Diagnosis and Treatment of Thoracic Outlet Syndrome 2.0

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 goal of the 2.0 Special Issue on “Diagnosis and Treatment of Thoracic Outlet Syndrome” is to discuss unique issues related to neurogenic, venous, and arterial thoracic outlet syndrome.

These will include but are not limited to:

• How long should a patient with neurogenic thoracic outlet syndrome be treated with physical therapy before they are offered first rib resection and anterior scalenectomy? Does failing PT make a patient more or less likely to benefit from operative intervention?
• Do Botox injections in neurogenic patients actually work to help patients to improve with physical therapy? If so, which patients are more likely to benefit?
• Does re-operation in neurogenic patients for scar tissue actually improve their outcomes? If so, which patients benefit the most, and what is the timing of the re-operation?
• How do you manage a patient who presents with neurogenic symptoms following first rib resection and anterior scalenectomy for venous thrombosis?
• What is the best algorithm to manage patients with both cervical spine disease with symptoms along with neurogenic thoracic outlet syndrome symptoms?
• What bony abnormalities are found in those patients who present with neurogenic, venous, and arterial thoracic outlet syndrome and how prevalent are these abnormalities?
• Does first rib resection and anterior scalenectomy improve those patients who present with a Gilliat–Sumner hand?
• How long should a patient remain on anti-coagulation following first rib resection and anterior scalenectomy and which anti-coagulant should be used?
• Should arterial stents be used preferentially over bypass in those patients who have first rib resection and anterior scalenectomy with or without cervical rib resection for arterial thoracic outlet syndrome? Does it depend on whether the arterial lesion is an aneurysm, thrombosis or embolization or just compression with ischemic pain?
• How does one decide to operate on children (<18 years of age) with neurogenic, venous, and arterial thoracic outlet syndrome—do you alter your treatment such as lysis, arterial replacement or Botox?

Prof. Dr. Julie Ann Freischlag
Dr. Gabriela Velazquez
Guest Editors

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• thoracic outlet syndrome
• neurogenic TOS
• venous TOS
• arterial TOS
• transaxillary first rib resection
• supraclavicular resection

• Diagnosis and Treatment of Thoracic Outlet Syndrome in Diagnostics (11 articles)