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Neurogenic thoracic outlet syndrome is a chronic, focal lesion of the lower trunk of the brachial plexus or of the T1 and C8 anterior primary rami, often arising due to distortion of neural structures by a fibrous congenital band extending from a C7 transverse process or cervical rib. Accordingly, patients present with chronic weakness or atrophy of the hand, most prominently of the thenar eminence, which receives most innervation from the T1 root. We present clinical, electrophysiologic, and imaging findings in a case of neurogenic thoracic outlet syndrome presenting in an adult with a history most suggestive of congenital brachial plexus palsy, another pathology sharing the mechanism of nerve compression or injury within the supracostoclavicular space. The patient had new right thenar eminence atrophy and a lifelong history of medial forearm sensory deficit and she improved after first rib resection. The convergence of two disorders in the same patient arising in different phases of life illustrates how anatomic or structural variation in this space can predispose to lower brachial plexus injury. [ABSTRACT FROM AUTHOR]

Diagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report the EDX findings in a cohort of patients who underwent surgery for nTOS and also analyze patient-related and intraoperative factors associated with positive EDX findings supportive of nTOS diagnosis. Baseline characteristics of patients, including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement, were gathered and analyzed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison. A total of 30 consecutive patients were included in this study comprising 11 (36.7%) men and 19 (63.3%) women, with a mean age of 44.6 ± 17.6 years. Twenty-two (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and 1 (3.3%) patient with type 2 nTOS. In terms of nTOS pattern, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P < 0.05) were significantly associated with positive EDX findings. Currently, EDX assessment may not be the best modality for diagnosis of nTOS. Interindividual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX. [ABSTRACT FROM AUTHOR]

Background: Spontaneous shoulder-girdle pain and scapular winging/dyskinesis can be caused by several neuromuscular disorders identifiable by electrodiagnostic studies (EDX). We describe a group of adolescent athletes with this clinical presentation but normal EDX, followed by later development of neurogenic thoracic outlet syndrome (NTOS). Methods: We identified patients referred for evaluation of NTOS that had a history of chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX. Each was refractory to conservative management and underwent supraclavicular decompression and brachial plexus neurolysis for NTOS. Functional disability was quantified by Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. Results: There were 5 female patients with a mean age at symptom onset of 14.2 ± 0.4 years, including spontaneous severe pain in the shoulder, scapula, and arm, along with prominent scapular winging/dyskinesis, and normal EDX. Symptoms had persisted for 18.9 ± 4.0 months prior to referral, with pronounced upper extremity disability (mean QuickDASH, 54.6 ± 6.9). By 3 months after surgical treatment for NTOS, all 5 patients experienced near-complete symptom resolution, including scapular winging/dyskinesis, with markedly improved function (mean QuickDASH, 2.2 ± 1.3) and a return to normal activity. Conclusions: A subset of patients with chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX may develop dynamic brachial plexus compression characteristic of NTOS, exhibiting an ischemic "Sunderland-zero" nerve conduction block for which surgical decompression can result in rapid and substantial clinical improvement. The presence of surgically treatable NTOS should be considered for selected patients with long-standing scapular winging/dyskinesis who fail conservative management. [ABSTRACT FROM AUTHOR]

Neurogenic thoracic outlet syndrome (NTOS) is characterized by the compression of the brachial plexus in the thoracic outlet region, caused by various etiologies. We report a case with clinical symptoms and imaging findings from ultrasound and magnetic resonance imaging (MRI) of NTOS due to an elongated C7 transverse process and a fibrous band of the middle scalene muscle, which was confirmed in decompression surgery.

Neurogenic thoracic outlet syndrome (nTOS) is caused by brachial plexus compression in the thoracic outlet. It accounts for 85%–95% of thoracic outlet syndrome (TOS) cases, which may also be caused by compression of the subclavian artery and vein. Compression occurs in the interscalene triangle, costoclavicular space or subpectoralis minor space, with congenital anomalies and repetitive overhead activities as contributing factors. Diagnosis is challenging due to overlapping symptoms with other conditions. Patients commonly report pain, numbness, tingling and weakness in the neck, shoulder and arm, exacerbated by arm elevation. Symptoms related to nTOS may manifest in the distribution of the upper (C5–C6), middle (C7) and lower plexus (C8–T1). Although widely used, provocative tests have varying degrees of sensitivity and specificity and may have high false-positive rates, complicating the diagnosis. Patterns on electrodiagnostic studies provide key diagnostic clues, such as reduced sensory response in the medial antebrachial cutaneous nerve and low compound motor action potential in the median nerve. Imaging techniques like magnetic resonance imaging (MRI), alongside procedures like diagnostic and therapeutic anterior scalene blocks, assist in identifying anatomical abnormalities and predicting surgical outcomes. Management of nTOS involves lifestyle changes, physical therapy, medication and botulinum toxin injections for symptomatic relief. Surgical options may include supraclavicular, transaxillary and infraclavicular approaches, each offering specific benefits based on patient anatomy and surgeon expertise. Minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery, enhance exposure and dexterity, leading to better outcomes. Future research should focus on developing precise diagnostic tools, understanding nTOS pathophysiology, standardising diagnostic criteria and surgical approaches, comparing long-term treatment outcomes and exploring preventive measures to improve patient care and quality of life. Level of Evidence: Level V (Therapeutic) [ABSTRACT FROM AUTHOR]

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

Thoracic outlet syndrome (TOS) is a group of conditions thought to be caused by the compression of neurovascular structures going to the upper extremity. TOS is a difficult disease to diagnose, and surgical treatment remains challenging. Many different surgical techniques for the treatment of TOS have been described in the literature and many reasonable to good outcomes have been reported, which makes it hard for surgeons to determine which techniques should be used. Our aim was to describe the rationale, techniques, and outcomes associated with the surgical treatment of TOS. Most patients in our center are treated primarily through a trans-axillary approach. We will elaborate on the technical details of performing trans-axillary thoracic outlet decompression. The essential steps during surgery are illustrated with videos. We focused on the idea behind performing a trans-axillary thoracic outlet decompression in primary cases. Institutional data on the outcomes of this surgical approach are described briefly. [ABSTRACT FROM AUTHOR]

The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use–related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery. [ABSTRACT FROM AUTHOR]

Background: The recurrence or persistence of symptoms after thoracic outlet decompression (TOD) in patients with neurogenic thoracic outlet syndrome (NTOS) is not uncommon. Some authors have shown significantly better clinical outcomes in patients who underwent TOD with exarticulation of the first rib compared to a group who underwent TOD with preservation of the dorsal portion of the first rib. Several other case series have shown significant improvement after redo surgery with removal of the dorsal first rib remnant. This indicates the importance of the dorsal part of the first rib in NTOS. However, radical exarticulation may not always be necessary. In this study, we tried to answer the question of whether there is a morphological difference in the dorsal part of the first rib in NTOS patients that might help in the diagnosis and treatment of NTOS. Methods: We used the CT data of 21 NTOS patients who underwent TOD surgery and measured the dorsal part of the first rib, then compared them with a quota sample. Results: We found no difference in the dorsal part of the first rib between NTOS patients and the quota sample in our data. Conclusions: As there was no detectable difference, we were not able to use these data to help decide whether exarticulation is necessary in achieving adequate symptom relief. Therefore, we advocate exarticulation of the first rib when TOD is indicated. [ABSTRACT FROM AUTHOR]

Selecting patients who will benefit from first rib resection for neurogenic thoracic outlet syndrome (nTOS) is made difficult by the variety of overlap symptoms with other musculoskeletal, neurogenic and psychological disease. A single diagnostic test is not available, and the diagnosis is typically made based on clinical findings and history. This case series assessed the utility of magnetic resonance imaging (MRI), with the patient's arm placed in a symptom provoking position above the head, as a component of diagnosis nTOS and selection of patients to offer surgery. Outcomes from first rib resection were assessed using the guidelines of The Society for Vascular Surgery for Thoracic Outlet Syndrome. The cases demonstrate that the loss of perineural fat signal on MRI of the brachial plexus with the arm in the provocative position is a useful tool for assessing patients who would benefit from first rib resection for nTOS. [ABSTRACT FROM AUTHOR]

Thoracic outlet syndrome (TOS) involves the compression of neurovascular structures in the thoracic outlet. TOS subtypes, including neurogenic (nTOS), venous (vTOS), and arterial (aTOS) are characterized by distinct clinical presentations and diagnostic considerations. This review explores the incidence, diagnostic challenges, and management of TOS with a focus on the innovative approach of Robotic First Rib Resection (R-FRR). Traditional management of TOS includes conservative measures and surgical interventions, with various open surgical approaches carrying risks of complications. R-FRR, a minimally invasive technique, offers advantages such as improved exposure, reduced injury risk to neurovascular structures, and shorter hospital stays. A comprehensive literature review was conducted to assess the outcomes of R-FRR for TOS. Data from 12 selected studies involving 397 patients with nTOS, vTOS, and aTOS were reviewed. The results indicate that R-FRR is associated with favorable intraoperative outcomes including minimal blood loss and low conversion rates to traditional approaches. Postoperatively, patients experienced decreased pain, improved function, and low complication rates. These findings support R-FRR as a safe and effective option for medically refractory TOS. [ABSTRACT FROM AUTHOR]

Objective: Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions. Design: Retrospective chart review. Setting: Single institution. Participants: Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded. Independent Variables: Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided. Main OutcomeMeasures: Rate of return to play (RTP) to collegiate athletics. Results: Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery. Conclusions: Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks. Clinical Relevance: This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities. [ABSTRACT FROM AUTHOR]

Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.

Thoracic outlet syndrome is an uncommon and controversial syndrome. Three different diagnoses can be made based on the compressed structure, arterial TOS, venous TOS, and neurogenic TOS, though combinations do exist as well. Diagnosing NTOS is difficult since no specific objective diagnostic modalities exist. This has resulted in a lot of controversy in recent decades. NTOS remains a clinical diagnosis and is mostly diagnosed based on the exclusion of an extensive list of differential diagnoses. To guide the diagnosis and treatment of TOS, a group of experts published the reporting standards for TOS in 2016. However, a consensus was not reached regarding a blueprint for a daily care pathway in this document. Therefore, we constructed a care pathway based on the reporting standards for both the diagnosis and treatment of NTOS patients. This care pathway includes a multidisciplinary approach in which different diagnostic tests and additional imaging techniques are combined to diagnose NTOS or guide patients in their treatment for differential diagnoses. The aim of the present work is to discuss and explain the diagnostic part of this care pathway. [ABSTRACT FROM AUTHOR]

Compression of the neurovascular structures of the upper extremity as they pass through the thoracic outlet result in thoracic outlet syndrome. The myriad of symptoms associated with the syndrome vary based on the structure(s) compressed: the subclavian artery/vein or the inferior trunk of the brachial plexus. This is a common site of compression especially in the presence of upper extremity injury, overuse or anatomical abnormalities. Majority of patients present with neurogenic pain and weakness; herein, we present the case of a patient with symptoms of both arterial and neurogenic compression caused by aberrant anterior scalene anatomy. These patients are excellent surgical candidates for first rib resection and anterior scalenectomy. A transaxillary approach offers the clinician an adequate window to identify anatomical abnormalities intraoperatively and safely excise the first rib and anterior scalene muscle. [ABSTRACT FROM AUTHOR]

Objectives: Thoracic outlet syndrome (TOS) is a group of disorders caused by impingement of the neurovascular structures at the thoracic outlet. Neurogenic TOS (nTOS), which is thought to be caused by a compression of the brachial plexus, accounts for more than 90% of the cases. Although treatment for nTOS is successful through physiotherapy and/or surgical decompression, little is known about the impact of psychosocial factors, namely, major depressive disorder (MDD), on postoperative outcomes such as non-routine discharge (NRD). Here, we assess whether MDD predicts the type of discharge following nTOS surgical intervention. Methods: A retrospective analysis of the National Inpatient Sample database from the years 2005-2018 was performed. Using the International Classification of Diseases Clinical Modification, Ninth and Tenth revisions, patients who underwent a surgical intervention for nTOS were identified. Our primary outcome was to investigate the effects of MDD on nTOS patient disposition status after surgical management; secondary outcomes included analysis of total hospital charges and length of stay. NRD was defined as anything beyond discharge home without healthcare services. Univariate and multivariable logistic regression analyses were conducted to assess MDD and other potential independent predictors of NRD and prolonged hospital stay (> 2 days) following surgical intervention. Results: A total of 6099 patients were identified: 596 (9.77%) patients with MDD and 5503 (90.23%) without MDD. On average, patients with MDD were older (39.6 ± 12.0 years vs. 36.0 ± 13.0 years; p < 0.001), female (80.7% vs. 63.5%; p < 0.001), white (89.6% vs. 85.6%; p = 0.030), and on Medicare (9.6% vs 5.2%; p < 0.001). Univariate and multivariable logistic regression models identified MDD as an independent risk factor associated with a higher risk of NRD (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI], 1.0-2.2). Additionally, chronic kidney disease (aOR, 2.60; 95% CI, 1.2-5.4), postoperative complications (aOR, 1.87; 95% CI, 1.2-2.9), and Medicare (aOR, 2.95; 95% CI, 1.9-4.7) were statistically significant predictors for higher risk of NRD. However, MDD was not associated with prolonged hospital stay (aOR, 1.00; 95% CI, 0.8-1.2) or higher median of total charges (MDD group: $27,867 vs. non-MDD group: $28,123; p = 0.799). Conclusion: Comorbid MDD was strongly associated with higher NRD rates following nTOS surgical intervention. MDD had no significant impact on length of hospital stay or total hospital charges. Additional prospective research is necessary in order to better evaluate the impact of MDD in patients with nTOS. [ABSTRACT FROM AUTHOR]

Objective: Scalene blocks are part of both the diagnostic and treatment algorithm for patients presenting with symptoms of neurogenic thoracic outlet syndrome (nTOS). However, there is a paucity of data on the utility of scalene botulinum toxin injection (BTI) before surgical decompression. We sought to determine the impact of BTI with and without surgery at a multidisciplinary referral center. Design: Retrospective cohort study. Setting: Single institution tertiary academic center, 2011 to 2020. Patients: Seventy-seven consecutive patients. Interventions: Scalene muscle BTI for nTOS with or without surgical decompression. Main Outcome Measures: Pain relief and Quick Disability of the Arm, Shoulder and Hand (QDASH) score. Results: Seventy-seven patients, with a mean age of 31.4 years, had BTI for symptoms of nTOS. All patients underwent pretreatment physical therapy through the Edgelow protocol for a mean duration of 3.4 months. However, 72.7% had dynamic vascular compression on duplex ultrasound with provocative maneuvers and 85.7% had a positive physical examination finding. After BTI, 77.9% reported subjective relief, confirmed by an improved QDASH disability score. Thirty-one patients (40.3%) then went on to have further persistent symptoms and proceeded with first rib resection. After BTI + Surgery, 96.8% reported symptomatic relief and had a median QDASH score improvement of 21 (range: 10-40), with all reaching minimal clinically important differences in the QDASH score after combination therapy. Conclusions: In this reported series of chemodenervation in patients with nTOS, BTI is helpful in alleviating symptoms before definitive surgical decompression. BTI followed by first rib resection provides additional symptom improvement over BTI alone. [ABSTRACT FROM AUTHOR]

Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS. We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation. A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88). Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS%5fcalc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery. [ABSTRACT FROM AUTHOR]

Purpose: The failure rate for operative decompression in neurogenic thoracic outlet syndrome (NTOS) is high compared to more distal nerve compression syndromes, such as cubital or carpal tunnel syndrome. Herein, we aimed to determine if a more radical approach, namely costovertebral exarticulation of the first rib, may improve the postoperative results in patients with NTOS. Methods: From October 2002 to December 2020, 105 operative decompressions in 95 patients were evaluated; in 10 cases, decompressions were performed bilaterally. We presented the clinical outcomes of 59 exarticulations compared to those of 46 conventional resections. Evaluation was performed at a minimum of one year post-operation using the DASH questionnaire. Results: The exarticulation group presented with significantly better clinical outcomes (two-sample t-test assuming unequal variances, p < 0.001). Conclusions: This study showed that significantly better results were obtained when exarticulation of the first rib was performed in patients with NTOS. This finding supports the hypothesis that, in certain cases, the proximal portion of the first rib plays a pivotal role in the pathogenesis of NTOS. [ABSTRACT FROM AUTHOR]

Neurogenic thoracic outlet syndrome (NTOS) is characterized by the compression of the brachial plexus in the thoracic outlet region, caused by various etiologies. We report a case with clinical symptoms and imaging findings from ultrasound and magnetic resonance imaging (MRI) of NTOS due to an elongated C7 transverse process and a fibrous band of the middle scalene muscle, which was confirmed in decompression surgery., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

The objective of this retrospective analysis of prospectively collected data was to assess the test-retest reliability and validity of the elevated arm stress test (EAST) as measured by the duration in a cohort of patients with suspected neurogenic thoracic outlet syndrome (NTOS). Patients evaluated for NTOS between January 2017 and September 2018 were identified. Test-retest reliability by the intraclass correlation coefficient was determined for duration of the EAST. For the validity analysis, patients were classified in a proven NTOS group or a symptomatic control group without NTOS using the Society for Vascular Surgery reporting standards and the outcome of thoracic outlet decompression surgery. A receiver operating characteristic curve was made for the duration of EAST. The area under the curve, and positive and negative predictive values were calculated for the EAST. In total, 428 patients with suspected NTOS were retrospectively analyzed. Of these patients, 61 were excluded because no EAST data was available. Another 101 patients were excluded because of inconclusive reporting standards, arterial or venous TOS, or because thoracic outlet decompression surgery was not performed or had a negative result. The validity analysis in the remaining 266 patients showed an area under the curve for the duration of the EAST of 0.62 (95% confidence interval, 0.55-0.69). The positive predictive value of the duration ranged between 65% and 66%, and the negative predictive value between 53% and 58%. For the test-retest reliability analysis, 118 patients were excluded because they performed only one measurement in a 100-day time period. Analysis in the remaining 148 patients showed an intraclass correlation coefficient value of 0.65 (95% confidence interval, 0.55-0.74) for duration. The EAST measured by the duration showed a moderate test-retest reliability, but the discriminative value was low in the diagnosis of NTOS. The outcome of the EAST measured by the duration should be used with caution. The elevated arm stress test (EAST) has an important role in the current Society for Vascular Surgery reporting standards for neurogenic thoracic outlet syndrome (NTOS), but the reliability and diagnostic value of the EAST is debated. This study shows the limitations of the conventional EAST in NTOS diagnostics and follow-up. The performance of the EAST measured by the duration showed a moderate test-retest reliability, but the discriminative value was low in the diagnosis of NTOS. This indicates that this provocation test should be used with caution in NTOS diagnostics. [ABSTRACT FROM AUTHOR]

Patients with neurogenic thoracic outlet syndrome report pain and upper-limb weakness. They complain about weakness occurring on the entire upper-limb, especially at the hand and the shoulder levels. Hydraulic dynamometers can reliably assess the strength of the hand, and isokinetic shoulder testing can provide accurate and reliable evaluations of the rotators strength. Yet, isokinetic proximal assessment needs expensive tools, whereas hydraulic hand dynamometers are cheap and easy to use. We aimed to assess the correlation between the isokinetic shoulder strength and the hand grip and the key pinch strength. The grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. Isokinetic rotators strength tests were performed using a Humac Norm® dynamometer at 60 and 180°/s. One-hundred and thirty patients had been included, 72% of women, mean age of 39.8 ± 9.5. Symptomatic hands presented a strength deficit of 12.2% on the grip (p < 0.0001) and 10% on the key pinch (p = 0.01). Isokinetic strength was lower on the symptomatic shoulders at 60 and 180°/s concerning medial rotators [â'10.3 and â'8.8%, respectively (p = 0.02)] and lateral rotators [â'10.8 and â'10%, respectively (p = 0.04 and p = 0.03)]. There was a moderate correlation between the grip strength of the symptomatic upper-limbs and the isokinetic rotators strength (p < 0.001). The key pinch strength wasmoderately correlated to the isokineticmedial and lateral rotators strength at 60°/s (p < 0.001). Hand dynamometers could prove useful during medical consultations or in outpatient management to assess upper-limb overall weakness, but isokinetic measurement remains the gold standard for a precise evaluation. [ABSTRACT FROM AUTHOR]

Christine Lim,1 Yasaman Kavousi,2 Ying Wei Lum,2 Paul J Christo1 1Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD, USACorrespondence: Paul J Christo Email pchristo@jhmi.eduAbstract: Neurogenic thoracic outlet syndrome (NTOS) represents a disorder believed to involve compression of one or more neurovascular elements as they exit the thoracic outlet. This comprehensive literature review will focus on the occurrence, classification, etiology, clinical presentation, diagnostic measures, and both nonoperative and operative therapies for NTOS. NTOS represents the most common subtype of thoracic outlet syndrome and can significantly impair quality of life. Botulinum toxin injection into the anterior scalene muscle, or even the middle scalene or pectoralis minor muscles, can reduce the symptoms of this syndrome. The best available evidence for botulinum toxin therapy to the cervicothoracic muscles supports the value of this treatment for reducing pain in the affected extremity, and for an approximate duration of 2 months or more. Surgical approaches and newer minimally invasive surgical approaches offer high rates of improvement in select centers.Keywords: thoracic outlet syndrome, neurogenic thoracic outlet syndrome, anterior scalene muscle, brachial plexus, compression neuropathy

Patients with neurogenic thoracic outlet syndrome report pain and upper-limb weakness. They complain about weakness occurring on the entire upper-limb, especially at the hand and the shoulder levels. Hydraulic dynamometers can reliably assess the strength of the hand, and isokinetic shoulder testing can provide accurate and reliable evaluations of the rotators strength. Yet, isokinetic proximal assessment needs expensive tools, whereas hydraulic hand dynamometers are cheap and easy to use. We aimed to assess the correlation between the isokinetic shoulder strength and the hand grip and the key pinch strength. The grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. Isokinetic rotators strength tests were performed using a Humac Norm® dynamometer at 60 and 180°/s. One-hundred and thirty patients had been included, 72% of women, mean age of 39.8 ± 9.5. Symptomatic hands presented a strength deficit of 12.2% on the grip (p < 0.0001) and 10% on the key pinch (p = 0.01). Isokinetic strength was lower on the symptomatic shoulders at 60 and 180°/s concerning medial rotators [−10.3 and −8.8%, respectively (p = 0.02)] and lateral rotators [−10.8 and −10%, respectively (p = 0.04 and p = 0.03)]. There was a moderate correlation between the grip strength of the symptomatic upper-limbs and the isokinetic rotators strength (p < 0.001). The key pinch strength was moderately correlated to the isokinetic medial and lateral rotators strength at 60°/s (p < 0.001). Hand dynamometers could prove useful during medical consultations or in outpatient management to assess upper-limb overall weakness, but isokinetic measurement remains the gold standard for a precise evaluation.

Thoracic outlet syndrome is an uncommon and controversial syndrome. Three different diagnoses can be made based on the compressed structure, arterial TOS, venous TOS, and neurogenic TOS, though combinations do exist as well. Diagnosing NTOS is difficult since no specific objective diagnostic modalities exist. This has resulted in a lot of controversy in recent decades. NTOS remains a clinical diagnosis and is mostly diagnosed based on the exclusion of an extensive list of differential diagnoses. To guide the diagnosis and treatment of TOS, a group of experts published the reporting standards for TOS in 2016. However, a consensus was not reached regarding a blueprint for a daily care pathway in this document. Therefore, we constructed a care pathway based on the reporting standards for both the diagnosis and treatment of NTOS patients. This care pathway includes a multidisciplinary approach in which different diagnostic tests and additional imaging techniques are combined to diagnose NTOS or guide patients in their treatment for differential diagnoses. The aim of the present work is to discuss and explain the diagnostic part of this care pathway.

Neurogenic thoracic outlet syndrome (NTOS) is one of the most controversial clinical entities in medicine. Several major case series have shown promising results of surgery; however, solid scientific evidence is lacking. The aim of this trial was to objectify the effect of thoracic outlet decompression (TOD). A single centre (high volume, tertiary TOS centre), non-blinded, randomised controlled trial was conducted with parallel group design. Patients with a diagnosis of NTOS refractory to conservative therapy were randomised to one of two intervention arms, receiving either a transaxillary thoracic outlet decompression (TA-TOD) or continued conservative treatment. After three months, the conservative treated group was also offered a TA-TOD. The primary outcome was change in Disability of the Arm, Shoulder and Hand (DASH) questionnaire score. Secondary outcomes were changes in Cervical Brachial Symptoms Questionnaire (CBSQ), TOS disability scale, and quality of life scores. Outcomes were assessed at baseline, three, six, and 12 months after inclusion. Fifty patients were enrolled in this trial: 25 in the TA-TOD group and 25 in the continued conservative treatment group. Follow up was completed in 24 and 22 patients, respectively. At three months, there was a statistically significant difference in DASH scores (TA-TOD: mean 45.15, 95% confidence interval [CI] 38.08 – 52.21; conservative treatment: mean 64.92, 95% CI 57.54 – 72.30; p <.001). All patients in the conservative treatment group applied for surgery three months after randomisation. After surgery of the conservative treatment group, there was no statistically significant difference between the groups for all primary and secondary outcome measures. TA-TOD for NTOS is effective in patients who do not respond to conservative treatment. Trial register number: NL63986.100.17. [ABSTRACT FROM AUTHOR]

Chronic compression of the inferior trunk of the brachial plexus can result in severe pain and progressive atrophy and weakness of the musculature of the forearm and hand, known as Gilliatt-Sumner hand (GSH). The objective of treatment for these patients is to stop further atrophy and pain. Restoration of motor function has been thought to be seldom achieved. The aim of the present contemporary case series was to describe the diagnosis, treatment, and outcomes of surgery for GSH. All patients referred between January 2017 and May 2021 with visible signs of a GSH were included. Visible GSH signs were defined as muscle atrophy of the abductor digiti minimi, abductor pollicis brevis, and/or interosseous musculature. All the patients had undergone additional electrodiagnostic (ED) assessments and high-resolution ultrasound (HRUS) studies. All the patients with a diagnosis of GSH had undergone thoracic outlet decompression (TOD) surgery using a transaxillary or supraclavicular approach. The outcomes were measured using the thoracic outlet syndrome disability scale, cervical brachial symptom questionnaire, and disability of the arm, shoulder, and hand scale scores and patient-reported outcomes of motor function, measured using a numerical rating scale (NRS). The standardized elevated arm stress test (sEAST) was used to assess the patients' motor function before and after TOD surgery. A total of 20 patients had been referred to our center with visible signs of a GSH. The clinical examination showed atrophy of the abductor digiti minimi, abductor pollicis brevis, and interosseous musculature in all 20 patients. The ED assessments showed plexopathy of the lower brachial plexus in all the patients. HRUS showed an indented inferior trunk of the brachial plexus (so-called wedge-sickle sign) in 18 patients (90%). Of the 20 patients, 17 had undergone TOD surgery (15 transaxillary TOD and 2 supraclavicular TOD). Three patients had refrained from surgery. The median follow-up interval was 15.0 months (interquartile range, 14.0 months). The thoracic outlet syndrome disability scale score had improved significantly (preoperatively: mean, 6.31; 95% confidence interval [CI], 5.49-7.13; postoperatively: mean, 4.25; 95% CI, 2.80-5.70; P =.026). The same improvement was seen for the cervical brachial symptom questionnaire scores (preoperatively: mean, 77.75; 95% CI, 66.63-88.87; postoperatively: mean, 42.65; 95% CI, 24.77-60.77; P =.001) and disability of the arm, shoulder, and hand scale scores (preoperatively: mean, 59.13; 95% CI, 51.49-66.77; postoperatively: mean, 40.96; 95% CI, 24.41-57.51; P =.032). The NRS score for muscle weakness and sEAST score showed no statistically significant differences before and after TOD for the whole group (mean preoperative NRS score for muscle weakness, 6.22; 95% CI, 4.31-8.14; mean postoperative NRS score for muscle weakness, 5.11; 95% CI, 3.25-6.97; P =.269). However, four patients (23.52%) had reported a ≥50% decrease in the NRS score for muscle weakness and a minimum increase of 20% in the total and average force using the sEAST. The NRS for numbness showed a statistically significant decrease for the whole group (preoperatively: mean, 5.67; 95% CI, 4.18-7.16; postoperatively: mean, 3.33; 95% CI, 1.37-5.29; P =.029). A combination of physical examination, ED assessments, and HRUS studies can differentiate GSH in the differential diagnosis. HRUS appears to have an advantage over ED studies in confirming GSH by visualization of compression of the brachial plexus. TOD surgery will stop the progressive muscle atrophy and significantly reduce neurogenic thoracic outlet syndrome complaints, and, in some patients, motor function will recover. [ABSTRACT FROM AUTHOR]

Background: Neurogenic thoracic outlet syndrome typically presents with paresthesia, pain, and impaired strength in the neck, shoulder, and arm, and is typically a diagnosis of exclusion. This condition is caused by compression of the brachial plexus, typically by a bony or soft tissue anomaly present congenitally and influenced by repetitive motion or significant trauma. Treatment typically involves removal of the first rib and anterior scalene to decompress the thoracic outlet and relieve stress to the brachial plexus if the patient has failed conservative treatment with physical therapy and lifestyle modifications. Case Presentation: We present a case of neurogenic thoracic outlet syndrome with arterial compression treated surgically via a transaxillary first rib and cervical rib resection in a patient with bilateral cervical ribs and osteochondromas of the ribs. [ABSTRACT FROM AUTHOR]

Thoracic outlet syndrome (TOS) can be a career-threatening injury for Major League Baseball (MLB) pitchers, often requiring surgical management. The purpose of this study is to determine the efficacy of surgical management for TOS as a function of return to play and quantitative pitching metrics. 27 MLB pitchers underwent surgical treatment for TOS between January 2001 and December 2017. Analysis of pre and postoperative pitching metrics were used to assess the effect of surgery on 20 pitchers who returned to pitch in MLB. All pitching metrics were compared via assessing performance two years prior to surgery and two years after surgery. For 20 pitchers who returned to pitch, MLB pitching metrics of earned run average (ERA), walks plus hits per innings pitched (WHIP), wins above replacement (WAR), and average fastball velocity were used to assess a pitcher's ability to return to preoperative performance level. Of the 27 pitchers, 20 pitchers were diagnosed with neurogenic thoracic outlet syndrome (NTOS) and seven with venous thoracic outlet syndrome (VTOS). The average age of onset of TOS was 28.6 years. There was no significant difference between the age of onset between the NTOS and VTOS populations (p = 0.272). Of the 27 pitchers, 20 (74.1%) were able to return to MLB play at a mean of 297 days (range, 105–638 days) after surgery. Pitching metrics demonstrated that pitcher ERA remained inferior postoperatively compared to baseline preoperative performance (3.66 vs 4.50, p = 0.03). Fastball velocity (p = 0.94) and strike percentage (p = 0.50) were equivalent to pre-injury performance. 74% of professional pitchers who undergo surgical intervention for TOS are able to return to play at the MLB level. With regards to performance, the majority of metrics were unchanged from prior to surgery, indicating return at a similar functional level. [ABSTRACT FROM AUTHOR]

Introduction Despite advancements in medical and surgical management, thoracic outlet syndrome (TOS) remains a complex and often understudied condition with variable outcomes. This study assessed hospitalization rates and outcomes, including patient characteristics, mortality risks, and healthcare costs associated with TOS hospitalizations. Methods We analyzed elective and nonelective hospitalization data for TOS between 2010 and 2021 from the National Inpatient Sample (NIS) and National Readmission Databases (NEDS) and classified the data into neurogenic, venous, and arterial subtypes using the International Classification of Diseases (ICD) diagnostic and procedural codes. The primary endpoint of this study was hospital-related all-cause mortality. Secondary outcomes included hospitalization costs, length of hospital stay, in-hospital complications, and 30-day readmissions. The odds of primary and secondary outcomes were assessed using multivariate hierarchical logistic regression analysis. Cox proportional hazard models were used to assess predictors of 30-day readmission. Results A total of 37,174 hospitalizations for TOS were identified in the NIS datasets included in our study. Of these, 7,397 (19.9%) were for venous TOS, 3,346 (9.0%) were for arterial TOS, and 26,430 (71.1%) were for neurogenic TOS. Patients with arterial TOS were significantly older (median age: 66; interquartile range (IQR): 54-77 years) compared with venous (63 years; IQR: 50-74) or neurogenic TOS (58 years; IQR: 53-73; P < 0.001). Scalenectomy, with or without first rib resection, was performed in 18% (6,692) of TOS hospitalizations, mainly in neurogenic TOS (16.7%, 4,405 cases) compared to venous (13%, 964 cases) and arterial TOS (38.1%, 1,273 cases). The median duration of hospitalization for TOS was three days (IQR: two to six days). The mean cost of care for all TOS hospitalizations was $107,481 (standard deviation (SD): $4,158). The mean cost of hospitalization was significantly higher for vascular TOS than neurogenic TOS ($114,824 vs. $98,278; P < 0.001) and for venous TOS than arterial TOS ($119,042 vs. $110,606; P = 0.041). Overall, in-hospital mortality was 446 (1.2%). Mortality rates were significantly higher in venous TOS compared to arterial TOS (263 (59.1%) vs. 182 (40.7%); adjusted hazards ratio (AHR): 1.56; 95% confidence interval (CI): 1.26-3.56; P = 0.041). Black race (adjusted Odds ratio (aOR): 3.86, 95% CI: 8.80-16.90; P = 0.043), deep vein thrombosis (aOR: 1.68, 95% CI: 1.18-2.03; P = 0.018), previous coronary artery bypass graft (aOR: 2.37, 95% CI: 1.84-3.92; P = 0.003), pulmonary embolism (aOR: 2.63, 95% CI: 1.23-3.45; P < 0.001), and postoperative sepsis with multiorgan failure (aOR: 3.33, 95% CI: 2.13-6.40; P = 0.032) were correlated with mortality. Conclusion Hospitalization duration and mortality rates for TOS are generally low, though vascular TOS has a longer length of stay and higher mortality than neurogenic TOS. Mortality was significantly associated with Black race, deep vein thrombosis, previous coronary artery bypass grafting (CABG), pulmonary embolism, and postoperative septicemia., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Uwumiro et al.)

This article presents a unique diagnostic test for the neurogenic thoracic outlet syndrome (nTOS). nTOS is one of the most misdiagnosed and controversial medical problems; the diagnosis is clinical, and there are few specific diagnostic criteria for this condition. We would like to share this unique diagnostic modality, the Tafler test, with medical professionals. The Tafler test helps diagnose nTOS, differentiate it from cervical radiculopathy and carpal tunnel syndrome, and effectively tailor treatment for its symptoms. The following case series aims to describe several patients with nTOS who had failed previous treatment with surgery, physical therapy, and analgesics. The implementation of the Tafler test as a treatment modality in combination with osteopathic manipulative treatment (OMT) and physical therapeutic modalities led to significant improvements in treatment efficiency., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Tafler et al.)

Background: Thoracic Outlet Syndrome (TOS) is a common condition caused by compression of neurovascular vessels traveling through the thoracic outlet. There are three categories of TOS, arterial (aTOS), neurogenic (nTOS), and venous (vTOS). These commonly present with pain in the neck, upper extremity weakness, paresthesia, swelling, and discoloration. TOS can be caused by a cervical rib, which is a rare and usually benign anomaly. This typically results in aTOS. Case: This case, however, presents a 13-year-old male patient with nTOS caused by a cervical rib. He presented with weakness and pain of his right arm and a prior history of a partial neck mass resection. A physical exam revealed a firm supraclavicular mass and X-ray images confirmed the diagnosis of nTOS. Surgical resection of the anomalous rib was performed via a supraclavicular approach. Due to the difficulty of this operation, a multidisciplinary surgery team was formed, ensuring a positive outcome for the patient. Conclusions: To our knowledge only two case reports of nTOS caused by a cervical rib compression of the brachial plexus exist. One was iatrogenic and the other treated non-surgically. Due to this lack of knowledge as well as the debate on surgical versus non-surgical treatment of TOS, this case report seeks to bolster the current literature with a positive outcome to correction of a rare presentation.