlled trials.

BACKGROUND: Diagnosis of thoracic outlet syndrome (TOS) is challenging; however, proper evaluation and treatment ensure relief from symptoms in most patients. A comprehensive approach to treatment is important, considering the multifactorial etiology of TOS. The objective of this systematic review is to describe the methods for evaluating the effectiveness and safety of acupuncture-based traditional medicine treatments for TOS. METHODS: A total of 13 databases will be searched, from their inception to the present date, for studies that have investigated the treatment of TOS. Databases that will be included are MEDLINE, Embase, AMED, Cochrane Library, CINAHL, and 4 Korean, 2 Chinese, and 2 Japanese databases.We will include randomized controlled trials (RCTs) assessing acupuncture-based traditional medicine for the treatment of any type of TOS. All RCTs on traditional medicine with any form of acupuncture will be eligible for inclusion. The methodologic quality of the RCTs will be analyzed using the Cochrane Collaboration tool to assess the risk of bias, and the confidence in the cumulative evidence will be assessed using the grading of recommendations assessment, development, and evaluation instrument. ETHICS AND DISSEMINATION: The results of this systematic review will be published in a peer-reviewed journal and disseminated both electronically and in print. The review will be updated to inform and guide health care practices. TRIAL REGISTRATION NUMBER: PROSPERO 2020 CRD42020164869.

Miscarriage is associated with cervical ribs in thoracic outlet syndrome patients.

The constancy of the number of cervical vertebrae in mammals is probably the result of selection against associated variations. A survey among patients with and without cervical ribs showed an association between miscarriage and the presence of cervical ribs. This supports the hypothesized selection against variations in cervical vertebral number.

Overview of venous pathology related to repetitive vascular trauma in athletes.

BACKGROUND: Athletes are generally young, high-functioning individuals. Pathology in this cohort is associated with a decrease in function and consequently has major implications on quality of life. Venous disorders can be attributed to a combination of vascular compression with a high burden of activity. OBJECTIVE: This article promotes increased awareness of these uncommon conditions specific to the athlete by summarizing pathophysiology, clinical features, investigation, and treatment protocols for use in clinical practice. Prognostic outcomes of these management regimens are also discussed, allowing for clinicians to counsel these high-functioning individuals appropriately. With the aim of providing an overview of sport-related venous pathology, a literature review was undertaken identifying articles that were independently reviewed by the authors. RESULTS: Lower limb venous thrombosis has been identified in young, high-functioning athletes attributed to both compression-related venous trauma, associated with repetitive movements resulting in intimal damage, and blunt trauma. The diagnosis and treatment follow the same protocols as for the general population. Of note, early ambulation is advocated, with an aim to return to premorbid (noncontact) function within 6 weeks. Athletes performing high-intensity repetitive upper limb movement, such as baseball players, are predisposed to upper limb deep venous thrombosis (DVT). Diagnosis follows the same protocols as for lower extremity DVT; however, the optimal treatment strategy remains debated. Current guidelines advocate the use of anticoagulation alone. A specific subset of primary upper limb DVT is effort thrombosis, where there is compression at the level of the thoracic outlet. Thrombolysis with first rib resection is indicated in the acute setting within 14 days. In cases of complete occlusion, surgical decompression with venous reconstruction may be required. Popliteal vein entrapment syndrome is also discussed. This entity has been identified as an overuse injury associated with popliteal vein compression. Duplex ultrasound examination is indicated as a first-line investigation, with conservative noninvasive options considered as an initial management strategy. Chronic venous insufficiency or persistent symptoms may require subsequent surgical decompression. CONCLUSIONS: Key conditions including upper extremity and lower extremity venous thrombosis, venous aneurysms, Paget-Schroetter syndrome (effort thrombosis), and popliteal vein entrapment syndrome are discussed. Further studies evaluating long-term outcomes on morbidity for current treatment regimens in upper extremity DVT, effort thrombosis, venous thoracic outlet syndrome, and popliteal venous entrapment syndrome are required.

[Pinch-off syndrom or costo clavicular forceps syndrom]. / Pinch-off syndrome ou syndrome de la Pince Costo-Claviculaire.

Implantable catheter systems are the most common procedure used for patients requiring chemotherapy or long-term drug administration. Several procedures are used for the installation of these systems. Patients with long-term subclavian venous catheters described a progressive rupture of the catheter which is a rare complication. This rupture is most often due to costoclavicular forceps or Pinch-off syndrome (POS). We report 07 cases of Pinch-off syndrome to evaluate our diagnostic and therapeutic approach.

Supraclavicular Thoracic Outlet Decompression in the High-Performance Military Population.

Background: Neurogenic thoracic outlet syndrome (nTOS) is a relatively common disorder and often affects younger, physically active populations. The modern American military is a population at risk for the development of nTOS given the intense physical training requirements. The purpose of this study is to determine functional recovery in the active duty military population resulting in full, unrestricted return-to-duty status following supraclavicular thoracic outlet decompression with partial first rib resection, partial anterior scalenectomy, and brachial plexus neurolysis. Methods: This retrospective study was approved by the Institutional Review Board at Walter Reed National Military Medical Center, Bethesda, Maryland to evaluate functional recovery following the surgery management of nTOS. In accordance with the Walter Reed National Military Medical Center Institutional Review Board, patient informed consent was obtained for this study. An institutional procedural database (Walter Reed National Military Medical Center Surgery Scheduling System) was queried for consecutive patients who underwent supraclavicular thoracic outlet decompression from January 2011 to May 2015. This study involved the completion of two survey instruments: the Disabilities of the Arm, Shoulder, and Hand survey and the Cervical Brachial Symptoms Questionnaire. Patients were asked to complete the preoperative surveys and the postoperative surveys. Results: Twenty responses were obtained with a 57% (20/35) overall response rate. Due to the low sample size, results were reported as a median rather than a mean to reduce the bias of outliers. Of the 20 patients who underwent supraclavicular thoracic outlet decompression, 85% reported improved functional recovery, 10% demonstrated no improvement but maintained stable functional and symptomatic deficits, and 5% demonstrated worsening of their functional and symptomatic status. The median total preoperative Disabilities of the Arm, Shoulder, and Hand score was calculated at 112 (interquartile range [IQR] 94-122) with an overall score reduction demonstrated by the median total postoperative Disabilities of the Arm, Shoulder, and Hand score of 50 (IQR 40-71). The median total score reduction of 57 (IQR 28.5-72) represented improved clinical and functional recovery (p < 0.001). The median total preoperative Cervical Brachial Symptoms Questionnaire score was 96 (IQR 74-111) with an overall score reduction revealed by the median total postoperative Cervical Brachial Symptoms Questionnaire score of 28 (IQR 19-45). The median total score reduction of 60 (IQR 23-77) reflected significant functional recovery consistent with clinical improvement (p < 0.001). Around 89% of patients had a predecompression temporary profile secondary to physical debilitation directly related to nTOS. Following surgery, temporary profile status was reduced to 39%. Around 61% of patients were able to complete and pass their service-specific physical fitness testing. Around 56% of patients demonstrated a full return-to-duty status without limitations. Conclusion: Supraclavicular partial first rib resection, partial anterior scalenectomy, and brachial plexus neurolysis results in significant improvement in functional recovery in the military active duty patient population. Prospective studies are warranted to further characterize and define nTOS functional recovery after surgery in this population.

Frequency of the Pectoralis Minor Compression Syndrome in Patients Treated for Thoracic Outlet Syndrome.

BACKGROUND: Pectoralis minor compression syndrome (PMCS) is a compression of the neurovascular structures in the subpectoral tunnel and remains underestimated in the management of patients with thoracic outlet syndrome (TOS). Its underdiagnosis may be responsible for incomplete or failed treatment. The aim of the study was to evaluate the frequency of PMCS in our experience. METHODS: We retrospectively reviewed all patients treated for TOS in our department. We selected those in whom PMCS was diagnosed with a systematic dynamic arteriography. Surgery was performed using the Roos axillary approach when a first rib resection was associated or an elective approach when a first rib resection was not associated. RESULTS: From January 2004 to December 2014, 374 surgeries for TOS were performed in 279 patients, which included 90 men (sex ratio = 0.48) with a mean age of 40.1 ± 10 years old. Among these patients, 63 (22.5%) underwent 82 interventions (21.9%) for PMCS, including 26 men (sex ratio = 0.70, P < 0.05) with a mean age of 37.9 ± 9.4 years old. Tenotomy of the pectoralis minor muscle was performed using axillary approach if it was associated with a first rib resection in 74 cases (90.2%) or through an elective approach in 8 cases (9.8%) if it was isolated. Four (4.9%) postoperative complications were found (1 hematoma [1.2%], 1 hemothorax [1.2%], 1 scapula alata [1.2%], and 1 subclavian vein thrombosis [1.2%]), all after an axillary approach. In 63 cases (79.7%), preoperative symptoms were resolved. In 14 cases (17.7%), symptom resolution was incomplete, and 2 patients (2.6%) had recurrent symptoms. CONCLUSIONS: Evaluation of PMCS in TOS is justified by its frequency and the simplicity and low morbidity of the surgical procedure.

Cervical Rib Prevalence and its Association with Thoracic Outlet Syndrome: A Meta-Analysis of 141 Studies with Surgical Considerations.

BACKGROUND: Cervical ribs (CR) are supernumerary ribs that arise from the seventh cervical vertebra. In the presence of CR, the boundaries of the interscalene triangle can be further constricted and result in neurovascular compression and thoracic outlet syndrome (TOS). The aim of our study was to provide a comprehensive evidence-based assessment of CR prevalence and their association with TOS as well as surgical approach to excision of CR and surgical patients' characteristics. METHODS: A thorough search of major electronic databases was conducted to identify any relevant studies. Data on the prevalence, laterality, and side of CR were extracted from the eligible studies for both healthy individuals and patients with TOS. Data on the type of TOS and surgical approach to excision of CR were extracted as well. RESULTS: A total of 141 studies (n = 77,924 participants) were included into the meta-analysis. CR was significantly more prevalent in patients with TOS than in healthy individuals, with pooled prevalence estimates of 29.5% and 1.1%, respectively. More than half of the patients had unilateral CR in both the healthy and the TOS group. The analysis showed that 51.3% of the symptomatic patients with CR had vascular TOS, and 48.7% had neurogenic TOS. Most CR were surgically excised in women using a supraclavicular approach. CONCLUSIONS: CR ribs are frequent findings in patients with TOS. We recommended counseling asymptomatic patients with incidentally discovered CR on the symptoms of TOS, so that if symptoms develop, the patients can undergo prompt and appropriate workup and treatment.

Thoracic outlet syndrome after the Nuss procedure for pectus excavatum: Is it a rare complication?

OBJECTIVE: The present study aims to elucidate the frequency of thoracic outlet syndrome after the Nuss procedure for pectus excavatum and the conditions in which thoracic outlet syndrome is likely to develop. METHODS: A retrospective study including 85 pectus excavatum patients (58 males and 27 females) was conducted. Thoracic outlet syndrome was defined as a condition in which the patient has numbness, lassitude, or pain of the upper limbs at rest or during motion of the upper limbs. The frequency of the thus-defined thoracic outlet syndrome was evaluated in 85 patients. Age, sex, Haller indices, and the positions of the correction bars were compared between the patients who developed thoracic outlet syndrome and those who did not. RESULTS: Preadolescent patients (18 out of 85) did not develop postoperative thoracic outlet syndrome. In total, 15.2% of adult male patients (7 out of 46) and 33% of adult female patients (7 out of 21) developed postoperative thoracic outlet syndrome. For both male and female groups, Haller indices were significantly greater for patients who had postoperative thoracic outlet syndrome than for those who did not. Correction bars were generally placed at higher intercostal spaces in patients who developed postoperative thoracic outlet syndrome than in those who did not. CONCLUSION: A considerable percentage of adult patients develop thoracic outlet syndrome after the Nuss procedure for pectus excavatum. Maturity of the thoracic wall, femininity, severity of the deformity (represented by greater Haller indices), and placement of correction bars at superior intercostal spaces are risk factors for postoperative thoracic outlet syndrome.

Perioperative Outcomes of Thoracic Outlet Syndrome Surgical Repair in a Nationally Validated Database.

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.

[Thoracic Outlet Syndrome]. / Thoracic-Outlet-Syndrom.

Introduction Thoracic outlet syndrome (TOS) is one of the most extensively discussed diagnoses. There is neither a clear and homogenous clinical presentation nor an accepted definition. The term describes a complex of symptoms and complaints caused by the compression of nerves and vascular structures at one of the three defined constrictions of the upper thoracic aperture. Methods Based on a comprehensive literature review, this article presents the etiology, epidemiology and clinical diagnostics as well as the possibilities and outcomes of surgical treatment. Results The thoracic outlet syndrome is currently subdivided into three main forms: vascular TOS (vasTOS) including arterial TOS (aTOS) and venous TOS (vTOS), neurogenic TOS (nTOS), which is further subdivided into typical (nTOS) and atypical TOS (disTOS), and a mixed form of nTOS and vasTOS (nvasTOS). The diagnosis is complex and difficult since the disTOS group comprises over 90 % of all patients. In addition to conservative treatment attempts, nTOS may be treated by surgical procedures focusing on the decompression of neurovascular structures. A significant improvement after surgery was found in up to 92 % of cases. The most common access sites are supraclavicular and transaxillary. 50 to 80 % of patients benefit from surgery in the long run. The rates of vascular or neurological complications reported by specialised centres are 0 to 2 %; minor complications such as pneumothorax, bleeding and lymphatic fistula are reported in up to 25 % of cases. Summary Most patients suffering from any form of TOS benefit from surgical treatment. Duration of symptoms, socioeconomic factors and, most notably, stringent diagnostic workup and an adequate operative procedure performed by an experienced centre are crucial to success.

A Fourteen-Year Experience with Vascular Anomalies Encountered during Transaxillary Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: Transaxillary approach to first rib resection and scalenectomy (TAFRRS) is a well-established technique for treatment of thoracic outlet syndrome (TOS). Although anatomic features encountered during TAFRRS are in general constant, vascular anomalies may be encountered but have not been described to date. Herein we describe vascular abnormalities encountered during TAFRRS. METHODS: We performed a retrospective review of a prospective practice database of 224 operations for TOS performed in 172 patients from March 2000 to March 2014. We excluded 10 patients with missing operative reports, 3 reoperations on the same patient, and 8 non-transaxillary resections. We recorded vascular anomalies identified in operative reports and reviewed computed tomography imaging to delineate the nature of these abnormalities. RESULTS: The overall incidence of vascular anomalies was 11% (22 of 203 TAFRRS). Most patients with anomalies had venous TOS (vTOS) (9 patients, 41%), followed by 7 (32%) with neurogenic TOS (nTOS). The remainder of the patients had arterial TOS (aTOS) (6 patients, 27%). Seven patients (32%) had an abnormal subclavian artery (SCA) with 5 (23%) having an abnormal arterial course in the anterior scalene muscle (ASM); 6 patients (27%) had an abnormal internal mammary artery (IMA) originating from distal SCA; 4 (18%) had abnormalities in the supreme thoracic artery (bifurcation or duplication); 2 (9%) had an abnormal branch from the SCA with anomalous location in the operative field; and 3 (14%) had an abnormal large venous branch penetrating the ASM. In the 19 patients with arterial anomalies, 8 (42%) were recognized as arterial branches penetrating the ASM, and 11 (58%) were noticed as they had anomalous arterial locations within the operative field. Most arterial anomalies were seen in vTOS (9, 45%), followed by nTOS (7, 35%). No intraoperative vascular complications occurred. Perioperative complications included 1 occurrence of postoperative transfusion for bleeding following axillary drain discontinuation and 2 Horner's syndromes. One aberrant IMA was electively ligated to allow complete thoracic outlet decompression. CONCLUSIONS: Arterial anomalies during TAFRRS are encountered in 11% of operations, and may present with vessel locations in unusual areas within the operative field, or as abnormal vessels penetrating the ASM, thus making scalenectomy precarious. Careful attention must be paid to possible abnormal locations of vessels in the thoracic outlet to avoid bleeding complications.

The enigma of neurogenic thoracic outlet syndrome following motor vehicle collisions.

BACKGROUND: The concept of neurogenic thoracic outlet syndrome (N-TOS) including upper and lower plexus syndromes secondary to soft tissue neck injury after motor vehicle collisions (MVCs) has been contentious. We considered that analysis of objective data from this group of patients could provide insight into this controversial type of N-TOS. METHODS: During the 10-year period January 2001 through December 2010 we examined patients who had received a diagnosis of N-TOS following an MVC. We graded the principal diagnosis based on the objective data from our physical examination. RESULTS: In total 263 patients received a diagnosis of N-TOS during the study period. At the highest accuracy level of diagnosis there were 56 patients with ulnar entrapment syndrome (UES), 40 with carpal tunnel syndrome (CTS) and 55 with nonorganic disease (NOD), for a total of 151 (57.4%) cases in which the diagnosis of N-TOS was brought into question. The elevated arm stress test (EAST) reproduced the symptoms of UES in 33 of the 56 patients of UES (58.9%) and reproduced the symptoms of CTS in 18 of the 40 patients with CTS (45.0%). CONCLUSION: There appears to be a high incidence of misdiagnosis of N-TOS following MVCs. The EAST is not a prime test for N-TOS.

BACKGROUND: Il n'y a pas consensus sur le concept de syndrome du défilé thoraco-brachial (SDTB) neurogène comprenant des syndromes du plexus brachial inférieur et supérieur consécutifs à une blessure aux tissus mous du cou découlant d'une collision de véhicules motorisés. Nous avons pensé que l'analyse de données objectives sur les patients touchés pourrait aider à comprendre ce type controversé de SDTB neurogène. METHODS: Durant une période de 10 ans, soit de janvier 2001 à décembre 2010, nous avons examiné des patients ayant reçu un diagnostic de SDTB neurogène après une collision de véhicules motorisés. Nous avons coté le diagnostic principal selon les données objectives de notre examen physique. RESULTS: Au total, 263 patients ont reçu un diagnostic de SDTB neurogène durant la période à l'étude. Au degré le plus précis de diagnostic, 56 patients étaient atteints de syndrome canalaire du nerf cubital, 40, de syndrome du canal carpien et 55, de maladies non organiques, pour un total de 151 patients, ou 57,4 % des cas pour lesquels le diagnostic de SDTB neurogène avait été envisagé. La manoeuvre du chandelier (test de Roos) a reproduit les symptômes du syndrome canalaire du nerf cubital chez 33 des 56 patients atteints (58,9 %) et ceux du syndrome du canal carpien chez 18 des 40 patients atteints (45,0 %). CONCLUSION: Il semble y avoir une forte incidence de mauvais diagnostics de SDTB neurogène après des collisions de véhicules motorisés. Le test de Roos n'est pas un test de premier choix pour ce syndrome.