Intermediate and Long-term Outcomes Following Surgical Decompression of Neurogenic Thoracic Outlet Syndrome in an Adolescent Patient Population

Abstract

Background: Although the diagnosis of thoracic outlet syndrome (TOS) is often missed, outcomes from surgical intervention significantly improve patient satisfaction. This article seeks to highlight patient characteristics, intraoperative findings, and both short and long-term outcomes of thoracic outlet decompression in the adolescent population. Methods: A retrospective chart review of patients between the ages of 13 and 21 years with a clinical diagnosis of neurogenic thoracic outlet syndrome (NTOS) who were treated surgically between 2000 and 2015 was performed. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient-reported outcome scores, including Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Cervical Brachial Symptom Questionnaire (CBSQ), and NTOS index, were obtained for a cohort of patients with follow-up ranging from 2 to 15 years. Results: The study population consisted of 54 patients involving 61 extremities. The most common procedures included neurolysis of the supraclavicular brachial plexus (60, 98.4%), anterior scalenectomy (59, 96.7%), and middle scalenectomy (54, 88.5%). First rib resection (FRR) was performed in 28 patients (45.9%). Long-term outcomes were collected for 24 (44%) of 54 patients with an average follow-up of 69.5 months (range, 24-180 months). The average VAS improved from 7.5 preoperatively to 1.8 postoperatively. The average SANE increased from 28.9 preoperatively to 85.4 postoperatively. The average postoperative scores were 11.4 for the QuickDASH, 27.4 for the CBSQ, and 17.2 for the NTOS index. Subgroup analysis of patients having FRR (28, 45.9%) demonstrated no difference in clinical outcome measures compared with patients who did not have FRR. Conclusion: Surgical treatment of NTOS in adolescent patients has favorable intermediate and long-term outcomes.

Histologic evidence of brachial plexus compression sites at the thoracic inlet and variations in formation of the lower trunk in cadavers

“…Though first rib resections with anterior scalenectomies have proven to be an effective method to treat neurologic TOS, a rib-sparing approach has been described in the literature and may reduce length of hospital stay and other 30-day complications (Jubbal et al, 2019;Maqbool et al, 2019). Recent literature by Ransom et al show no difference in intermediate-and long-term outcomes in adolescents who underwent first rib resection and those who did not (Ransom et al, 2022). However, rib resection may be indicated in those with recurrent neurologic TOS symptoms (Annest et al, 2021).…”

Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes

“…The level of functional disability was assessed using the 11-item version of the Disabilities of the Arm, Shoulder, and Hand survey instrument (QuickDASH), which has been designed and validated for a variety of upper extremity disorders including NTOS. 2,6,9,12,16,17…”

“…In experienced hands, first rib resection, scalenectomy, and brachial plexus neurolysis via supraclavicular and/or transaxillary approaches have yielded excellent results. [7][8][9][10][11][12][13][14][15][16][17] However, it is estimated that anywhere from 5% to 30% of patients can experience minimal improvement or later symptom recurrence following surgical intervention. [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] Previous studies have shown that incomplete first rib resection, reattachment of residual scalene muscle, and fibrous scarring around the brachial plexus are most frequently implicated in persistent or recurrent NTOS.…”

“…In experienced hands, first rib resection, scalenectomy, and brachial plexus neurolysis via supraclavicular and/or transaxillary approaches have yielded excellent results. 7-17 However, it is estimated that anywhere from 5% to 30% of patients can experience minimal improvement or later symptom recurrence following surgical intervention. 18-33…”

Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series

“…11-14 Surgical decompression can be safely conducted through transaxillary, supraclavicular, or posterior approaches, with excellent early results and sustained outcomes. 15-25…”