New Techniques for Thoracic Outlet Syndromes

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Hatzenbuehler, MD; E-mail: jhatz intermed. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC. Advanced Search. Toggle navigation. Subscribe Register Login.

Your Name: optional. Your Email:. Specifically, these imaging studies can identify abnormal branching patterns or an abnormal course of the brachial plexus, each of which may be associated with nerve compression. Dynamic changes causing narrowing of those spaces through which the brachial plexus traverses may also predispose patients to nTOS and may be identifiable with proper positioning of the patient when obtaining images [ 3 ].

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The utility of MRI appears to be dependent on the specific technique utilized. One study examined 42 cases of TOS, which were managed with surgical decompression. This study demonstrated poor correlation between MRI and intraoperative findings. Additionally, the use of diffusion tensor imaging sequences to visualize nerve fascicles is employed in the modeling technique of tractography, which allows for a more comprehensive assessment of peripheral nerve injury [ 9 ].

In this study, however, compression was also identifiable using ultrasonography in all patients with MRN-identified nerve lesions [ 10 ]. Electrodiagnostic testing is also of utility in the diagnosis of nTOS. In addition, axonal loss of brachial plexus neurons is present on electrodiagnostic testing in those patients ultimately diagnosed with nTOS.

Thus, combined evaluation of nerve fibers originating at both levels is recommended [ 11 ]. Still, reduced SNAP of the ulnar nerve or decreased thenar M-wave voltage are associated with impingement of the brachial plexus [ 3 ]. Another diagnostic modality that is important in the evaluation of nTOS is scalene injection.

Although this technique is not new, it continues to undergo modifications that further enhance its diagnostic efficacy. Scalene injection can be a qualitative diagnostic tool that is additionally predictive of surgical outcomes in those patients under consideration for surgical management. It may also be considered as an alternative treatment modality for appropriately selected patients. The results demonstrated statistically-significant increases in function motor capacity. This suggests that anterior scalene muscle blocks may provide quantifiable information that may assist in successful and accurate diagnosis of nTOS [ 13 ].

High-performance athletes are a special population that may require a more intense post-procedural exercise regimen to accurately assess the effect on patient symptomatology and verify a successful scalene block [ 14 ]. Further refining the diagnostic techniques outlined above, as well as developing new objective diagnostic tools, is important not only to improve accuracy and consistency in the diagnosis of nTOS, but also to allow for the diagnosis to be made in a more efficient and timely manner.

In nTOS in particular, early surgical intervention following symptom onset is associated with improved patient outcomes, particularly in patients greater than forty years of age [ 15 , 16 ]. The utility of clinical presentation in the diagnosis of TOS, however, remains extremely important, and its value cannot be overemphasized. This underscores the significance of recognizing clinical characteristics consistent with TOS to establish the proper diagnosis. Finally, it is worthwhile to mention the role of genetics in the diagnosis of TOS. Although no specific genetic mutations have been identified in association with the development of TOS, there is at least one case report of TOS presenting in multiple family members, suggesting the potential for a genetic predisposition to development of the syndrome [ 18 ].

In particular, variations in HOX gene expression are implicated in the development of anomalies of the axial skeleton, including the presence of a cervical first rib [ 19 ]. With the increasing use of genetics in medicine, it is possible that genetic analysis will become an important factor in the diagnosis of TOS in the future.

With proper patient selection, the operative management of nTOS has excellent outcomes.

History of TOS - NeoVista®

Appropriate patient selection and management is a key determining factor in surgical success. Successful stratification of patients into appropriate management protocols is accomplished with implementation of several selection strategies. Exclusion of cervical or other peripheral nerve compression syndromes is a critical component of a thorough preoperative evaluation. Patients who are less than 40 years of age, present with a shorter symptoms duration and are non-smokers have better outcomes than other patients undergoing surgical management of TOS [ 20 , 21 ].

This institute selects patients with nTOS who are refractory to an eight-week course of physical therapy and responsive to anterior scalene muscle blocks with Botox or lidocaine for surgical intervention [ 1 ]. In contrast, another major referral center for TOS implements an approach in which nTOS patients are deemed appropriate for operative management only if they demonstrate symptomatic improvement with 8—16 weeks of physical therapy.

There is evidence, however, that a subset of patients presenting with nTOS with co-existing arterial involvement is refractory to, and sometimes worsened with, physical therapy. Anterior scalene blocks with lidocaine may be used to predict patients who will respond positively to operative intervention, particularly in patients over the age of forty.

Response to scalene block was not as predictive of surgical success in patients under the age of 40 in this study. Additionally, patients over the age of 40 who presented with a longer duration of symptoms had a significantly lower rate of positive surgical outcomes. Patients less than forty years of age did not demonstrate this association [ 16 ]. These findings reiterate the importance of appropriate patient selection when evaluating those patients over the age of 40 for surgical management.

Assessment of the vascular structures of the thoracic outlet may also be an important component of the pre-operative evaluation of patients presenting with nTOS. Even without vascular symptoms, internal jugular and subclavian vein stenoses have a high incidence in patients presenting with nTOS. Although it is unclear what relationship this finding may have with surgical outcomes, recognition of asymptomatic vascular changes in patients presenting with neurogenic TOS symptoms may be useful information when determining patient appropriateness for surgical intervention.

Various approaches including supraclavicular, infraclavicular and transaxillary approaches are all employed with equivalent excellent outcomes achieved at high volume centers. Some institutions describe the use of Video-Assisted Thoracoscopic Surgery VATS as a minimally-invasive approach to first rib resection, with one reported advantage of this approach being a clearer visualization of the operative field, potentially minimizing injury to the neurovascular bundle.

One institute utilizes a three-incision method in which two working and one scope port are placed. The median operative time was 85 min, and the median post-operative length of stay was 72 h [ 25 ]. A larger study examined 58 patients undergoing 66 rib resections eight bilateral with a different VATS technique requiring a transaxillary incision with a single port placement just below the incision.

With this technique, These complications included surgical site infection, pneumothorax, pulmonary embolism and pneumonia. The average length of hospital stay post-operatively was 2.

Another minimally-invasive technique described in the literature is that of robotic first rib resection. One institution reports excellent results in five patients who underwent robotic first rib resection for venous TOS with no reported morbidities. This technique requires four incisions in total. At one-year follow-up, all patients maintained patent subclavian veins without any additional intervention. The average length of hospital stay was three days [ 27 ]. Given that most experienced centers routinely performing first rib resection with traditional approaches via the supraclavicular or transaxillary incision have a much shorter length of hospital stay of one day post-operatively and that these approaches require only a single incision, implementation of the above techniques has not yet occurred on a large scale [ 1 ].

A final novel technique that is worth mentioning is that of the endoscopic-assisted transaxillary approach. One series of 22 patients undergoing first rib resection with the endoscopic-assisted transaxillary approach for better visualization of the operative field reported no complications associated with vascular, neural or pleural damage with success rates comparable to those of the traditional transaxillary approach [ 30 ]. Surgical complications associated with decompression of the thoracic outlet include pneumothorax, wound infection, hematoma and hemothorax.

At our institution, there were no arterial, venous or nerve root injuries in ten years of treating patients undergoing FRRS procedures, of which were for the neurogenic form of TOS specifically [ 20 ]. Despite the high rate of success with minimal complications associated with surgical decompression, medical management may be the most appropriate option for certain patients.

Physical therapy, modifications to daily activities to keep symptom exacerbation at a minimum and complementation of the treatment regimen with pharmacologic agents are all medical measures that may be employed in the treatment of nTOS [ 32 ]. Duration to symptom onset may be associated with increased success of medical management, as patients in this study experienced a short duration of symptoms with a mean of three months from symptom onset to evaluation and intervention [ 33 ].

Anterior scalene muscle injection not only serves as a both diagnostic and prognostic tool; it also plays a role as a therapeutic tool in patients with nTOS. A recent study shows Shorter symptom duration prior to the first injection was associated with increased improvement in those patients with a traumatic etiology, while the response of patients presenting with other etiologies of TOS was not affected by symptom duration [ 34 ].

Alternatively, a double-blind, randomized, controlled trial of 38 subjects did not demonstrate significant improvement in pain in patients undergoing anterior scalene injection with Botox vs. Notably, patients enrolled in this study had a mean symptom duration of six years [ 35 ]. In conclusion, neurogenic thoracic outlet syndrome remains a challenging entity to diagnose, but demonstrates excellent outcomes once a diagnosis is confirmed and treatment initiated. Recent statements clarify the defining factors of neurogenic thoracic outlet syndrome by clearly outlining a set of criteria consistent with the diagnosis of nTOS.

It might go away,…. One in three American women will die from some form of the disease, including:. We have been on a journey for almost 2 years looking for answers to the constant pain my now 17 year old daughter has in her right arm mostly in the bicep region. Can TOS cause bruising of this type? Any information would be appreciated.


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First of all Thank you!. I have a protruding clavicle, torn rotator cuff,winged scapula and rounded shoulder.

The Thoracic Outlet Syndrome Is Overdiagnosed

I have all the secondary issues, extremely strained scalene, SCM and pect major and minor muscles. My vision, sinus, jaw and teeth shifting have been affected as well as digestive issues. I started with orthro who only wanted to treat symptoms. I live in a fairly rural town in Northwest IL. Hoping for a Sunny Side of the street and your help. Thanks again!

Self Massage for Thoracic Outlet Syndrome – reduce pain, tingling, and numbness

I would definitely hope you can find a provider who will help get to the root of the problem. Wishing you all the best! Meaning if I came to Virginia, what would the length of time be needed to get properly diagnosed and treated? Thanks for reaching out, Scott. Yes, UVA serves people from around the world. Good luck! I have rib removal of my left top rib.

No relief they took my scalene muscle. I was deemed partically disablied by State if New York. No pain meds no Dr nothing. I live with chronic pain every day. I been suffering chronic neck pain for about two years now with headaches since middle school. I had theoratic outlet syndrome with a blood clot in my arm, so I ended up having surgery with removal of my fisrt rib.

I just want to mention that I have been a pitcher my whole life and currently playing. I just want to know if I have compression of nerves or blood vessels. The feeling is just a ache sore neck pain that never goes away now. Plz get back to me!!



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