Lessons Learned in the Surgical Treatment of Neurogenic Thoracic Outlet Syndrome Over 10 Years
Vascular and Endovascular Surgery 1-4 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574415583850 ves.sagepub.com
Kendall C. Likes, BS1, Megan S. Orlando, BA1, Quinn Salditch1, Serene Mirza1, Anne Cohen1, Thomas Reifsnyder, MD1, Ying Wei Lum, MD1, and Julie A. Freischlag, MD1
Abstract Objective: To evaluate our extensive experience over a decade in the treatment of patients with neurogenic thoracic outlet syndrome (NTOS) who underwent first rib resection and scalenectomy (FRRS). Methods: Patients treated with FRRS for NTOS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. Results: Over 10 years, 286 patients underwent 308 FRRS. During the first 5-year period, 127 FRRS were performed (96 F, 31 M), with an average age of 36.9 years. During the second 5-year period, 181 FRRS were performed (143 F, 38 M), with an average age of 33 years. A total of 24 children (age 18years) underwent FRRS, 9 during the first 5 years and 15 during the second 5 years. When comparing the second 5-year period to the first 5-year period, patients were younger (P ¼ .066), reported a significantly shorter length of preoperative symptoms (35.4 vs 52.1 months, P < .01), prior narcotic use decreased from 31.5% to 23.8% (P < .05), and a history of prior surgical intervention on the ipsilateral side (head, neck, and shoulder) increased from 30.1% to 51.9% (P < .01). Use of lidocaine blocks as a diagnostic tool (57%-35.4%, P ¼ .06) and Botox blocks as a therapeutic tool (29.1%-12.7%, P < .01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10-year period was 13.4 months. Conclusion: Excellent results were seen in this surgical series reported for NTOS. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the second 5 years of surgical intervention. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring fewer lidocaine and/or Botox injections preoperatively. Keywords NTOS, TOS, FRRS
Introduction Thoracic outlet syndrome (TOS) is a condition that occurs due to compression of the nerves of the brachial plexus, the subclavian vein, and/or the subclavian artery during passage through the thoracic outlet. Neurogenic TOS (NTOS) is the most common subtype (95% of cases) and often presents in adults aged 20 to 40 years old, with greater prevalence among women. Patients often present with weakness, paresthesia, and/or pain in the affected upper extremity and frequently have a history of chronic and repetitive motion activities or trauma. Conservative management for NTOS includes physical therapy (PT), anesthetic and/or steroid injections, and lifestyle modification. For patients failing conservative therapy, a first rib resection and scalenectomy (FRRS) is considered the gold standard treatment and is often performed via a transaxillary approach. The treatment of NTOS has been a controversial topic among medical providers and vascular surgeons due to the lack
of objective diagnostic criteria and vague symptomatology. Therefore, it is often difficult to select patients with NTOS who will benefit from surgical intervention. The literature reports variable outcomes and a lack of predictors of success. Appropriate patient selection remains the best way to achieve lasting results and successful outcomes following surgical intervention for NTOS. We sought to review our own extensive experience in the treatment of patients with NTOS who underwent FRRS from a single high-volume institution over a decade. The purpose 1 Division of Vascular and Endovascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
Corresponding Author: Kendall C. Likes, Division of Vascular and Endovascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Halsted 668, 600N Wolfe St, Baltimore, MD 21287, USA. Email: [email protected]
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of this study was to summarize our findings over the last 10 years in treating NTOS and to describe the changing presentation and management of patients with NTOS over a decade, including patient attributes associated with surgical outcomes and the formulation of pre- and postoperative treatment plans to maximize successful outcomes and postoperative quality of life (QoL).
Methods We performed a retrospective review of a database approved by the Johns Hopkins Institutional Review Board. The database is prospectively maintained by the Johns Hopkins Division of Vascular Surgery and Endovascular Therapy. The database has approval to follow and record data regarding the presentation, treatment, and outcomes for all patients presenting to the Johns Hopkins Medical Institutions with symptoms of TOS. Patient data were compiled from August 2003 to July 2013. Included in the database is all information regarding patient demographic and clinical characteristics, such as their initial presentation, previous treatment modalities, and therapies; treatment course; and patient complications, outcomes, and follow-up. Any additional information pertinent to this study was obtained from the electronic patient medical record system. Patients who presented with symptoms of prolonged pain, weakness, numbness, and/or tingling in the neck, shoulder, or arm, had a prior history of trauma or repetitive motion injury in the affected upper extremity, and/or experienced symptomatic relief in the affected upper extremity following an anterior scalene block with lidocaine were diagnosed as having NTOS. Patients with NTOS underwent 8 weeks or more of PT before being considered for FRRS. Patients whose symptoms did not improve following conservative treatment methods, such as PT and scalene blocks, underwent FRRS through a transaxillary approach, as is the preferred method at our institution. All patients who underwent FRRS for NTOS between June 2003 and June 2013 were included in this study. Follow-up included postoperative clinic visits to assess symptoms in all patients.
Results Between 2003 and 2013, our practice saw a total of 538 patients who underwent 594 FRRS procedures for indications of neurogenic (308 procedures), venous (261 procedures), and arterial (25 procedures) TOS. Three hundred and eight FRRS procedures were performed on 286 patients with NTOS between 2003 and 2013. Basic patient demographics and history, as obtained during the patient’s initial clinic visit, are reported in Table 1. During the first 5-year period, 73 (57.5%) of the 127 patients underwent an anterior scalene block with lidocaine. Of the 73 blocks, 65 (89%) were positive and 8 (11%) were negative. Of patients undergoing FRRS who had a positive lidocaine block, 58 (89%) improved following the operation. Of the 8 patients undergoing FRRS with a negative lidocaine block,
Table 1. Demographics and History of Patients Treated With First Rib Resection and Scalenectomy (FRRS) for Neurogenic Thoracic Outlet Syndrome. 2003-2008 2008-2013 FRRS procedures Females Males Average age, years (range) Length of symptoms, months Etiology—chronic repetitive motion (%) Trauma Children (%) History of smoking (%) Prior narcotic use (%) Prior surgery on the affected upper extremity
127 96 31 36.9 (13-62) 52.1 48 (37.8) 52 (40.1) 9 (7.1) 21 (17) 40 (30.1) 39 (30.1)
181 143 38 33 (14-63) 35.4 78 (43.1) 79 (43.6) 15 (8.3) 24 (13) 43 (23.8) 94 (51.9)
7 (87.5%) improved following FRRS. During the first 5 years, 37 (29.1%) of the 127 patients underwent a Botox block. Of the 37 blocks, 17 (45.9%) were positive and 20 (54.1%) were negative. Of the patients undergoing FRRS who had a positive Botox block, 15 (88%) improved following surgery. Of the 20 patients undergoing FRRS with a negative Botox block, 17 (85%) improved following FRRS. Of the 127 procedures during the first 5 years, there were 26 (20.5%) inconsequential intraoperative pneumothoraces, 2 (1.6%) wound infections, 1 (0.8%) hematoma requiring reoperation, and 1 (0.8%) hemothorax. There were no injuries to the artery, vein, or nerve root. Overall, 113 (89%) patients experienced symptomatic relief following surgical intervention. Average follow-up was 19 months for this patient subset. During the second 5-year period, 88 (35.4%) of the 181 patients had an anterior scalene block with lidocaine. Of the 88 patients with NTOS having blocks, 82 (93.2%) had a positive block and 6 (6.8%) had a negative block. Of the patients undergoing FRRS who had a positive lidocaine block, 78 (95.1%) improved following the operation. Of the 6 patients undergoing FRRS with a negative lidocaine block, all 6 (100%) improved following FRRS. Just 23 (12.7%) of the 181 patients had a Botox block during the second 5-year period. Of these, 15 (65.2%) had a positive outcome and 8 (34.8%) had a negative outcome. Of patients undergoing FRRS who had a positive Botox block, 15 (100%) improved following surgery. Of the 8 patients undergoing FRRS with a negative Botox block, 7 (87.5%) improved following FRRS. Of the procedures during the second 5 years, there were 53 (29.3%) inconsequential intraoperative pneumothoraces, 2 (1.1%) wound infections, 1 (0.6%) hematoma that did not require reoperation, and 1 (0.6%) vein injury. There were no injuries to the subclavian artery or nerve root. Overall, 168 (92.8%) had a positive outcome following surgical intervention. Average length of follow-up was 9.4 months for this subset of patients. When comparing the clinical characteristics and demographics of patients during the second 5-year period to those
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of the first 5-year period, patients were significantly younger (P ¼ .066). Patients also reported a significantly shorter length of preoperative symptoms (52.1 vs 35.4 months, P < .01) before presenting to clinic. In addition, prior narcotic use decreased from 31.5% to 23.8% (P < .05) and a history of prior surgical intervention on the ipsilateral side (head, neck, shoulder) increased from 30.1% to 51.9% (P < .01) when comparing the second 5-year period to the first. Use of lidocaine blocks as a diagnostic tool (57%-35.4%, P ¼ .06) and Botox blocks as a therapeutic tool (29.1%-12.7%, P < .01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10-year period was 13.4 months.
Discussion The objective of this study was to summarize our extensive 10-year experience in the treatment of patients with NTOS who underwent FRRS and to identify trends over time. Over the past decade, our institution has investigated numerous patient factors and looked at outcomes in this large set of patients with NTOS. In our experience, patients were not only significantly younger in the second 5-year period, but they were also sent to us earlier, with a shorter length of symptoms, indicating more accurate referrals. In a previous study, we categorized all patients referred to our specialized TOS practice to determine the diagnostic accuracy of both physician-referred and selfreferred patients.1 This study examined a large cohort of patients and sought to identify trends in patient presentation, clinical diagnoses, treatment patterns, and therapeutic outcomes for a TOS-specific clinic. Over a 5-year period, we found that there were 621 patients referred for TOS. Of the 525 physician referrals, 478 (91%) patients were found to have TOS. Of the 93 selfreferrals, 90 (97%) patients had TOS. The analysis revealed a number of patterns concerning patient presentation and referrals and helped to identify candidates for further management to guide treatment courses for patients with TOS. This study found that both referring physicians and patients are accurate in their preliminary diagnosis of TOS, most likely due to the role medical literature, social media, and electronic correspondence play in informing patients and physicians about TOS. In a specialized TOS practice, two-thirds of patients are sent to TOS-specific PT and of these, one-third improve from this alone. Ultimately, just a third of patients referred for NTOS undergo FRRS with a 91% success rate. So excellent outcomes are seen using conservative therapies and surgical invention for NTOS in a specialized TOS practice. Our outcomes were excellent in the first 5-year period and even better in the second. Chang and colleagues had previously found that QoL increased immediately following FRRS.2 In this study, both the Disabilities of the Arm, Shoulder and Hand (DASH) survey, which increased 0.85 points per month following FRRS, and the Short Form-12, which showed an increase of 0.24 points per month for the mental component score and an
increase of 0.15 points per month for the physical component score following FRRS, demonstrated a short-term increase in QoL in patients undergoing FRRS for NTOS. This study also showed that 67% of these patients returned to work and other baseline activities at 4 months on average following surgery. Similarly, our practice examined long-term outcomes for patients with NTOS and found that outcomes following FRRS are sustained over time.3 The first of its kind, Rochlin and colleagues sent 162 patients with NTOS 3 validated QoL instruments—the Short Form-12, the Brief Pain Inventory, and the Cervical Brachial Symptom Questionnaire—to assess longterm QoL following FRRS. This study found that QoL does not deteriorate long term, as there was no significant downward trend in physical or mental components of the patients with NTOS. Also, it was found that patient factors, such as comorbidities, smoking, age, and chronic use of narcotics, were more predictive of long-term QoL than preoperative scalene blocks. This emphasizes the importance of considering patient factors when selecting patients for surgical intervention. Patients undergoing FRRS for NTOS were significantly younger when comparing the second 5-year period to the first 5-year period, most likely due to surgical candidate selection. Lum and colleagues previously looked at the effect a range of patient demographics and clinical characteristics had on surgical outcomes.4 Patients were stratified to age-groups 1 year postoperatively to ensure sufficient recovery from the primary surgery. Treating dual-sided NTOS symptoms with bilateral FRRS procedures is safe and effective if patients are closely monitored postoperatively.7 In addition, this study found that active smoking status was associated with poor outcomes in NTOS, underscoring the importance of smoking reduction or cessation prior to surgery among NTOS surgical candidates. The study emphasized that the appropriate treatment of patients with poor outcomes varies by symptom type. For example, the fact that the majority of patients with unresolved symptoms remained dependent on narcotics suggested that long-term pain management was the preferred intervention for this patient subset. Symptom assessment is crucial in formulating a lasting successful treatment course, and patient factors should be thoroughly assessed when selecting surgical candidates. Similarly, our practice recently examined a cohort of patients who presented to the clinic with recurrent symptoms of TOS after prior surgical intervention for TOS at another institution.8 Seven patients presented with NTOS symptoms after undergoing previous scalenectomy and/or brachial plexus lysis and were found to have a remaining first rib on chest radiograph. All 7 improved following transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Eight patients presented with symptoms of TOS following first rib resection and scalenectomy and were found to have an anterior or posterior remaining first rib fragment on chest radiography. All of these patients improved following complete FRRS. This study found that patients presenting with recurrent symptoms of TOS following prior surgical intervention should be evaluated for a remaining or residual first rib. In this patient subset, removing the remaining or residual first rib resulted in excellent outcomes. This study showed that the entire first rib should be removed at the time of the initial TOS operation to prevent recurrent symptoms of TOS. In the current study, we decided to look at the changes over the past decade in a specialized TOS practice. We identified a number of patterns in patient demographics and clinical characteristics and found that over time, we received quicker referrals and more accurate patient selection. The reason pneumothorax rates were higher than reported in other practices is probably due to the fact that our practice regularly performs a complete excision of the first rib. Successful surgical outcomes following FRRS were excellent, and follow-up was great for the 10-year period.
Conclusion Excellent results were seen in our reported surgical series for NTOS. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the
second 5 years of surgical intervention. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring fewer interventions preoperatively. Patient factors should be considered when selecting surgical candidates, and accurate symptom assessment is of key importance in formulating a successful treatment plan. It is important to follow patients closely 1 year after surgery to determine whether additional interventions, such as postoperative PT and time off from work, are necessary to ensure successful lasting results and improved QoL. Authors’ Note This article was presented as a plenary presentation at the Society for Vascular Surgery Annual Meeting in Boston, Massachusetts, June 6, 2014.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Likes K, Rochlin DH, Salditch Q, et al. Diagnostic accuracy of physician and self-referred patients for thoracic outlet syndrome is excellent. Ann Vasc Surg. 2014;28(5):1100-1105. 2. Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg. 2998;49(3): 630-637. 3. Rochlin DH, Gilson MM, Likes KC, Graf E, Ford N, Christo PJ, . . . Freischlag JA. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg. 2013;57(2):436-443. 4. Lum YW, Brooke BS, Likes K, et al. Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2012; 55(5):1370-1375. 5. Chang KZ, Graf E, Davis K, Demos J, Roethle T, Freischlag JA. Spectrum of thoracic outlet syndrome presentation in adolescents. Arch Surg. 2011;146(12):1383-1387. 6. Rochlin DH, Like KC, Gilson MM, Christo PJ, Freischlag JA. Management of unresolved, recurrent, and/or contralateral neurogenic symptoms in patients following first rib resection and scalenectomy. J Vasc Surg. 2012;56(4):1061-1067. 7. Rochlin DH, Orlando MS, Likes KC, Jacobs C, Freischlag JA. Bilateral first rib resection and scalenectomy is effective for treatment of thoracic outlet syndrome. J Vasc Surg. 2014; 60(1):185-190. 8. Likes KC, Dapash T, Rochlin DH, Freischlag JA. Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome. Ann Vasc Surg. 2014;28(4):939-945.
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Vascular and Endovascular Surgery 1-4 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574415583850 ves.sagepub.com
Kendall C. Likes, BS1, Megan S. Orlando, BA1, Quinn Salditch1, Serene Mirza1, Anne Cohen1, Thomas Reifsnyder, MD1, Ying Wei Lum, MD1, and Julie A. Freischlag, MD1
Abstract Objective: To evaluate our extensive experience over a decade in the treatment of patients with neurogenic thoracic outlet syndrome (NTOS) who underwent first rib resection and scalenectomy (FRRS). Methods: Patients treated with FRRS for NTOS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. Results: Over 10 years, 286 patients underwent 308 FRRS. During the first 5-year period, 127 FRRS were performed (96 F, 31 M), with an average age of 36.9 years. During the second 5-year period, 181 FRRS were performed (143 F, 38 M), with an average age of 33 years. A total of 24 children (age 18years) underwent FRRS, 9 during the first 5 years and 15 during the second 5 years. When comparing the second 5-year period to the first 5-year period, patients were younger (P ¼ .066), reported a significantly shorter length of preoperative symptoms (35.4 vs 52.1 months, P < .01), prior narcotic use decreased from 31.5% to 23.8% (P < .05), and a history of prior surgical intervention on the ipsilateral side (head, neck, and shoulder) increased from 30.1% to 51.9% (P < .01). Use of lidocaine blocks as a diagnostic tool (57%-35.4%, P ¼ .06) and Botox blocks as a therapeutic tool (29.1%-12.7%, P < .01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10-year period was 13.4 months. Conclusion: Excellent results were seen in this surgical series reported for NTOS. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the second 5 years of surgical intervention. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring fewer lidocaine and/or Botox injections preoperatively. Keywords NTOS, TOS, FRRS
Introduction Thoracic outlet syndrome (TOS) is a condition that occurs due to compression of the nerves of the brachial plexus, the subclavian vein, and/or the subclavian artery during passage through the thoracic outlet. Neurogenic TOS (NTOS) is the most common subtype (95% of cases) and often presents in adults aged 20 to 40 years old, with greater prevalence among women. Patients often present with weakness, paresthesia, and/or pain in the affected upper extremity and frequently have a history of chronic and repetitive motion activities or trauma. Conservative management for NTOS includes physical therapy (PT), anesthetic and/or steroid injections, and lifestyle modification. For patients failing conservative therapy, a first rib resection and scalenectomy (FRRS) is considered the gold standard treatment and is often performed via a transaxillary approach. The treatment of NTOS has been a controversial topic among medical providers and vascular surgeons due to the lack
of objective diagnostic criteria and vague symptomatology. Therefore, it is often difficult to select patients with NTOS who will benefit from surgical intervention. The literature reports variable outcomes and a lack of predictors of success. Appropriate patient selection remains the best way to achieve lasting results and successful outcomes following surgical intervention for NTOS. We sought to review our own extensive experience in the treatment of patients with NTOS who underwent FRRS from a single high-volume institution over a decade. The purpose 1 Division of Vascular and Endovascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
Corresponding Author: Kendall C. Likes, Division of Vascular and Endovascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Halsted 668, 600N Wolfe St, Baltimore, MD 21287, USA. Email: [email protected]
Downloaded from ves.sagepub.com at WESTERN OREGON UNIVERSITY on June 1, 2015
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of this study was to summarize our findings over the last 10 years in treating NTOS and to describe the changing presentation and management of patients with NTOS over a decade, including patient attributes associated with surgical outcomes and the formulation of pre- and postoperative treatment plans to maximize successful outcomes and postoperative quality of life (QoL).
Methods We performed a retrospective review of a database approved by the Johns Hopkins Institutional Review Board. The database is prospectively maintained by the Johns Hopkins Division of Vascular Surgery and Endovascular Therapy. The database has approval to follow and record data regarding the presentation, treatment, and outcomes for all patients presenting to the Johns Hopkins Medical Institutions with symptoms of TOS. Patient data were compiled from August 2003 to July 2013. Included in the database is all information regarding patient demographic and clinical characteristics, such as their initial presentation, previous treatment modalities, and therapies; treatment course; and patient complications, outcomes, and follow-up. Any additional information pertinent to this study was obtained from the electronic patient medical record system. Patients who presented with symptoms of prolonged pain, weakness, numbness, and/or tingling in the neck, shoulder, or arm, had a prior history of trauma or repetitive motion injury in the affected upper extremity, and/or experienced symptomatic relief in the affected upper extremity following an anterior scalene block with lidocaine were diagnosed as having NTOS. Patients with NTOS underwent 8 weeks or more of PT before being considered for FRRS. Patients whose symptoms did not improve following conservative treatment methods, such as PT and scalene blocks, underwent FRRS through a transaxillary approach, as is the preferred method at our institution. All patients who underwent FRRS for NTOS between June 2003 and June 2013 were included in this study. Follow-up included postoperative clinic visits to assess symptoms in all patients.
Results Between 2003 and 2013, our practice saw a total of 538 patients who underwent 594 FRRS procedures for indications of neurogenic (308 procedures), venous (261 procedures), and arterial (25 procedures) TOS. Three hundred and eight FRRS procedures were performed on 286 patients with NTOS between 2003 and 2013. Basic patient demographics and history, as obtained during the patient’s initial clinic visit, are reported in Table 1. During the first 5-year period, 73 (57.5%) of the 127 patients underwent an anterior scalene block with lidocaine. Of the 73 blocks, 65 (89%) were positive and 8 (11%) were negative. Of patients undergoing FRRS who had a positive lidocaine block, 58 (89%) improved following the operation. Of the 8 patients undergoing FRRS with a negative lidocaine block,
Table 1. Demographics and History of Patients Treated With First Rib Resection and Scalenectomy (FRRS) for Neurogenic Thoracic Outlet Syndrome. 2003-2008 2008-2013 FRRS procedures Females Males Average age, years (range) Length of symptoms, months Etiology—chronic repetitive motion (%) Trauma Children (%) History of smoking (%) Prior narcotic use (%) Prior surgery on the affected upper extremity
127 96 31 36.9 (13-62) 52.1 48 (37.8) 52 (40.1) 9 (7.1) 21 (17) 40 (30.1) 39 (30.1)
181 143 38 33 (14-63) 35.4 78 (43.1) 79 (43.6) 15 (8.3) 24 (13) 43 (23.8) 94 (51.9)
7 (87.5%) improved following FRRS. During the first 5 years, 37 (29.1%) of the 127 patients underwent a Botox block. Of the 37 blocks, 17 (45.9%) were positive and 20 (54.1%) were negative. Of the patients undergoing FRRS who had a positive Botox block, 15 (88%) improved following surgery. Of the 20 patients undergoing FRRS with a negative Botox block, 17 (85%) improved following FRRS. Of the 127 procedures during the first 5 years, there were 26 (20.5%) inconsequential intraoperative pneumothoraces, 2 (1.6%) wound infections, 1 (0.8%) hematoma requiring reoperation, and 1 (0.8%) hemothorax. There were no injuries to the artery, vein, or nerve root. Overall, 113 (89%) patients experienced symptomatic relief following surgical intervention. Average follow-up was 19 months for this patient subset. During the second 5-year period, 88 (35.4%) of the 181 patients had an anterior scalene block with lidocaine. Of the 88 patients with NTOS having blocks, 82 (93.2%) had a positive block and 6 (6.8%) had a negative block. Of the patients undergoing FRRS who had a positive lidocaine block, 78 (95.1%) improved following the operation. Of the 6 patients undergoing FRRS with a negative lidocaine block, all 6 (100%) improved following FRRS. Just 23 (12.7%) of the 181 patients had a Botox block during the second 5-year period. Of these, 15 (65.2%) had a positive outcome and 8 (34.8%) had a negative outcome. Of patients undergoing FRRS who had a positive Botox block, 15 (100%) improved following surgery. Of the 8 patients undergoing FRRS with a negative Botox block, 7 (87.5%) improved following FRRS. Of the procedures during the second 5 years, there were 53 (29.3%) inconsequential intraoperative pneumothoraces, 2 (1.1%) wound infections, 1 (0.6%) hematoma that did not require reoperation, and 1 (0.6%) vein injury. There were no injuries to the subclavian artery or nerve root. Overall, 168 (92.8%) had a positive outcome following surgical intervention. Average length of follow-up was 9.4 months for this subset of patients. When comparing the clinical characteristics and demographics of patients during the second 5-year period to those
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of the first 5-year period, patients were significantly younger (P ¼ .066). Patients also reported a significantly shorter length of preoperative symptoms (52.1 vs 35.4 months, P < .01) before presenting to clinic. In addition, prior narcotic use decreased from 31.5% to 23.8% (P < .05) and a history of prior surgical intervention on the ipsilateral side (head, neck, shoulder) increased from 30.1% to 51.9% (P < .01) when comparing the second 5-year period to the first. Use of lidocaine blocks as a diagnostic tool (57%-35.4%, P ¼ .06) and Botox blocks as a therapeutic tool (29.1%-12.7%, P < .01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10-year period was 13.4 months.
Discussion The objective of this study was to summarize our extensive 10-year experience in the treatment of patients with NTOS who underwent FRRS and to identify trends over time. Over the past decade, our institution has investigated numerous patient factors and looked at outcomes in this large set of patients with NTOS. In our experience, patients were not only significantly younger in the second 5-year period, but they were also sent to us earlier, with a shorter length of symptoms, indicating more accurate referrals. In a previous study, we categorized all patients referred to our specialized TOS practice to determine the diagnostic accuracy of both physician-referred and selfreferred patients.1 This study examined a large cohort of patients and sought to identify trends in patient presentation, clinical diagnoses, treatment patterns, and therapeutic outcomes for a TOS-specific clinic. Over a 5-year period, we found that there were 621 patients referred for TOS. Of the 525 physician referrals, 478 (91%) patients were found to have TOS. Of the 93 selfreferrals, 90 (97%) patients had TOS. The analysis revealed a number of patterns concerning patient presentation and referrals and helped to identify candidates for further management to guide treatment courses for patients with TOS. This study found that both referring physicians and patients are accurate in their preliminary diagnosis of TOS, most likely due to the role medical literature, social media, and electronic correspondence play in informing patients and physicians about TOS. In a specialized TOS practice, two-thirds of patients are sent to TOS-specific PT and of these, one-third improve from this alone. Ultimately, just a third of patients referred for NTOS undergo FRRS with a 91% success rate. So excellent outcomes are seen using conservative therapies and surgical invention for NTOS in a specialized TOS practice. Our outcomes were excellent in the first 5-year period and even better in the second. Chang and colleagues had previously found that QoL increased immediately following FRRS.2 In this study, both the Disabilities of the Arm, Shoulder and Hand (DASH) survey, which increased 0.85 points per month following FRRS, and the Short Form-12, which showed an increase of 0.24 points per month for the mental component score and an
increase of 0.15 points per month for the physical component score following FRRS, demonstrated a short-term increase in QoL in patients undergoing FRRS for NTOS. This study also showed that 67% of these patients returned to work and other baseline activities at 4 months on average following surgery. Similarly, our practice examined long-term outcomes for patients with NTOS and found that outcomes following FRRS are sustained over time.3 The first of its kind, Rochlin and colleagues sent 162 patients with NTOS 3 validated QoL instruments—the Short Form-12, the Brief Pain Inventory, and the Cervical Brachial Symptom Questionnaire—to assess longterm QoL following FRRS. This study found that QoL does not deteriorate long term, as there was no significant downward trend in physical or mental components of the patients with NTOS. Also, it was found that patient factors, such as comorbidities, smoking, age, and chronic use of narcotics, were more predictive of long-term QoL than preoperative scalene blocks. This emphasizes the importance of considering patient factors when selecting patients for surgical intervention. Patients undergoing FRRS for NTOS were significantly younger when comparing the second 5-year period to the first 5-year period, most likely due to surgical candidate selection. Lum and colleagues previously looked at the effect a range of patient demographics and clinical characteristics had on surgical outcomes.4 Patients were stratified to age-groups 1 year postoperatively to ensure sufficient recovery from the primary surgery. Treating dual-sided NTOS symptoms with bilateral FRRS procedures is safe and effective if patients are closely monitored postoperatively.7 In addition, this study found that active smoking status was associated with poor outcomes in NTOS, underscoring the importance of smoking reduction or cessation prior to surgery among NTOS surgical candidates. The study emphasized that the appropriate treatment of patients with poor outcomes varies by symptom type. For example, the fact that the majority of patients with unresolved symptoms remained dependent on narcotics suggested that long-term pain management was the preferred intervention for this patient subset. Symptom assessment is crucial in formulating a lasting successful treatment course, and patient factors should be thoroughly assessed when selecting surgical candidates. Similarly, our practice recently examined a cohort of patients who presented to the clinic with recurrent symptoms of TOS after prior surgical intervention for TOS at another institution.8 Seven patients presented with NTOS symptoms after undergoing previous scalenectomy and/or brachial plexus lysis and were found to have a remaining first rib on chest radiograph. All 7 improved following transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Eight patients presented with symptoms of TOS following first rib resection and scalenectomy and were found to have an anterior or posterior remaining first rib fragment on chest radiography. All of these patients improved following complete FRRS. This study found that patients presenting with recurrent symptoms of TOS following prior surgical intervention should be evaluated for a remaining or residual first rib. In this patient subset, removing the remaining or residual first rib resulted in excellent outcomes. This study showed that the entire first rib should be removed at the time of the initial TOS operation to prevent recurrent symptoms of TOS. In the current study, we decided to look at the changes over the past decade in a specialized TOS practice. We identified a number of patterns in patient demographics and clinical characteristics and found that over time, we received quicker referrals and more accurate patient selection. The reason pneumothorax rates were higher than reported in other practices is probably due to the fact that our practice regularly performs a complete excision of the first rib. Successful surgical outcomes following FRRS were excellent, and follow-up was great for the 10-year period.
Conclusion Excellent results were seen in our reported surgical series for NTOS. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the
second 5 years of surgical intervention. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring fewer interventions preoperatively. Patient factors should be considered when selecting surgical candidates, and accurate symptom assessment is of key importance in formulating a successful treatment plan. It is important to follow patients closely 1 year after surgery to determine whether additional interventions, such as postoperative PT and time off from work, are necessary to ensure successful lasting results and improved QoL. Authors’ Note This article was presented as a plenary presentation at the Society for Vascular Surgery Annual Meeting in Boston, Massachusetts, June 6, 2014.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Likes K, Rochlin DH, Salditch Q, et al. Diagnostic accuracy of physician and self-referred patients for thoracic outlet syndrome is excellent. Ann Vasc Surg. 2014;28(5):1100-1105. 2. Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg. 2998;49(3): 630-637. 3. Rochlin DH, Gilson MM, Likes KC, Graf E, Ford N, Christo PJ, . . . Freischlag JA. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg. 2013;57(2):436-443. 4. Lum YW, Brooke BS, Likes K, et al. Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2012; 55(5):1370-1375. 5. Chang KZ, Graf E, Davis K, Demos J, Roethle T, Freischlag JA. Spectrum of thoracic outlet syndrome presentation in adolescents. Arch Surg. 2011;146(12):1383-1387. 6. Rochlin DH, Like KC, Gilson MM, Christo PJ, Freischlag JA. Management of unresolved, recurrent, and/or contralateral neurogenic symptoms in patients following first rib resection and scalenectomy. J Vasc Surg. 2012;56(4):1061-1067. 7. Rochlin DH, Orlando MS, Likes KC, Jacobs C, Freischlag JA. Bilateral first rib resection and scalenectomy is effective for treatment of thoracic outlet syndrome. J Vasc Surg. 2014; 60(1):185-190. 8. Likes KC, Dapash T, Rochlin DH, Freischlag JA. Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome. Ann Vasc Surg. 2014;28(4):939-945.
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