Neurogenic thoracic outlet syndromes: a comparison of true and nonspecific syndromes after surgical treatment (original) (raw)
Related papers
Journal of Vascular Surgery
Objective: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. Methods: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and c 2 analyses. Follow-up results were assessed by changes in 11-item version of Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and patient-rated outcomes. Results: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean 6 standard error degree of local tenderness to palpation (1.7 6 0.1 vs 2.0 6 0.1; P ¼ .032), the number of positive clinical diagnostic criteria (9.0 6 0.3 vs 10.1 6 0.1; P ¼ .001), Cervical-Brachial Symptom Questionnaire scores (68.0 6 4.1 vs 78.0 6 2.7; P ¼ .045), and Short-Form 12-item physical quality-of-life scores (35.6 6 1.5 vs 32.0 6 0.8; P ¼ .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was À15.6 6 3.0 (À29.5% 6 5.7%) compared with À29.8 6 2.4 (À47.9% 6 3.6%) for surgery (P ¼ .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P < .0001). Conclusions: The present study has demonstrated contemporary outcomes for physical therapy and surgery in a wellstudied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for w90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery.
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 preopera-tively 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.
Neurogenic thoracic outlet syndrome: Are anatomical anomalies significant?
South African Journal of Surgery, 2015
Thoracic outlet syndrome (TOS) is controversial in terms of definition, anatomy, aetiology and treatment. The definition of TOS is generally accepted as 'upper extremity symptoms due to compression of the neurovascular bundle in the area of the neck just above the first rib'. [1] The thoracic outlet, also known as the cervicothoracobrachial junction, consists of three important compartments through which vital structures such as nerves and blood vessels run. These compartments are the interscalene space, the costoclavicular space and the retropectoralis minor space. Neurogenic TOS, resulting from nerve compression, is the most common pathology, accounting for >95% of TOS cases. [1] The majority of cases result from anatomical distortion at the interscalene triangle. [2] For various reasons, the described anatomical spaces transform and evolve into 'entrapment spaces'. The aetiology of this is largely unclear, but it is thought that changes may be congenital or acquired, and that these alterations involve either the bony structures or the soft tissues. [1,2] The observation of anatomical anomalies, especially of the brachial plexus, initiated this study. The aetiology of neurogenic TOS is multifactorial, with bony tissue abnormalities and soft-tissue abnormalities described as definite contributors to the syndrome. These abnormalities contribute to the syndrome by altering the space within which the brachial plexus trunks run. Brachial plexus anomalies, however, have not classically been described in direct association with TOS. Recent interest in brachial plexus anomalies suggests them as a cause for various pathologies, including TOS. [3] We hypothesised that brachial plexus anomalies, alone or in conjunction with additional pathology, are almost always associated with neurogenic TOS. The objective of this study was to attempt to clearly define anatomical anomalies causing TOS. Methods The study design is a retrospective review from a prospectively maintained computer database of patients presenting with TOS, over a 10-year period. From the computer database, the records of all patients with TOS were scrutinised, and information regarding their preoperative symptoms, investigations, operative surgery and clinical outcomes documented. The neurological presentation of pain, paraesthesia, weakness, wasting of the hand muscles and the segmental distribution in conjunction with the clinical investigations (including the elevated arm stress test), investigations (a chest radiograph, magnetic
Early versus Late Surgical Treatment for Neurogenic Thoracic Outlet Syndrome
ISRN Neurology, 2013
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 E...
Neurogenic Thoracic Outlet Syndrome Reviewed
Albanian Journal of Trauma and Emergency Surgery
Neurogenic Thoracic Outlet Syndrome (NTOS) is a rare, but controversial syndrome in relation to its diagnosis, treatment modality, and approaches in case of surgical treatment. In the English literature, there are sparse studies dealing with these aspects. We conducted a PubMed 2000-2017 literature review and found a total of 3953 cases reported with NTOS. The clinical characteristics, etiology, electrophysiological and radiological work-up and treatment options were reviewed and reported. It seems that, as far as surgical indication criteria are concerned, there is a consensus for NTOS in its motor deficit stage and its techniques are generally well established. This review showed that differential diagnosis, radiological, and electrophysiological criteria for correct diagnosis of NTOS are not controversial. However, surgical indications and types of approaches and techniques reflect the surgeon’s affiliation with specialties dealing with NTOS (vascular, plastic, hand, orthopedic o...
Outcomes after surgery for thoracic outlet syndrome
Journal of Vascular Surgery, 2001
This study determined whether there is an association between psychological and socioeconomic characteristics and the long-term outcome of operative treatment for patients with sensory neurogenic thoracic outlet syndrome (N-TOS). Methods: Clinical records, preoperative psychological testing results, and long-term follow-up questionnaire data were reviewed for consecutive patients who underwent surgery for N-TOS from 1990 to 1999. Multivariate logistic regression models were developed as a means of identifying independent risk factors for postoperative disability. Results: Operative decompression of the brachial plexus via a supraclavicular approach was performed for upper extremity pain and paresthesia with no mortality and minimal morbidity in 170 patients. After an average follow-up period of 47 months, 65% of patients reported improved symptoms, and 64% of patients were satisfied with their operative outcome. However, 35% of patients remained on medication, and 18% of patients were disabled. Preoperative factors associated with persistent disability include major depression (odds ratio [OR], 15.7; P = .02), not being married (OR, 7.9; P = .04), and having less than a high school education (OR, 8.1; P = .09). Conclusion: Operative decompression was beneficial for most patients. Psychological and social factors, including depression, marital status, and education, are associated with self-reported disability. The impact of the preoperative treatment of depression on the outcome of TOS decompression should be studied prospectively.
Physiotherapy Intervention for Neurogenic Thoracic Outlet Syndrome: A Case Study
Journal of emerging technologies and innovative research, 2018
Background: Thoracic outlet syndrome is a result of compression of nerve and blood vessels in the passage between the clavicle and first rib affects 1-2% of population. Neurogenic thoracic outlet syndrome(NTOS) is common than vascular thoracic outlet syndrome(VTOS) and commonly affects middle aged women. Generally, TOS presents with pain, numbness, weakness and occasionally with loss of movements.
Proposed Pathogenesis for a Subgroup of Patients with Neurogenic Thoracic Outlet Syndrome
Journal of Clinical Surgery and Research
Most patients with Neurogenic Thoracic Outlet Syndrome (TOS) have upper extremity pain and paresthesia with normal neurologic examination and objective tests. The purpose of this study was to determine the pathologic nature of the resected first ribs in a subgroup of patients TOS who experienced resolution of symptoms postoperatively. Methods: In a retrospective study, we compared normal human cadaver first ribs (control, C) with first ribs from patients with proven NTOS (N). Ribs were examined for anatomic features. Preoperative and postoperative dynamic Magnetic Resonance Angiograms (MRA) of the affected and contralateral upper extremities were examined. Results: There were 41 first ribs from patients with DNTOS and 12 normal first ribs from human cadavers. In all patients (100%) with DNTOS there was a bony tubercle which corresponded to the area of subclavian vein groove in the normal ribs. Conclusion: A bony tubercle at the site of the subclavian vein groove in patients with DNT...
Prospective Study of the Functional Recovery After Surgery for Thoracic Outlet Syndrome
European Journal of Vascular and Endovascular Surgery, 2008
Objectives. 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. Material and methods. 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. Results. Twenty-three consecutive patients were included in the study, the average age was 37 years (range: 22e54). 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 ¼ 0.01). Conclusions. 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. Ó