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Microaxial left ventricular assist devices (mLVADs) have traditionally been placed through a transfemoral or transaxillary arterial approach. Transfemoral access is restrictive, significantly limiting postoperative patient ambulation. Transaxillary placement is preferred but not feasible in a subset of patients due to small arterial diameter or tight angulation of the thoracic outlet. Transcarotid delivery has been utilized for other cardiovascular device deployment with good success; however, this approach has not been described for mLVAD support. We present a case series of transcarotid placement of mLVADs in cases where a transaxillary and transfemoral approach was not feasible. From May 2017 to April 2019, six patients in cardiogenic shock required mLVAD support achieved via a transcarotid approach. Technical success was achieved in all patients. One patient was directly weaned from mLVAD support and two patients died on mLVAD support. Escalation to venoarterial extracorporeal membrane oxygenation (VA-ECMO) was required for three patients, two of whom subsequently died. There were no bleeding or valvular complications related to device placement, and no obvious or known neurologic complications related to mLVAD support. Transcarotid placement of mLVADs expands the utility of these devices as an alternative to traditional support strategies or prohibitive arterial anatomy; however, further study is needed to determine its efficacy.

Background There are several surgical treatment options for neurogenic thoracic outlet syndrome (n-TOS). However, the first rib has been shown to be the common denominator of all TOS forms and the degree of its resection has been shown to correlate with the long-term success. Objective To demonstrate the feasibility of posterior upper rib excision (PURE) and report early outcomes. Methods Nine patients presented with signs and symptoms of n-TOS. Preoperative evaluation involved physical and neurological examination, arm visual analog score (VAS), cervical X-ray, magnetic resonance imaging (MRI) of the cervical spine, and brachial plexus MRI. All patients were operated at a single institution by a single surgeon. Postoperatively, clinical and radiological data were collected. Results There were 2 men and 7 women in the study with 10 procedures performed. The age range was 18 to 45 with mean of 36.6 yr. Mean preoperative arm visual analog scale score was 7.8. The patients underwent posterior upper rib excision (PURE) by a single surgeon. One patient had bilateral surgery. The causes of TOS were fibrous bands, enlarged C7 transverse processes, narrow scalene triangle, and accessory ribs. All patients improved after surgery in terms of arm pain and quality of life. Postoperative mean visual analog scale score was 1.1 at 6 mo. In addition, neurological examination was normal at 6 mo postoperatively and all patients returned to their previous full-time jobs. Conclusion Posterior upper rib excision is a feasible surgical option for n-TOS.

Study design A retrospective radiographic study. Objective To investigate the reliability of using magnetic resonance imaging (MRI) to measure thoracic outlet parameters and whether supine MRI could supersede upright x-ray in measuring these parameters. Summary of background data On x-ray, overlapped soft and bony tissues make sternum contour invisible. Thus, measuring thoracic inlet (TI) alignment on x-ray may be inaccurate. MRI could clearly show anatomy around TI. Methods A total of 124 adolescents with idiopathic thoracolumbar/lumbar scoliosis were recruited. The visibility of T1 upper endplate and the upper end of sternum on the lateral standing x-ray films was rated. For patients with moderate or good clarity forT1 upper endplate and the upper end of sternum on x-ray films, thoracic inlet angle (TIA), T1 slope (T1S), and neck tilt (NT) were measured by 3 observers on standing x-ray films and supine MR images, respectively. Intraclass correlation coefficients (ICC) were used to determine the intraobserver, interobserver, and method reliability. The paired t test was performed to compare the measurements between the 2 methods. The correlation coefficients between the 2 methods were analyzed by regression analysis. Results The visibility of TI region on x-ray films was unsatisfactory, whereas all the landmarks were clear on MR images. Only 81 patients' x-ray films were graded as moderate or good visibility in the TI region. Both the intraobserver ICC and interobserver ICC were better in the MRI set than in the x-ray set among all the observers for 3 TI parameters. The paired t test demonstrated that no significant difference was noted in terms of TIA, T1S, and NT (P=0.572, 0.203, and 0.637, respectively). Regression analysis demonstrated high correlation coefficients for TIA, T1S, and NT (R=0.612, 0.629, and 0.722, respectively). Conclusions MRI serves as a good substitute for x-ray scans with regard to the measurement of TI alignment, with superior reliability.

Subclavius posticus muscle is a supernumerary anatomical variation of the subclavius muscle. The aim of this study was to show the possible contribution of the posticus muscle in the development of unilateral thoracic outlet syndrome (TOS) in overhead athletes, presenting hypertrophy of the dominant arm due to their sport activity. Reported here are 2 young overhead athletes complaining pain, paresthesia, weakness in the dominant upper limb, although presenting none of the main shoulder and neurological disorders. After developing subclavian vein thrombosis, TOS was suspected and finally diagnosed by dynamic magnetic resonance angiography, which also showed bilateral subclavius posticus muscle in both patients. Despite bilateral subclavius posticus, TOS was only evident in the dominant limb in which the association of hypertrophy of lateral cervical muscles, resulting from the overhead sport activity, to the subclavius posticus likely led to a significant reduction of the upper thoracic outlet space.

Presence of a cervical rib results from overdevelopment of the seventh cervical vertebrae.(1-3) The cervical rib along with scalene muscles can cause neurogenic thoracic outlet syndrome.(4,5) Rib resection is typically done via anterior approach, using either supraclavicular or transaxillary route.(6,7) We present an operative video detailing supraclavicular resection of a cervical rib causing neurogenic thoracic outlet syndrome with direct decompression of the lower trunk of the brachial plexus. The patient presented with severe symptoms including hand atrophy. We were able to directly visualize the rib and resect it, along with scalene musculature. We present 3-mo follow-up data noting clinical improvement in neuropathic symptoms.

Thoracic outlet syndrome (TOS) is a blanket term encapsulating many different clinical entities. Neurologic or neurogenic TOS (NTOS) is its main contributor, but it remains a complicated and sometimes controversial entity. NTOS incorporates numerous types, etiologies, clinical presentations, diagnostic findings, and therapeutic modalities. This article reviews the spectrum of disease within the thoracic outlet that affects the brachial plexus, with a special emphasis on the commonly afflicted sports medicine patient.

Venous thoracic outlet syndrome is a relatively rare condition. One variety that is related to effort, often referred to as Paget-Schroetter syndrome, is seen more often in persons who are athletic or occupationally active. This condition can have significant morbidity if left untreated. Diagnosis is best undertaken with duplex ultrasound or venogram. The current standard for treatment includes catheter-directed thrombolysis with surgical correction of the thoracic outlet and subclavian vein with some variability of this depending upon the presentation. Some cases may require anticoagulation for approximately 12 wk. Return to play should be expected in successfully corrected cases that include a collaborative rehabilitation program.

OBJECTIVE Thoracic outlet syndrome (TOS) is defined as a constellation of clinical symptoms caused by the entrapment of neurovascular structures (subclavian vessels and the brachial plexus) en route to the upper limb via the superior thoracic outlet. Nonspecific neurogenic TOS is not easy to diagnose because there is no investigational technique that has proven to be the diagnostic gold standard. DESIGN In this study, our aim was to investigate the role of provocative F response in the diagnosis of nonspecific neurogenic TOS. F wave analysis of median and ulnar nerves in neutral and provocative maneuvers was carried out in 21 patients with a clinical diagnosis of nonspecific neurogenic TOS and in 15 healthy volunteers. RESULTS All findings were within reference range in both groups, and no statistical difference was noted among subject groups, with or without provocative maneuvers. CONCLUSIONS We conclude that the nonspecific neurogenic TOS is a temporary compression process that does not result in a structural damage on the nerve; therefore, significant electrophysiologic changes are not elicited.

Background Thoracic outlet artery injuries due to blunt trauma are uncommon. Exposure of these arteries is associated with significant morbidity and mortality. An endovascular approach is a less invasive alternative approach for these technically challenging injuries. Methods A retrospective review of patients who presented with blunt traumatic injuries to the innominate, subclavian, and axillary arteries between 1998 and 2009 was performed. Demographic data, concomitant injuries, preoperative workup, treatment, and outcomes were recorded. Results During the study period, 34 patients (80% men) meeting selection criteria were admitted (11 innominate, 16 subclavian, and 7 axillary). Management was nonoperative in 6, open in 16, and endovascular in 12 patients. In the latter group, eight patients had successful stent-graft insertions. These were approached in an antegrade femoral or retrograde brachial fashion. In three cases of complete artery transaction, both methods were used. Shorter operative time (149 minutes vs. 230 minutes; p = 0.03) and less blood loss (50 mL vs. 1,225 mL; p = 0.03) were seen in the endovascular group compared with the open repair group. There was a trend for less blood transfusion, but it was not significant (0 median units vs. 4.5 median units; p = 0.3). Hospital length of stay was shorter (19 days vs. 29 days; p = 0.4). Conclusions Covered stents are a feasible alternative to open repair in the multiply injured blunt trauma patients with thoracic outlet arterial injuries. This can be used in the damage control setting as it offers shorter operative time, less blood loss, and overall less morbidity to the patient. Long-term follow-up is needed.

OBJECTIVE: Methods were invented that made it possible to image peripheral nerves in the bod y and to image neural tracts in the brain. The history, physical basis, and dyadic tensor concept underlying the methods are reviewed. Over a 15-year period, these techniques—magnetic resonance neurography (MRN) and diffusion tensor imaging—were deployed in the clinical and research community in more than 2500 published research reports and applied to approximately 50 000 patients. Within this group, approximately 5000 patients having MRN were carefully tracked on a prospective basis. METHODS: A uniform Neurography imaging methodology was applied in the study group, and all images were reviewed and registered b y referral source, clinical indication, efficacy of imaging, and quality. Various classes of image findings were identified and subjected to a variety of small targeted prospective outcome studies. Those findings demonstrated to be clinically significant were then tracked in the larger clinical volume data set. RESULTS: MRN demonstrates mechanical distortion of nerves, hyperintensity consistent with nerv e irritation, nerve swelling, discontinuity, relations of nerves to masses, and image features revealing distortion of nerves at entrapment points. These findings are often clinically relevant and warrant full consideration in the diagnostic process. They result in specific pathological diagnoses that are comparable to electrodiagnostic testing in clinical efficacy. A review of clinical outcome studies with diffusion tensor imaging also shows convincing utility. CONCLUSION: MRN and diffusion tensor imaging neural tract imaging have been validated as indispensable clinical diagnostic methods that pro vide reliable anatomic pathological information. There is no alternative diagnostic method in many situations. With the elapsing of 15 years, tens of thousands of imaging studies, and thousands of publications, these methods should no longer be considered experimental.

OBJECTIVE: The muscular axillary arch is a musculotendinous structure that arises from the latissimus dorsi muscle and crosses the axilla before inserting to the humerus, brachial fascia, or coracoid process. Case reports have described the neurovascular compression symptoms caused by this anatomic variant and have reported that the symptoms can be relieved by division of the muscle. However, there has been little information published regarding this topic in the neurosurgical literature. METHODS: We evaluated 70 axillary dissections in 35 cadavers to assess for the presence of this anomaly. RESULTS: The muscular axillary arch was identified unilaterally in 3 (8.6%) of the 35 cadavers. All 3 arches arose from the anterior border of the latissimus dorsi muscle and inserted at a point along a line extending from the coracoid process to the intertubercular groove deep to the insertion of the pectoralis major muscle. All 3 arches crossed over the neurovascular bundle in the axilla. CONCLUSION: Compression by the muscular axillary arch should be considered in the differential diagnosis of patients with thoracic outlet and hyperabduction syndromes.

Acute vascular insufficiency in the upper limb suggests the possibility of an embolic phenomenon1-3. The most common source of upper-extremity emboli is from the subclavian artery, with less likely potential sources being the superficial palmar arch and cardiac vessels1. Thoracic outlet compression represents the most frequently reported cause of subclavian arterial disease1,2,4, and arterial-related problems associated with thoracic outlet compression, although extremely uncommon, have also been reported5. In addition to the detection of historical features and the performance of provocative maneuvers during the clinical examination, the use of noninvasive magnetic resonance angiography has been reported to be particularly helpful in the diagnosis of thoracic outlet compression6,7. We report an unusual clinical case in which a peripheral embolic disorder was identified in a young adult with an associated history of recurrent shoulder instability as well as a deformity of the first rib. Although magnetic resonance angiography failed to identify the pathology in the subclavian artery, it was subsequently confirmed by arteriography. The patient was informed that data concerning this case would be submitted for publication. Ahealthy nineteen-year-old college freshman had pain in the right wrist after being struck by a football during a friendly competition. The symptoms persisted for several weeks. When the patient returned home from college, he was evaluated by a hand specialist who suspected the diagnosis of extensor carpi ulnaris tendinitis and treated the condition with a corticosteroid injection. The wrist pain continued and became associated with diffuse numbness, alteration in temperature, and pain extending up the forearm. Of note is the fact that, following a traumatic ipsilateral shoulder dislocation at twelve years of age, the patient had experienced three to four episodes of shoulder subluxation during strenuous activities, although …

Thoracic outlet syndromes (TOS) can be classified as vascular-type TOS (arterial and venous), true neurologic TOS, and the more recently coined disputed neurologic TOS (disputed N-TOS). True neurologic TOS is a rare entity that presents clinically with wasting of the small muscles of the hand, with established pathoanatomy that responds to surgical treatment aimed at preventing progressive neurologic deterioration. Vascular TOS has specific objective clinical findings consistent with arterial compromise, venous compression, or both. Disputed N-TOS, on the other hand, is a vague, subjective pain syndrome with no specific underlying pathoanatomy, and no objective clinical and electrophysiologic findings. It is often treated with varied surgical approaches ranging from transaxillary first rib resection, resection of the scalenus anticus and various other muscles in the vicinity, to resection of various fibromuscular bands and ligaments and neurolysis of the supraclavicular brachial plexus. The results at long term follow-up are generally not encouraging in the posttraumatic disputed N-TOS group covered under a worker's compensation policy. Disputed N-TOS has become the most common indication for surgery for TOS in the United States, accounting for at least 90% of all operations. Diagnosis of disputed N-TOS cannot be made in the presence of the more common true distal peripheral entrapment neuropathies, such as carpal tunnel syndrome and cubital tunnel syndrome, even though it is tempting to bundle it and justify its diagnosis and existence with the clinical concept of double-crush injuries.

Summary: Brachial plexus surgical treatment, though complex, has evolved substantially over the past 40 years as technology and microsurgical techniques have continued to improve. Options for repair, depending on the type and level of injury, include neurolysis, direct repair, nerve grafting, nerve transfer, arthrodesis, and muscle and tendon transfer. A comprehensive review of the indications, preoperative work-up, and surgical approach is presented, along with outcomes, complications, and postoperative management. We conclude with a discussion of the evaluation and management of patients with thoracic outlet syndrome.

STUDY DESIGN In a study investigating the correlation between a set of designed criteria and judgments of surgical experience, 100 cervical magnetic resonance images from different patients were used. OBJECTIVES To demonstrate reliable and reproducible anatomic measurements that can aid spine surgeons in selecting surgical approaches for anterior spine fusion in the cervicothoracic region. SUMMARY OF BACKGROUND DATA Surgical approaches to the cervicothoracic junction vary among surgeons. Whereas sternotomy provides maximum exposure, less extensive approaches are preferred to minimize surgical trauma, provided surgical goals are not compromised. No quantitative criteria currently exist to determine before surgery the least invasive surgical approach for sufficiently exposing pertinent anatomy. METHODS Thirteen geometric variables designed to be clinically practical and to expose important anatomic relations were used to evaluate 100 sagittal scout cervical magnetic resonance image sequences. An experienced spine surgeon independently rated each image for the most appropriate surgical approach to the C5-T2 region. The ratings were tested for interrater reliability using a second spine surgeon. After testing for interrater and intrarater reliability, the geometric measurements were correlated with the surgeon's selected surgical approaches for each intervertebral segment (P < 0.05). RESULTS Instrument manubrial thoracic distances, reflecting standardized heights of intervertebral discs above or below the superior tip of the manubrium, were the most reliable, reproducible, and correlative with the choice of surgical approach. All the measurements but one, the instrument manubrial thoracic distance for T1/T2, demonstrated interrater and intrarater reliability, with an interclass correlation of at least 0.70. The primary surgeon-investigator indicated the anterior approach with sternotomy (n = 3) or the transverse cervical approach (n = 97) for the C7/T1 exposure, and the anterior approach with sternotomy (n = 43) or the transverse cervical approach (n = 57) for the T1/T2 exposure. The interrater questionnaire reliability results indicated statistical agreement between the primary surgeon-investigator and the second cervical spine surgeon at all vertebral segments evaluated. Instrument manubrial thoracic distances showed the strongest significant correlation with the surgical approach, demonstrating a statistical power of 1. For the C7/T1 exposure, the instrument manubrial thoracic distance for C7/T1 was 1.9 +/- 2 cm (95% confidence interval [CI] = 1.41 to 2.22) for the transverse cervical approach, and -3.3 +/- 1.3 cm (95% CI = -4.79 to -1.75)] for the anterior approach with sternotomy. The instrument manubrial thoracic distance measurements for C5/C6, C6/C7, and T1/T2 also showed nonoverlapping 95% confidence intervals for the transverse cervical versus the anterior approach with sternotomy for the C7/T1 exposure. For the T1/T2 exposure, all four instrument manubrial thoracic distance measurements again showed statistically significant differences between approaches, with nonoverlapping 95% confidence intervals and a statistical power of 1. In addition, the measurements elaborating the anterior-to-posterior distance of the thoracic outlet and the measurements of the angle between the planes of the intervertebral disc and the sternum also showed statistically significant differences between approaches for the T1/T2 segment, with a statistical power of at least 0.9. CONCLUSIONS Strong correlations exist between objective measurements and the choice of surgical approach for anterior spine fusion. Among investigated anatomic relations, the instrument manubrial thoracic distance correlated most reliably with the surgeons' choice of the anterior approach. Such objective measurements represent tools that cervical spine surgeons can use to determine the surgical approach.

Although most clavicular fractures in adults heal with no or minimal persistent symptoms, the rate of symptomatic malunion or nonunion of displaced fractures of the clavicle has ranged from 3% to 5% in a number of reports1-5. In a previous study of fifteen clavicular nonunions and malunions2, the senior one of us (J.F.C.) found that seven patients experienced intermittent or chronic symptoms associated with impingement on the thoracic outlet. These symptoms occurred most often when the patient abducted the shoulder or elevated the arm to an overhead position. Such patients are sometimes treated for cervical disc disease or, as in this case report, managed with resection of the first rib without relief of symptoms. We and others3,5-7 have observed that the diagnosis and the surgical correction of thoracic outlet syndrome secondary to clavicular malunion may be delayed. Because clavicular fractures usually heal without sequelae, patients who present with late symptoms may be considered malingerers or compensation seekers7-10. Also, some physicians may advise against surgical correction because of the long-standing tradition of nonoperative treatment of clavicular fractures11,12 and because of an appropriate concern that operative treatment of the malunited fracture is associated with a risk of damage to the underlying neurovascular structures12,13. Fatal subclavian vascular injuries from a fractured clavicle have been occasionally reported13-16. The purpose of this report is to present a case of thoracic outlet syndrome produced by a clavicular malunion and to illustrate our technique of clavicular osteotomy to correct the problem. A thirty-six-year-old man who operated heavy equipment sustained a fracture to the right clavicle and subsequently was diagnosed as having thoracic outlet syndrome. Because of persistent pain, numbness, and inability …

Tc-macroaggregated albumin (MAA) uptake in the vertebrae has been reported in central vein occlusion, although its sternal uptake is rarely seen. We present a case in which Tc-MAA SPECT/CT showed spotty uptake in the sternum. Contrast-enhanced CT revealed marked narrowing of the left subclavian vein at the thoracic outlet with a developed collateral vein running, in the left anterior chest subcutaneous tissue, between the sternum and left axilla. In this case, IV injection of Tc-MAA from the left forearm probably led to bone marrow uptake in the sternum due to retrograde venous flow through the collateral vein.

SUMMARY BACKGROUND DATA: During the past five decades, significant improvements have been made in the diagnosis and treatment of thoracic outlet syndrome (TOS) secondary to sports activities, breast implants, or median sternotomy. METHODS, RESULTS, AND CONCLUSIONS: Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular decompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurysm or occlusion was treated successfully in 240 patients. Dorsal sympathectomy was performed concomitantly in 71 patients for occlusion or embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained pain syndrome and causalgia that did not improve with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal sympathectomy. The use of hyaluronic acid significantly reduced recurrent scarring.

Background: Incomplete removal of the first rib in operations intended to decompress the thoracic outlet is often seen after the single transaxillary approach (often leaving a posterior stump) or supraclavicular techniques (leaving an anterior stump). The former may also cause neurogenic and vascular injuries because the exposure is often poor in attempting complete removal of the first rib posteriorly and the surgeon faces a significant struggle. Study Design: A new operative procedure is described entailing two stages using two separate incisions: a transaxillary and posterior incision done at the same sitting that accomplishes complete removal of the first rib with less risk. This combined approach is done with the help of a new arm holder device during the transaxillary stage followed by a small incision behind the trapezius ridge for posterior access to the rib. Results: I present 33 patients in whom this operation was implemented, with a cure rate of 79%, improvement in 15%, and unchanged in 6%, with no complications or mortality. Technical details are presented. Conclusions: A double-incision approach is recommended as a safer and more effective method to accomplish complete removal of the first rib than are single transaxillary supraclavicular techniques in cases with thoracic outlet obstruction.

Thoracic outlet syndrome, although uncommon in children, may be precipitated during rapid growth in adolescence, especially in association with a cervical rib. Four children exhibited the aching, tiredness in the limb, and occasional paresthesia in adolescence. Two had a cervical rib requiring removal, after which the symptoms disappeared. The other two were treated nonoperatively with shoulder-strengthening exercises and avoidance of posturing that elicited the symptoms. It is proposed that in a child, the anatomy of the thoracic outlet is constantly changing with growth and development of the structures that form the thoracic outlet, as well as those that traverse the outlet itself. A conservative approach to these symptoms is warranted in the first instance to allow further growth and remodeling of the thoracic outlet, which may be sufficient to accommodate the nerve roots and brachial plexus and alleviate the symptoms. Excision of the cervical rib in the presence of increasing and chronic symptoms can be quite beneficial.

OBJECTIVE: To record symptoms and signs, operative findings, and long-term outcome in operated and nonoperated patients with the diagnosis of thoracic outlet syndrome after a motor vehicle accident. DESIGN: Descriptive prospective study. SETTING: Pain clinic population in the Toronto Hospital (Western Division), Toronto, Ontario, Canada. PATIENTS: Thirty-two patients diagnosed as having thoracic outlet syndrome after injuries sustained in a car accident (based on specific symptoms and signs as well as exclusion of other disorders generating brachialgia). INTERVENTIONS: Conservative management versus transaxillary or supraclavicular exploration of the thoracic outlet. OUTCOME MEASURES: Pain/symptom relief. RESULTS: Most patients presented with pain and paresthesiae, but conspicuous discoloration of the symptomatic extremity was seen in 41%. Osseous anomalies were seen in 22% of the patients in simple neck x-rays. Vascular studies were abnormal in 24% of tested patients. During transaxillary first rib resection in 15 patients, 87% were found to have musculotendinous and less often osseous anomalies compromising primarily the lower trunk of the brachial plexus. Long-term follow up demonstrated very good pain relief (based on patients' estimates) only in 47% of the operated patients and 20% of the conservatively treated patients. Reoperation was necessary in six cases through a supraclavicular decompression with only one patient experiencing substantial improvement with long-term follow-up. The difficulties in diagnosis as well as reasons for failures of conservative and surgical management are discussed, and the authors' current protocol for diagnosis and management is presented. Language: en

A 69-year-old man was found to have a loud continuous bruit in the neck. Duplex carotid ultrasound showed high-velocity turbulent flow in the dilated and pulsatile right internal jugular vein. Computed tomography angiogram demonstrated markedly enlarged right internal jugular vein with a posteriorly located arteriovenous communication. Invasive angiography revealed an arteriovenous fistula originating from the right subclavian artery draining into the dilated and tortuous right internal jugular vein. An endovascular coil was successfully deployed in the fistula tract. Subclavian artery-internal jugular vein fistula is rare. Our case is most likely iatrogenic towing to previous central venous cannulation during coronary bypass grafting. The anatomic challenge of this fistula, being located in the thoracic outlet, makes endovascular repair particularly favourable.

Background The incidence of scapular winging is unclear, but it may be more common than previously thought. It can be difficult to diagnose because the presenting complaint and physical examination may direct the practitioner toward more common shoulder and neck conditions. Ongoing scapular dysfunction may result in inappropriate or failed surgery. Our goals were to (1) describe the common misdiagnoses (instability, labral abnormality, impingement, and cervical spine disease), the clinical scenarios and examination findings leading to diagnostic difficulty, the definitive treatment options available, and the clinical outcomes and complications; and (2) review the important aspects of the patient history, physical examination of the scapula, and associated studies necessary to make the correct diagnosis of scapular winging. Methods We reviewed the literature relative to, and our own experience with, the treatment of scapular winging and identified a series of patients with this condition who were initially misdiagnosed with other shoulder or spine abnormalities. In our literature search, only nine clinical studies reported on a series of patients with scapular winging that was initially misdiagnosed or had a delay in diagnosis (n = 53 patients). We examined these cases for presenting or preexisting diagnoses and for surgical procedures that had been performed before the diagnosis of scapular winging. Results For patients ultimately diagnosed with scapular winging, initial presentations and diagnoses included rotator cuff disorders (20%), glenohumeral instability (8%), peripheral nerve disorders (6%), cervical spine disease (6%), acromioclavicular disorders (6%), thoracic outlet syndrome (4%), and unknown or unspecified (41%). The most common surgical procedures performed before definitive scapular winging treatment were rotator cuff (22%), instability (22%), nerve (14%), acromioclavicular (12%), cervical spine (5%), and thoracic outlet (4%) procedures. Conclusions Clinically, scapular winging often mimics more common shoulder abnormalities and can result in unnecessary or unsuccessful surgical procedures. Diagnosis can be readily achieved with simple physical examination and specific provocative maneuvers in conjunction with electromyography and nerve conduction studies. Prompt diagnosis and recognition can avoid substantial shoulder dysfunction.

A 32-year-old woman presented with a 5-year history of left shoulder pain, medial hand and forearm numbness, and progressive hand weakness and atrophy. Electrodiagnostic studies were characteristic of true neurogenic thoracic outlet syndrome,1 and a chest X-ray showed bilateral elongated C7 transverse processes. High-resolution ultrasound studies revealed compression of the left lower trunk (LT) between a fibrous band and artery (figure, A). Magnetic resonance neurography (figure, B) and operative exploration (figure, C) confirmed the ultrasound findings. Clinical improvement was noted following surgical neurolysis of the LT. High-resolution ultrasound may be a useful and quick bedside tool to identify causative structural pathology in this classic neuromuscular disorder.

Clavicular fractures are common, representing 2.6% to 4% of all fractures and 44% of those in the shoulder girdle1,2. Midshaft fractures, which account for approximately 80% of clavicular fractures, historically were treated nonoperatively, even in the presence of substantial displacement2,3. Recent studies have shown that the rate of nonunion with displaced midshaft fractures treated nonoperatively may be as high as 15%3-5. Furthermore, clavicular osteosynthesis is reported to be a safe and reliable treatment of midshaft clavicular fractures, with midshaft nonunion rates as low as 2.2%5. Despite the success of clavicular osteosynthesis, compression of neurovascular structures of the thoracic outlet has been reported as a noteworthy complication6. We describe the results of an osteosynthesis of a clavicular fracture nonunion that resulted in a postoperative acute dynamic thoracic outlet syndrome. In addition, we present an intraoperative diagnostic test that can be performed to avoid such a complication. To our knowledge, there are no previously reported cases of acute dynamic thoracic outlet syndrome following clavicular osteosynthesis for fracture nonunion. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A forty-five-year-old right-hand-dominant healthy man sustained a closed mid-diaphyseal clavicular fracture secondary to a fall thirteen years earlier, and was treated nonoperatively at another institution. He presented to our clinic for evaluation of a painful atrophic fracture nonunion (Fig. 1). Physical examination demonstrated a normal radial pulse with no right upper-extremity sensory or motor deficits, and the patient was advised to undergo operative treatment of the nonunion with an intramedullary device and corticocancellous allograft chips (Fig. 2). Postoperatively, he developed progressive implant failure (Fig. 3) and had no signs of union due to compliance issues, which included performing push-ups in …

Medical (n 5 47) 20 (43%) 12 (26%) 14 (30%) 35 (75%) 9 (19%) Surgical (n 5 118) 23 (20%) 10 (9%) 10 (9%) 23 (20%) 4 (3%)

During 1968-1973, 122 patients with 126 arterial injuries were treated. In 94 instances (90 patients), these injuries involved extremities. Systolic blood pressure was below 90 mm Hg upon admission in 55.6% of all patients and 37.7% of those with injuries to arteries of the extremities. The decision for operative exploration and repair of arteries of extremities was based largely on clinical grounds (shock, loss of pulse). Preoperative arteriography was needed infrequently, while operative angiography was nearly routine. Although several cases of late revascularization or traumatic thrombosis of renal artery have been reported, hypertension complicates the postoperative period, and early, aggressive approach is essential. Mortality was 10.6%, from aortic injuries. There were no deaths among patients with arterial injuries distal to inguinal ligament or thoracic outlet. The amputation rate from reconstruction failure was 1.1%, none occurring in the last 3 years of the series. The high patency rate and lack of evidence of pulmonary embolization suggest that associated venous injuries be repaired routinely. Arterial injuries represent ideal lesions (normal arterial wall with excellent run-in and run-off). Prompt treatment of shock and early, proper management of patients' mechanical disruptions will salvage many lives and most limbs.

Between 1966 and 1975, 425 patients with thoracic outlet symptoms were studied: 146 operative procedures were carried out in 103 of these patients. Division of soft tissues, only, in 129 cases offered relief of symptoms. In 10 cases bone resections (four cervical ribs, one second rib, one clavicle, and four first ribs) were done in an attempt to relieve the outlet problems. Preoperative evaluation included neurological consultation, x-rays of the neck and chest, detailed non-invasive oscillographic recordings of arterial flow during various outlet maneuvers, angiograms and in many instances electromyograms and nerve conduction studies. The axillary surgical approach to be various compression areas was preferred in that hyperabduction of the arm and costoclavicular maneuvers could be carried out under direct observation of the involved vessels. Accurate appraisal of the compression point could be assessed before and after the involved structure was divided or removed. Complications were limited to two hematomas postoperatively, and transient paralysis of the diaphragm in one patient. In all patients the vessel compression was relieved at the time of operation. In no instance was the first rib emperically removed as a "cure all" procedure. Six months following operation, patients were reevaluated and all except 8 patients (11 operative procedures) had relief of symptoms for a success rate of 92.5%.

Transaxillary Approach for First Rib Resection to Relieve Thoracic Outlet Syndrome DAVID ROOS; Annals of Surgery

The neurosurgeon is often consulted in cases of shoulder-arm pain that have as their cause compression of the neurovascular bundle in the thoracic outlet. He or she should, therefore, be familiar with the clinical presentation and differential diagnosis of this syndrome, as well as the electrographic and angiographic findings that may be present in this condition. If the diagnosis is established and the patient proves refractory to conservative treatment with physical therapy, medication, exercises, and modification of activities, the neurosurgeon may elect to perform scalenotomy, paying particular attention to the fibrous bands and anomalies in the scalene group of muscles that may play a major role in the compression of the brachial plexus and brachial vessels. Resection of a cervical rib or anomalous first rib may also prove necessary. Primary arterial and venous problems, which occur in approximately ten percent of these cases, are best left to the thoracic surgeon, but the transthoracic approach plus sympathectomy, if indicated, may be carried out by the neurosurgeon if he has been trained in this procedure. Emotional problems are often present in patients with this syndrome, but careful selection of surgical candidates will lead to a favorable outcome in 80% or better of such cases.

Preface H.I. Machleder Part I: The Vascular Examination 1. The Initial Clinical Examination H.I. Machleder 2. Noninvasive Vascular Laboratory Assessment D.S. Sumner 3. Angiography in the Diagnosis and Management of Vascular Disorders of the Upper Extremity A.S. Gomes Part II: The Cumulative Trauma Disorders 4. Introduction to Neurovascular Compression Syndromes at the Thoracic Outlet H.I. Machleder 5. Neurogenic Thoracic Outlet Compression Syndrome H.I. Machleder 6. Electrophysiological Evaluation of Patients with Cervicobrachial Pain Syndromes S.E. Jordan, H.I. Machleder 7. Somatosensory Evoked Potentials in the Assessment of Upper Extremity Neurovascular Compression M.R. Nuwer 8. Evaluation and Treatment of Repetitive Motion Disorders of the Upper Extremity in Office Workers and Musicians E.F. Pascarelli 9. Arterial Compression at the Thoracic Outlet H.I. Machleder 10. Venous Compression at the Thoracic Outlet H.I. Machleder 11. Surgical Approaches to Primary and Recurrent Thoracic Outlet Compression Syndromes D.B. Ross 12. The Management of Neuropathic Pain J.P. Schwartz, A. Belzberg Part III: Intrinsic and Aquired Disorders of the Upper Extremity Vessels 13. Small Artery Disease of the Upper Extremity K. Williamson, J.M. Edwards, L.M. Taylor, G.J. Landry, J.M. Porter 14. The Axillo-Subclavian and Brachial Arteries H.I. Machleder 15. Hemangiomas an Vascular Malformation of the Upper Extremity P.E. Burrows, T. Laor 16. Complications of Vascular Access in the Upper Extremity L.L. Powell, S.E. Wilson Part IV: Vascular Manifestations Systemic Disorders 17. Upper Extremity manifestations of Systemic Vascular Disorders D.J. Klashman, S.C. Ng, D.H. Kono, H.E. Paulus 18. Current Techniques in Thoracoscopic Sympathectomy S.S. Ahn, K.M. Ro, J.P. Johnson

The elusive diagnosis of thoracic outlet syndrome and its controversial relationship with carpal tunnel syndrome is examined by a retrospective study of 1000 cases of carpal tunnel syndrome and 63 cases of thoracic outlet syndrome. Thoracic outlet syndrome is rare and difficult to accurately diagnose. The signs and symptoms of thoracic outlet syndrome lack specificity. The ancillary tests used to evaluate patients with expected thoracic outlet compression also add little objectivity to the diagnostic process. Carpal tunnel syndrome is still as inaccurately diagnosed as thoracic outlet syndrome. Carpal tunnel syndrome can easily be confused with thoracic outlet syndrome when it presents with shoulder pain. The spontaneous occurrence of these two syndromes in a single patient is extremely rare. The relationship of carpal tunnel and thoracic syndromes does not represent an example of the double crush syndrome. In this study, the incidence of combined carpal tunnel and thoracic outlet syndromes approached zero. Surgical treatment of the carpal tunnel syndrome alleviated pain from the upper extremity in the majority of patients.

A five year experience with 20 patients who had penetrating vascular injuries of the thoracic outlet was reviewed. A median sternotomy with extension into the right neck was used to explore six patients with right subclavian vascular injuries. With injuries to the origin of the left common carotid artery, repair was accomplished through a median sternotomy combined with a left anterior thoracotomy in one patient and through a left posterolateral thoracotomy in the other. Injury to the left subclavian vessels occurred in five patients and was exposed through a left anterolateral thoracotomy combined with a supraclavicular incision in four patients and through a supraclavicular incision with clavicular resection in one patient. Axillary vessel trauma generally was managed with an extrathoracic incision only. The two deaths in this series were due to postoperative respiratory complications (mortality rate of 10%). Twenty arteries were repaired and all were patent on follow-up examination. Associated neural and venous injury caused significant morbidity in 28% and 10% of patients, respectively. As a result of this experience we continue to recommend an extended median sternotomy for repair of right-sided cervicothoracic vascular injury. Anterior or posterolateral thoracotomy combined with a supraclavicular incision is advocated for trauma to left-sided vessels of the thoracic outlet. When possible, injured veins should be repaired rather than ligated.

Thirty-five cases of thoracic outlet syndrome complicating whiplash or cervical strain injury were studied. Thirty cases had confirmation by the demonstration of slowed ulnar nerve conduction velocity (UNCV) through the thoracic outlet. Two distinct groups of patients were found. An acute group, seen an average of 3 1/2 months post injury, had severe neck pain with often mild or incidental thoracic outlet syndrome. A chronic group, with symptoms persisting more than 2 years after cervical injury, often had thoracic outlet symptoms as the predominant complaint. This study suggests that the arm aches and parethesias seen in association with both acute and chronic cervical strain injury are most often secondary to thoracic outlet syndrome.

Many painful conditions affect the shoulder. They can be divided into those extrinsic or intrinsic to the shoulder. The extrinsic conditions include disorders of the cervical spine and thoracic outlet, as well as postural conditions. Intrinsic lesions include acute and chronic calcific tendinitis, bicipital tenosynovitis, arthritis, and adhesive capsulitis. Each disorder has a characteristic clinical pathologic set of diagnostic features, arthrographic picture, and treatment requirements.

When major injuries occur to the thoracic outlet, common practice is to obtain an arteriogram without other clinical evidence of vascular injury, because of the purported high association of thoracic outlet trauma and vascular injuries, including ruptured aortae. In order to evaluate this association, a review was undertaken of all patients admitted to a major hospital over 5.5 years who underwent angiography or other evaluative measures as a result of their thoracic outlet trauma. There were no great vessel or aortic injuries without overt clinical criteria. Angiography for aortic and great vessel injury is unnecessary unless there is a widened mediastinum or other overt clinical indications of vascular injury. Judicious use or avoidance of angiography is therefore encouraged for multiple reasons.

Upper extremity symptoms of arterial or venous origin are a rarer manifestation of the thoracic outlet syndrome than those caused by brachial plexus compression. Since the authors' original report in 1967, a better understanding of the necessity for detailed history and physical examination preoperatively and advances in angiography and computed tomography have made the selection of patients for thoracic outlet decompression and vascular reconstruction more reliable. Refinement in vascular surgical techniques and the advent of effective thrombolytic therapy have made the results of therapy more consistent. First rib resection and scalenectomy are curative for the majority of patients whose symptoms are caused by compression of the brachial plexus. Removal of the embologenic focus with vascular reconstruction and thoracodorsal sympathectomy are generally required in the presence of subclavian artery compression or aneurysm producing peripheral emboli. In patients who have venous compromise, thrombectomy or thrombolytic therapy and relief of subclavian venous compression may minimize future disability.