Special Issue "Diagnosis and Treatment of Thoracic Outlet Syndrome"

A special issue of Diagnostics (ISSN 2075-4418).

Deadline for manuscript submissions: closed (30 November 2017)

Printed Edition Available!
A printed edition of this Special Issue is available here.

Special Issue Editors

Guest Editor
Prof. Dr. Julie Ann Freischlag

Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
Website | E-Mail
Phone: 916-734-7131
Guest Editor
Dr. Natalia O. Glebova

Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
E-Mail
Phone: 303-724-2696
Fax: 303-724-2693

Special Issue Information

Dear Colleagues,

Thoracic outlet syndrome (TOS) is a spectrum of disorders resulting from the compression of the neurovascular structures within the thoracic outlet. The three main subtypes of TOS are defined by the anatomic structure affected by the extrinsic compression. In the most common subtype—neurogenic TOS—the brachial plexus is compressed and symptoms include pain, arm paresthesias, and sometimes weakness. Venous TOS is characterized by the compression of the subclavian vein and its resultant thrombosis. Arterial TOS is the least common and is distinguished by the compression of the subclavian artery and development of aneurysms or stenoses with distal embolization. Treatment options include physical therapy and surgical first rib resection via the transaxillary or supraclavicular approach. Diagnosis of TOS and appropriate patient selection for intervention are challenging due to the frequent presence of vague symptoms in neurogenic TOS. Due to the relative rarity of this condition, different approaches to diagnosis and management exist, and optimum management strategies continue to evolve.

The primary goals of this Special Issue on “Diagnosis and Treatment of Thoracic Outlet Syndrome” are to describe new and established diagnostic and treatment modalities for TOS; to discuss approaches to complex clinical situations, such as reoperative treatment; and to review new research developments in the field of TOS.

 

Prof. Dr. Julie Ann Freischlag
Dr. Natalia O. Glebova
Guest Editor

Manuscript Submission Information

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Keywords

  • thoracic outlet syndrome

  • neurogenic TOS

  • venous TOS

  • arterial TOS

  • transaxillary first rib resection

  • supraclavicular resection

Published Papers (11 papers)

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Editorial

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Open AccessEditorial The Art of Caring in the Treatment of Thoracic Outlet Syndrome
Diagnostics 2018, 8(2), 35; https://doi.org/10.3390/diagnostics8020035
Received: 17 April 2018 / Revised: 15 May 2018 / Accepted: 15 May 2018 / Published: 19 May 2018
PDF Full-text (156 KB) | HTML Full-text | XML Full-text
Abstract
Those who diagnose and treat patients with thoracic outlet syndrome, especially those patients
with neurogenic thoracic outlet syndrome, have a practice, which needs to include many modalities to
diagnose, treat, and intervene to improve their quality of life for the present and for
[...] Read more.
Those who diagnose and treat patients with thoracic outlet syndrome, especially those patients
with neurogenic thoracic outlet syndrome, have a practice, which needs to include many modalities to
diagnose, treat, and intervene to improve their quality of life for the present and for the future.[...] Full article

Research

Jump to: Editorial, Review

Open AccessArticle A Prospective Evaluation of Duplex Ultrasound for Thoracic Outlet Syndrome in High-Performance Musicians Playing Bowed String Instruments
Diagnostics 2018, 8(1), 11; https://doi.org/10.3390/diagnostics8010011
Received: 26 December 2017 / Revised: 19 January 2018 / Accepted: 22 January 2018 / Published: 25 January 2018
Cited by 3 | PDF Full-text (208 KB) | HTML Full-text | XML Full-text
Abstract
Thoracic outlet syndrome (TOS) is a neurovascular condition involving the upper extremity, which is known to occur in individuals who perform chronic repetitive upper extremity activities. We prospectively evaluate the incidence of TOS in high-performance musicians who played bowed string musicians. Sixty-four high-performance
[...] Read more.
Thoracic outlet syndrome (TOS) is a neurovascular condition involving the upper extremity, which is known to occur in individuals who perform chronic repetitive upper extremity activities. We prospectively evaluate the incidence of TOS in high-performance musicians who played bowed string musicians. Sixty-four high-performance string instrument musicians from orchestras and professional musical bands were included in the study. Fifty-two healthy volunteers formed an age-matched control group. Bilateral upper extremity duplex scanning for subclavian vessel compression was performed in all subjects. Provocative maneuvers including Elevated Arm Stress Test (EAST) and Upper Limb Tension Test (ULTT) were performed. Abnormal ultrasound finding is defined by greater than 50% subclavian vessel compression with arm abduction, diminished venous waveforms, or arterial photoplethysmography (PPG) tracing with arm abduction. Bowed string instruments performed by musicians in our study included violin (41%), viola (33%), and cello (27%). Positive EAST or ULTT test in the musician group and control group were 44%, and 3%, respectively (p = 0.03). Abnormal ultrasound scan with vascular compression was detected in 69% of musicians, in contrast to 15% of control subjects (p = 0.03). TOS is a common phenomenon among high-performance bowed string instrumentalists. Musicians who perform bowed string instruments should be aware of this condition and its associated musculoskeletal symptoms. Full article
Open AccessArticle A Patient-Centered Approach to Guide Follow-Up and Adjunctive Testing and Treatment after First Rib Resection for Venous Thoracic Outlet Syndrome Is Safe and Effective
Received: 2 January 2018 / Revised: 17 January 2018 / Accepted: 19 January 2018 / Published: 23 January 2018
Cited by 1 | PDF Full-text (1912 KB) | HTML Full-text | XML Full-text
Abstract
Controversies in the treatment of venous thoracic outlet syndrome (VTOS) have been discussed for decades, but still persist. Calls for more objective reporting standards have pushed practice towards comprehensive venous evaluations and interventions after first rib resection (FRR) for all patients. In our
[...] Read more.
Controversies in the treatment of venous thoracic outlet syndrome (VTOS) have been discussed for decades, but still persist. Calls for more objective reporting standards have pushed practice towards comprehensive venous evaluations and interventions after first rib resection (FRR) for all patients. In our practice, we have relied on patient-centered, patient-reported outcomes to guide adjunctive treatment and measure success. Thus, we sought to investigate the use of thrombolysis versus anticoagulation alone, timing of FRR following thrombolysis, post-FRR venous intervention, and FRR for McCleery syndrome (MCS) and their impact on patient symptoms and return to function. All patients undergoing FRR for VTOS at our institution from 4 April 2000 through 31 December 2013 were reviewed. Demographics, symptoms, diagnostic and treatment details, and outcomes were collected. Per “Reporting Standards of the Society for Vascular Surgery for Thoracic Outlet Syndrome”, symptoms were described as swelling/discoloration/heaviness, collaterals, concomitant neurogenic symptoms, and functional impairment. Patient-reported response to treatment was defined as complete (no residual symptoms and return to function), partial (any residual symptoms present but no functional impairment), temporary (initial improvement but subsequent recurrence of any symptoms or functional impairment), or none (persistent symptoms or functional impairment). Sixty FRR were performed on 59 patients. 54.2% were female with a mean age of 34.3 years. Swelling/discoloration/heaviness was present in all but one patient, deep vein thrombosis in 80%, and visible collaterals in 41.7%. Four patients had pulmonary embolus while 65% had concomitant neurogenic symptoms. In addition, 74.6% of patients were anticoagulated and 44.1% also underwent thrombolysis prior to FRR. Complete or partial response occurred in 93.4%. Of the four patients with temporary or no response, further diagnostics revealed residual venous disease in two and occult alternative diagnoses in two. Use of thrombolysis was not related to FRR outcomes (p = 0.600). Performance of FRR less than or greater than six weeks after the initiation of anticoagulation or treatment with thrombolysis was not related to FRR outcomes (p = 1). Whether patients had DVT or MCS was not related to FRR outcomes (p = 1). No patient had recurrent DVT. From a patient-centered, patient-reported standpoint, VTOS is equally effectively treated with FRR regardless of preoperative thrombolysis or timing of surgery after thrombolysis. A conservative approach to venous interrogation and intervention after FRR is safe and effective for symptom control and return to function. Additionally, patients with MCS are effectively treated with FRR. Full article
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Open AccessArticle Long-Term Functional Outcome of Surgical Treatment for Thoracic Outlet Syndrome
Received: 14 December 2017 / Revised: 3 January 2018 / Accepted: 11 January 2018 / Published: 12 January 2018
Cited by 2 | PDF Full-text (209 KB) | HTML Full-text | XML Full-text
Abstract
First rib resection for thoracic outlet syndrome (TOS) is clinically successful and safe in most patients. However, long-term functional outcomes are still insufficiently known. Long-term functional outcome was assessed using a validated questionnaire. A multicenter retrospective cohort study including all patients who underwent
[...] Read more.
First rib resection for thoracic outlet syndrome (TOS) is clinically successful and safe in most patients. However, long-term functional outcomes are still insufficiently known. Long-term functional outcome was assessed using a validated questionnaire. A multicenter retrospective cohort study including all patients who underwent operations for TOS from January 2005 until December 2016. Clinical records were reviewed and the long-term functional outcome was assessed by the 11-item version of the Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Sixty-two cases of TOS in 56 patients were analyzed: 36 neurogenic TOS, 13 arterial TOS, 7 venous TOS, and 6 combined TOS. There was no 30-day mortality. One reoperation because of bleeding was performed and five patients developed a pneumothorax. Survey response was 73% (n = 41) with a follow-up ranging from 1 to 11 years. Complete relief of symptoms was reported postoperatively in 27 patients (54%), symptoms improved in 90%, and the mean QuickDASH score was 22 (range, 0–86). Long-term functional outcome of surgical treatment of TOS was satisfactory, and surgery was beneficial in 90% of patients, with a low risk of severe morbidity. However, the mean QuickDASH scores remain higher compared with the general population, suggesting some sustained functional impairment despite clinical improvement of symptoms. Full article
Open AccessArticle Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation
Diagnostics 2017, 7(3), 40; https://doi.org/10.3390/diagnostics7030040
Received: 28 April 2017 / Revised: 26 June 2017 / Accepted: 29 June 2017 / Published: 4 July 2017
Cited by 3 | PDF Full-text (8995 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior
[...] Read more.
Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior scalene. This results in possible impingement of BP nerves within the muscle belly and, therefore, predisposition for nTOS. We hypothesized that some cases of disputed nTOS result from these BP branching variants. We tested the association between BP piercing and nTOS symptoms, and evaluated the capability of ultrasonographic identification of patients with clinically relevant variations. Eighty-two cadaveric necks were first dissected to assess BP variation frequency. In 62.1%, C5, superior trunk, or superior + middle trunks pierced the anterior scalene. Subsequently, 22 student subjects underwent screening with detailed questionnaires, provocative tests, and BP ultrasonography. Twenty-one percent demonstrated atypical BP branching anatomy on ultrasound; of these, 50% reported symptoms consistent with nTOS, significantly higher than subjects with classic BP anatomy (14%). This group, categorized as a typical TOS, would be missed by provocative testing alone. The addition of ultrasonography to nTOS diagnosis, especially for patients with BP branching variation, would allow clinicians to visualize and identify atypical patient anatomy. Full article
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Graphical abstract

Open AccessArticle Creating a Registry for Patients with Thoracic Outlet Syndrome
Diagnostics 2017, 7(2), 36; https://doi.org/10.3390/diagnostics7020036
Received: 3 March 2017 / Revised: 10 May 2017 / Accepted: 24 May 2017 / Published: 17 June 2017
Cited by 1 | PDF Full-text (150 KB) | HTML Full-text | XML Full-text
Abstract
The creation of any patient database requires substantial planning. In the case of thoracic outlet syndrome, which is a rare disease, the Society for Vascular Surgery has defined reporting standards to serve as an outline for the creation of a patient registry. Prior
[...] Read more.
The creation of any patient database requires substantial planning. In the case of thoracic outlet syndrome, which is a rare disease, the Society for Vascular Surgery has defined reporting standards to serve as an outline for the creation of a patient registry. Prior to undertaking this task, it is critical that designers understand the basics of registry planning and a priori establish plans for data collection and analysis. Full article
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Graphical abstract

Review

Jump to: Editorial, Research

Open AccessReview Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions
Diagnostics 2018, 8(1), 21; https://doi.org/10.3390/diagnostics8010021
Received: 19 February 2018 / Revised: 9 March 2018 / Accepted: 15 March 2018 / Published: 20 March 2018
Cited by 3 | PDF Full-text (242 KB) | HTML Full-text | XML Full-text
Abstract
The diagnosis of thoracic outlet syndrome (TOS) has long been a controversial and challenging one. Despite common presentations with pain in the neck and upper extremity, there are a host of presenting patterns that can vary within and between the subdivisions of neurogenic,
[...] Read more.
The diagnosis of thoracic outlet syndrome (TOS) has long been a controversial and challenging one. Despite common presentations with pain in the neck and upper extremity, there are a host of presenting patterns that can vary within and between the subdivisions of neurogenic, venous, and arterial TOS. Furthermore, there is a plethora of differential diagnoses, from peripheral compressive neuropathies, to intrinsic shoulder pathologies, to pathologies at the cervical spine. Depending on the subdivision of TOS suspected, diagnostic investigations are currently of varying importance, necessitating high dependence on good history taking and clinical examination. Investigations may add weight to a diagnosis suspected on clinical grounds and suggest an optimal management strategy, but in this changing field new developments may alter the role that diagnostic investigations play. In this article, we set out to summarise the diagnostic approach in cases of suspected TOS, including the importance of history taking, clinical examination, and the role of investigations at present, and highlight the developments in this field with respect to all subtypes. In the future, we hope that novel diagnostics may be able to stratify patients according to the exact compressive mechanism and thereby suggest more specific treatments and interventions. Full article
Open AccessReview Pectoralis Minor Syndrome: Subclavicular Brachial Plexus Compression
Diagnostics 2017, 7(3), 46; https://doi.org/10.3390/diagnostics7030046
Received: 12 May 2017 / Revised: 29 June 2017 / Accepted: 30 June 2017 / Published: 28 July 2017
Cited by 3 | PDF Full-text (2555 KB) | HTML Full-text | XML Full-text
Abstract
The diagnosis of brachial plexus compression—either neurogenic thoracic outlet syndrome (NTOS) or neurogenic pectoralis minor syndrome (NPMS)—is based on old fashioned history and physical examination. Tests, such as scalene muscle and pectoralis minor muscle blocks are employed to confirm a diagnosis suspected on
[...] Read more.
The diagnosis of brachial plexus compression—either neurogenic thoracic outlet syndrome (NTOS) or neurogenic pectoralis minor syndrome (NPMS)—is based on old fashioned history and physical examination. Tests, such as scalene muscle and pectoralis minor muscle blocks are employed to confirm a diagnosis suspected on clinical findings. Electrodiagnostic studies can confirm a diagnosis of nerve compression, but cannot establish it. This is not a diagnosis of exclusion; the differential and associated diagnoses of upper extremity pain are always considered. Also discussed is conservative and surgical treatment options. Full article
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Open AccessReview Choosing Surgery for Neurogenic TOS: The Roles of Physical Exam, Physical Therapy, and Imaging
Diagnostics 2017, 7(2), 37; https://doi.org/10.3390/diagnostics7020037
Received: 23 May 2017 / Revised: 15 June 2017 / Accepted: 16 June 2017 / Published: 23 June 2017
Cited by 4 | PDF Full-text (425 KB) | HTML Full-text | XML Full-text
Abstract
Neurogenic thoracic outlet syndrome (nTOS) is characterized by arm and hand pain, paresthesias, and sometimes weakness resulting from compression of the brachial plexus within the thoracic outlet. While it is the most common subtype of TOS, nTOS can be difficult to diagnose. Furthermore,
[...] Read more.
Neurogenic thoracic outlet syndrome (nTOS) is characterized by arm and hand pain, paresthesias, and sometimes weakness resulting from compression of the brachial plexus within the thoracic outlet. While it is the most common subtype of TOS, nTOS can be difficult to diagnose. Furthermore, patient selection for surgical treatment can be challenging as symptoms may be vague and ambiguous, and diagnostic studies may be equivocal. Herein, we describe some approaches to aid in identifying patients who would be expected to benefit from surgical intervention for nTOS. We describe the role of physical examination, physical therapy, and imaging in the evaluation and diagnosis of nTOS. Full article
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Open AccessReview Vascular TOS—Creating a Protocol and Sticking to It
Diagnostics 2017, 7(2), 34; https://doi.org/10.3390/diagnostics7020034
Received: 17 March 2017 / Revised: 27 May 2017 / Accepted: 4 June 2017 / Published: 10 June 2017
Cited by 3 | PDF Full-text (6999 KB) | HTML Full-text | XML Full-text
Abstract
Thoracic Outlet Syndrome (TOS) describes a set of disorders that arise from compression of the neurovascular structures that exit the thorax and enter the upper extremity. This can present as one of three subtypes: neurogenic, venous, or arterial. The objective of this section
[...] Read more.
Thoracic Outlet Syndrome (TOS) describes a set of disorders that arise from compression of the neurovascular structures that exit the thorax and enter the upper extremity. This can present as one of three subtypes: neurogenic, venous, or arterial. The objective of this section is to outline our current practice at a single, high-volume institution for venous and arterial TOS. VTOS: Patients who present within two weeks of acute deep vein thrombosis (DVT) are treated with anticoagulation, venography, and thrombolysis. Those who present later are treated with a transaxillary first rib resection, then a two-week post-operative venoplasty. All patients are anticoagulated for 2 weeks after the post-operative venogram. Those with recurrent thrombosis or residual subclavian vein stenosis undergo repeat thrombolysis or venoplasty, respectively. ATOS: In patients with acute limb ischemia, we proceed with thrombolysis or open thrombectomy if there is evidence of prolonged ischemia. We then perform a staged transaxillary first rib resection followed by reconstruction of the subclavian artery. Patients who present with claudication undergo routine arterial duplex and CT angiogram to determine the pathology of the subclavian artery. They then undergo decompression and subclavian artery repair in a similar staged manner. Full article
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Open AccessReview New Diagnostic and Treatment Modalities for Neurogenic Thoracic Outlet Syndrome
Diagnostics 2017, 7(2), 28; https://doi.org/10.3390/diagnostics7020028
Received: 1 March 2017 / Revised: 7 May 2017 / Accepted: 24 May 2017 / Published: 27 May 2017
Cited by 1 | PDF Full-text (209 KB) | HTML Full-text | XML Full-text
Abstract
Neurogenic thoracic outlet syndrome is a widely recognized, yet controversial, syndrome. The lack of specific objective diagnostic modalities makes diagnosis difficult. This is compounded by a lack of agreed upon definitive criteria to confirm diagnosis. Recent efforts have been made to more clearly
[...] Read more.
Neurogenic thoracic outlet syndrome is a widely recognized, yet controversial, syndrome. The lack of specific objective diagnostic modalities makes diagnosis difficult. This is compounded by a lack of agreed upon definitive criteria to confirm diagnosis. Recent efforts have been made to more clearly define a set of diagnostic criteria that will bring consistency to the diagnosis of neurogenic thoracic syndrome. Additionally, advancements have been made in the quality and techniques of various imaging modalities that may aid in providing more accurate diagnoses. Surgical decompression remains the mainstay of operative treatment; and minimally invasive techniques are currently in development to further minimize the risks of this procedure. Medical management continues to be refined to provide non-operative treatment modalities for certain patients, as well. The aim of the present work is to review these updates in the diagnosis and treatment of neurogenic thoracic outlet syndrome. Full article
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