Neurogenic thoracic outlet syndrome: Bringing order to chaos

Illig, Karl A.

doi:10.1016/j.jvs.2018.04.030

Cited by 16 publications

(8 citation statements)

References 3 publications

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“…Thoracic outlet syndrome (TOS) is one of the most controversial disorders in medicine, with multiple recent editorials having been published on the subject (Ahmad and Murthy, 2018; Burt, 2018; Illig, 2018). TOS comprises a variety of symptoms and physical findings resulting from the external compression of vessels and/or nerves as they pass through multiple narrow spaces between the thorax and the upper limb (Jubbal et al, 2018; Kaplan et al, 2018).…”

Section: Introductionmentioning

confidence: 99%

Microvascular Response to the Roos Test Has Excellent Feasibility and Good Reliability in Patients With Suspected Thoracic Outlet Syndrome

et al. 2019

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Background: Exercise oximetry allows operator-independent recordings of microvascular blood flow impairments during exercise and can be used during upper arm provocative maneuvers. Objective: To study the test-retest reliability of upper-limb oximetry during the Roos test in patients with suspected thoracic outlet syndrome (TOS). Materials and Methods: Forty-two patients (28 men, 14 women; mean age: 40.8 years) were examined via transcutaneous oxygen pressure (TcpO2) recordings during two consecutive Roos tests in the standing position. The minimal decrease from rest of oxygen pressure (DROPmin) value was recorded after each maneuver was performed on both arms. The area under the receiver operating characteristic (ROC) curve defined the DROPmin diagnostic performance in the presence of symptoms during the tests. The Mann–Whitney U -test was used to compare the DROPmin in the symptomatic vs. asymptomatic arms. The test-retest reliability was analyzed with Bland-Altman representations. The results are presented as means ± standard deviations (SD) or medians [25–75 percentiles]. Results: The symptoms by history were different from the symptoms expressed during the Roos maneuvers in one-third of the patients. The DROPmin measurements were −19 [−36; −7] mmHg and −8 [−16; −5] mmHg in the symptomatic ( n = 108) and asymptomatic ( n = 60) arms, respectively. When TOS observed on ultrasound imaging was the endpoint, the area under the ROC curve (AUC) was 0.725 ± 0.058, with an optimal cutoff point of −15 mmHg. This value provided 67% sensitivity and 78% specificity for the presence TOS via ultrasound. When symptoms occurring during the test represented the endpoint, the AUC was 0.698 ± 0.04, with a cutoff point of −10 mmHg. This provided 62% sensitivity and 66% specificity for the presence of pain in the ipsilateral arm during the test. The test-retest reliability of DROPmin proved to be good but not perfect, partly because of unreliability of the provocation maneuvers. Conclusion: To the best of our knowledge, this study is the first to investigate microvascular responses during the Roos maneuver in patients with suspected TOS. The presence of symptoms was significantly associated with ischemia. TcpO2 facilitated the recording of both macrovascular and microvascular responses to the Roos test. The Roos maneuver should probably be performed at least twice in patients with suspected TOS.

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Section: Introductionmentioning

confidence: 99%

Microvascular Response to the Roos Test Has Excellent Feasibility and Good Reliability in Patients With Suspected Thoracic Outlet Syndrome

et al. 2019

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“…A significant update to the criteria used for establishing a diagnosis of NTOS includes a positive response to an injection of local anesthetic. 59 Treatment includes BTX-A to the anterior scalene muscle, or the middle scalene or pectoralis minor muscles as well as surgery. The best available evidence for BTX-A 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.…”

Section: Discussionmentioning

confidence: 99%

Evaluation and Management of Neurogenic Thoracic Outlet Syndrome with an Overview of Surgical Approaches: A Comprehensive Review

Lim¹,

Kavousi²,

Lum³

et al. 2021

JPR

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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.

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“…Although asymptomatic compression of the neuro-vascular bundle during arm movement is found in many apparently healthy subjects, thoracic outlet syndrome (TOS) is considered as a relatively rare disease (Demondion et al, 2006;Burt, 2018;Illig, 2018). According to the standards of the Society for Vascular Surgery, TOS should be considered of arterial origin only if patients have "clinical symptoms due to documented symptomatic ischemia or objective subclavian artery damage caused by compression at the level of the first rib or other related anomalous bone structures" (Illig et al, 2016).…”

Section: Introductionmentioning

confidence: 99%

Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome

et al. 2022

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ObjectiveThoracic outlet syndrome (TOS) should be considered of arterial origin only if patients have clinical symptoms that are the result of documented symptomatic ischemia. Simultaneous recording of inflow impairment and forearm ischemia in patients with suspected TOS has never been reported to date. We hypothesized that ischemia would occur in cases of severely impaired inflow, resulting in a non-linear relationship between changes in pulse amplitude (PA) and the estimation of ischemia during provocative attitudinal upper limb positioning.DesignProspective single center interventional study.MaterialFifty-five patients with suspected thoracic outlet syndrome.MethodsWe measured the minimal decrease from rest of transcutaneous oximetry pressure (DROPm) as an estimation of oxygen deficit and arterial pulse photo-plethysmography to measure pulse amplitude changes from rest (PA-change) on both arms during the candlestick phase of a “Ca + Pra” maneuver. “Ca + Pra” is a modified Roos test allowing the estimation of maximal PA-change during the “Pra” phase. We compared the DROPm values between deciles of PA-changes with ANOVA. We then analyzed the relationship between mean PA-change and mean DROPm of each decile with linear and second-degree polynomial (non-linear) models. Results are reported as median [25/75 centiles]. Statistical significance was p < 0.05.ResultsDROPm values ranged −11.5 [−22.9/−7.2] and − 12.3 [−23.3/−7.4] mmHg and PA-change ranged 36.4 [4.6/63.8]% and 38.4 [−2.0/62.1]% in the right and left forearms, respectively. The coefficient of determination between median DROPm and median PA-change was r2 = 0.922 with a second-degree polynomial fitting, but only r2 = 0.847 with a linear approach.ConclusionOxygen availability was decreased in cases of severe but not moderate attitudinal inflow impairments. Undertaking simultaneous A-PPG and forearm oximetry during the “Ca + Pra” maneuver is an interesting approach for providing objective proof of ischemia in patients with symptoms of TOS suspected of arterial origin.

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Neurogenic thoracic outlet syndrome: Bringing order to chaos

Cited by 16 publications

References 3 publications

Microvascular Response to the Roos Test Has Excellent Feasibility and Good Reliability in Patients With Suspected Thoracic Outlet Syndrome

Microvascular Response to the Roos Test Has Excellent Feasibility and Good Reliability in Patients With Suspected Thoracic Outlet Syndrome

Evaluation and Management of Neurogenic Thoracic Outlet Syndrome with an Overview of Surgical Approaches: A Comprehensive Review

Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome

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