Treatment for thoracic outlet syndrome

Povlsen, Bo; Hansson, Thomas; Povlsen, Sebastian

doi:10.1002/14651858.cd007218.pub3

Cited by 74 publications

(47 citation statements)

References 34 publications

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“…Thrombolysis followed by endovascular stenting does not appear to be as beneficial as surgery [ 62 ]. However, the benefits of surgical therapy remain to be demonstrated in a rigorous fashion [ 63 ]. Consequently, the writing committee of this guidance document was divided as to the value of surgical repair of thoracic outlet syndrome.…”

Section: Guidancementioning

confidence: 99%

Guidance for the treatment of deep vein thrombosis and pulmonary embolism

Streiff

Agnelli

Connors

et al. 2016

J Thromb Thrombolysis

284

188

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This guidance document focuses on the diagnosis and treatment of venous thromboembolism (VTE). Efficient, cost effective diagnosis of VTE is facilitated by combining medical history and physical examination with pre-test probability models, D dimer testing and selective use of confirmatory imaging. Clinical prediction rules, biomarkers and imaging can be used to tailor therapy to disease severity. Anticoagulation options for acute VTE include unfractionated heparin, low molecular weight heparin, fondaparinux and the direct oral anticoagulants (DOACs). DOACs are as effective as conventional therapy with LMWH and vitamin K antagonists. Thrombolytic therapy is reserved for massive pulmonary embolism (PE) or extensive deep vein thrombosis (DVT). Inferior vena cava filters are reserved for patients with acute VTE and contraindications to anticoagulation. Retrievable filters are strongly preferred. The possibility of thoracic outlet syndrome and May-Thurner syndrome should be considered in patients with subclavian/axillary and left common iliac vein DVT, respectively in absence of identifiable triggers. The optimal duration of therapy is dictated by the presence of modifiable thrombotic risk factors. Long term anticoagulation should be considered in patients with unprovoked VTE as well as persistent prothrombotic risk factors such as cancer. Short-term therapy is sufficient for most patients with VTE associated with transient situational triggers such as major surgery. Biomarkers such as D dimer and risk assessment models such the Vienna risk prediction model offer the potential to customize VTE therapy for the individual patient. Insufficient data exist to support the integration of bleeding risk models into duration of therapy planning.

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Section: Guidancementioning

confidence: 99%

Guidance for the treatment of deep vein thrombosis and pulmonary embolism

Streiff

Agnelli

Connors

et al. 2016

J Thromb Thrombolysis

284

188

View full text Add to dashboard Cite

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“…Surgical removal of rib 1 would likely not relieve the symptoms of compression around a more laterally placed trunk. A scalenectomy could place the piercing trunks in danger of damage unless appropriately identified [31]. Scalene botulinum toxin injection could be effective, so US could be applied to preselect patients with piercing variants for this treatment.…”

Section: Discussionmentioning

confidence: 99%

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation

et al. 2017

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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.

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“…The only treatment option associated with clear evidence of improved pain is first rib resection. 108 Other treatments (including local anaesthetic scalene muscle injections, exercise and physiotherapy, and standard neuropathic pain treatments) have a mixed evidence base in TOS but continue to be implemented before or instead of surgical intervention. 20 109…”

Section: Thoracic Outlet Syndromementioning

confidence: 99%

Pain management in patients with vascular disease

Seretny

2016

British Journal of Anaesthesia

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Vascular disease covers a wide range of conditions, including arterial, venous, and lymphatic disorders, with many of these being more common in the elderly. As the population ages, the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population. Pain management can be complex, as there are often multiple co-morbidities to be considered. An understanding of the underlying pain mechanisms is helpful in the logical direction of treatment, particularly in chronic pain states, such as phantom limb pain or complex regional pain syndrome. Acute pain management for vascular surgery presents a number of challenges, including coexisting anticoagulant medication, that may preclude the use of regional techniques. Within the limited evidence base, there is a suggestion that epidural analgesia provides better pain relief and reduced respiratory complications after major vascular surgery. For carotid endarterectomy, there is again some evidence supporting the use of local anaesthetic analgesia, either by infiltration or by superficial cervical plexus block. Chronic pain in vascular disease includes post-amputation pain, for which well-known risk factors include high pain levels before amputation and in the immediate postoperative period, emphasizing the importance of good pain control in the perioperative period. Complex regional pain syndrome is another challenging chronic pain syndrome with a wide variety of treatment options available, with the strongest evidence being for physical therapies. Further research is required to gain a better understanding of the underlying pathophysiological mechanisms in pain associated with vascular disease and the best analgesic approaches to manage it.

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Treatment for thoracic outlet syndrome

Cited by 74 publications

References 34 publications

Guidance for the treatment of deep vein thrombosis and pulmonary embolism

Guidance for the treatment of deep vein thrombosis and pulmonary embolism

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation

Pain management in patients with vascular disease

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