Search Results (59)

Background and Objectives: Many patients suffer from chronic pain of the shoulder, neck, upper back, and/or arm. They may be diagnosed with fibromyalgia, complex regional pain syndrome, myofascial pain, thoracic outlet, subacromial pain, cervical radiculopathy, cervicogenic headaches, post-mastectomy pain, and/or occupational shoulder disorder. The pectoralis minor (PM) is the only muscle of the scapula controlled by the lower trunk of the brachial plexus. In the Human Disharmony Loop (HDL), this neurologic asymmetry produces persistent protraction of the scapula. Protraction deforms the scapula’s connections, generating headaches and neck stiffness, upper back tightness, shoulder weakness, and hand numbness. We hypothesize patients with the above who meet HDL diagnostic criteria will benefit from PM tenotomy with brachial plexus neurolysis (PM+ICN). Materials and Methods: Patients diagnosed with the above disorders who also met HDL criteria of medial coracoid tenderness and scapula protraction on exam underwent PM+ICN, with secondary neurolysis after 3 months if needed. Clinical neuropathy was diagnosed via the scratch-collapse test. Outcomes included self-reported Visual Analogue Score pain scores, active shoulder abduction range of motion (ROM), prevalence of occipital headaches. Results: N = 318 patients were included. Average age was 51; 68.0% were female. Following treatment, average pain decreased from 7.3/10 to 2.1/10 (p < 0.001), average shoulder ROM increased from 96 to 170 degrees (p < 0.001), and occipital headaches decreased from 76.7% to 1.6% (p < 0.001). Scapular protraction normalized from 98.8% static to 92.5% none (p < 0.001). Overall, 17% required subsequent neurolysis, chiefly of the axillary, radial, and ulnar nerves. The pain reductions were statistically indistinguishable across all diagnoses (p = 0.709, I² = 0.02%). Average follow-up was 22 months. Conclusions: PM+ICN significantly reduced self-reported pain and headaches in select intractable patients. The PM pathologizing the scapula may constitute a shared anatomic mechanism that contributes to chronic pain across heterogenous disorders of the upper limb. Full article

Thoracic outlet syndrome (TOS) is a rare neurovascular compression disorder involving the brachial plexus and/or subclavian vessels at the cervicothoracobrachial junction. Clinical presentation is often nonspecific and may overlap with peripheral neuropathies, cervical spine disorders, and musculoskeletal conditions, making diagnosis challenging. Although clinical evaluation remains central to diagnosis, imaging plays a complementary role in supporting the diagnosis of TOS by identifying the affected neurovascular structures, localizing the site of compression, and elucidating the underlying anatomical or pathological causes. Moreover, imaging is essential for excluding alternative diagnoses, including thoracic malignancies and inflammatory or degenerative vascular diseases that may mimic TOS. This review provides a comprehensive overview of the radiological anatomy of the thoracic outlet, the etiological factors contributing to neurovascular compression, and the strengths and limitations of current imaging modalities used in the evaluation of TOS. Full article

Background and Objectives: This study aimed to evaluate postoperative outcomes following transaxillary first rib resection with concomitant anterior scalenotomy (Roos procedure) for Thoracic Outlet Syndrome, using an ambispective design with a standardized two-year multimodal follow-up in a prospectively observed subgroup. Materials and Methods: This ambispective observational cohort study included 32 patients (87.5% women; mean age, 33.8 years) who underwent transaxillary first rib resection with anterior scalenotomy for Thoracic Outlet Syndrome. Of these, seven patients comprised the retrospective cohort, having undergone surgery between 2017 and 2019, while the remaining 25 patients were enrolled prospectively and underwent surgery from 2020 onwards. Patients were classified as having neurogenic, vascular (arterial or venous), or mixed Thoracic Outlet Syndrome. Retrospective data were obtained from medical records, while prospectively treated patients were followed according to a predefined postoperative protocol. Longitudinal changes in clinical outcomes were analyzed using mixed linear and logistic regression models. Results: All analyzed symptoms improved after surgery (p < 0.05), with a significant reduction in upper limb edema over time (OR = 0.44, p = 0.002). The prevalence of positive provocative tests decreased notably across all maneuvers postoperatively. Pathological color duplex ultrasound findings of the upper limb vessels resolved almost completely during follow-up. Patient-reported outcome measures (CBSQ, DASH, and BPI) demonstrated meaningful postoperative improvement with sustained benefits over time. Electrophysiological evaluation revealed notable improvement in median sensory and motor nerve conduction parameters. Conclusions: Transaxillary first rib resection with anterior scalenotomy appears to improve clinical, functional, and objective outcomes in patients with Thoracic Outlet Syndrome; however, findings should be interpreted with caution due to the ambispective design, small sample size, and cohort heterogeneity, and require confirmation in larger prospective studies. Full article

Background: The pectoralis minor muscle can be a source of musculoskeletal-related chest pain by contributing to thoracic outlet syndrome. Needling interventions applied to chest wall muscles have an inherent risk of puncturing sensitive structures, e.g., the pleura. Objective: The objective of this study was to preliminarily investigate the safety and accuracy of two needling approaches targeting the pectoralis minor muscle. Methods: A pincer- and flat-needle approach targeting the pectoralis minor muscle was conducted in five Thiel-embalmed cadavers and 10 healthy volunteers by an experienced and a novice clinician. The needle was inserted until the clinician considered that the pectoralis minor muscle was reached. Each clinician conducted 10 needle insertions with each approach. In cadavers, the accuracy of needle placement was identified with both ultrasound imaging and anatomical dissection. In healthy volunteers, needle placement accuracy was evaluated with ultrasound imaging. Results: Accurate needle penetration of the pectoralis minor muscle was 80–90% and 40–70% for experienced and novice clinicians, respectively, with the pincer approach. One pleural puncture was observed in one cadaver specimen with this approach by the novice clinician. Accurate needle penetration of the pectoralis minor muscle was 100% and 90% for experienced and novice clinicians, respectively, with the flat approach. The novice clinician required 3.5 times longer to perform the flat approach than the experienced clinician. Conclusions: The results of this pilot feasibility study suggest that a pincer-needle approach seems to be less accurate than the flat-needle approach and substantially more error-prone for a novice clinician, which, in a clinical context, could pose a potential risk of pneumothorax based on the pleural puncture observed in one cadaver specimen. In contrast, our preliminary results revealed that the flat-needle approach could have better accuracy and safety, particularly when performed under real ultrasound guidance. Full article

Background and Objectives: The aim of this retrospective study was to assess brachial plexus decompression throughout the sequential stages of the Roos procedure and to elucidate the role of first rib resection in the surgical management of Thoracic Outlet Syndrome (T.O.S). Materials and Methods: A total of 34 patients with a mean age of 34.6 years were included in this retrospective analysis. All patients underwent transaxillary first rib resection following anterior scalenotomy, consistent with the Roos procedure. Intraoperative brachial plexus functionality was assessed using recording electrodes for sensory and motor stimulation on the deltoid, biceps, triceps brachii, and abductor digiti minimi muscles. Mixed linear models with log-transformed data were used to assess changes in muscle measurements across surgical stages, with statistical significance at p less than 0.05. Results: The electromyographic values of the deltoid, biceps brachii, triceps brachii, and abductor digiti minimi muscles were significantly higher in the final post-operative neutral position compared to both the post-anterior scalenotomy and initial preoperative neutral positions. No significant differences were observed between the initial preoperative neutral position and the post-anterior scalenotomy values for these muscles. However, the abductor digiti minimi muscle exhibited a trend toward decreased values following anterior scalenotomy in comparison to the initial neutral position. Conclusions: Intraoperative outcomes of brachial plexus decompression during the Roos procedure demonstrate that first rib resection contributes to complete decompression of the relevant anatomical structures in Thoracic Outlet Syndrome. Full article

Problem Statement: Upper crossed syndrome (UCS), as first described by Janda, refers to a group of muscle imbalances in which tightness in the upper trapezius and levator scapulae dorsally cross with tightness in the pectoralis major and minor muscles, and weakness of deep cervical flexors cross ventrally with weakness of the middle and lower trapezius. Postural alterations from this dysfunction, including forward head, rounded shoulders, and scapular dyskinesis, contribute to upper-back and shoulder pain, particularly among office workers who spend long periods of the workday on a computer. Upper crossed syndrome is a significant contributor to both neck pain and shoulder pain among computer users, which have been rated at 55–69%, and 15–52%, respectively. Despite its prevalence, knowledge about UCS and its treatment remains spotty among primary care physicians. In addition, improvements in workstation ergonomics along with hourly work breaks may be considered as primary prevention strategies for UCS. Objectives: This narrative review examines and synthesizes evidence about the epidemiology and diagnosis of UCS, along with clinical recommendations for physiotherapeutic approaches to treatment. Ergonomic measures in the workplace, including changes in the design of computer workstations so that both the keyboard and monitor are at the proper heights to minimize the risk of long-term musculoskeletal disorders, are also critical. Methods: The first author, a Doctor of Behavioral Health, performed the initial literature search, which was reviewed by the second author, a PhD in sports injury epidemiology. The third author, a chiropractor and practice owner, provided clinical recommendations for stretching and strengthening exercises, which were also described in the literature. Discussion: While easily treatable when caught early, UCS may become resistant to noninvasive approaches over time, and more severe pathologies of the neck and shoulder, including impingement, thoracic outlet syndrome, and cervicogenic headaches may result. Because there is no specific ICD code for UCS, it is important for physicians to recognize the early signs, consider them in the context of workplace-related injuries, and understand physiotherapeutic strategies for symptom resolution. Full article

Vascular surgery has evolved from durable yet invasive open reconstructions to less traumatic endovascular techniques. While endovascular repair reduces perioperative morbidity, it introduces durability challenges and the need for lifelong surveillance. Laparoscopic surgery bridged some gaps but was hindered by steep learning curves and technical limitations. Robotic-assisted surgery represents a “third revolution”, combining the durability of open repair with the recovery and ergonomic benefits of minimally invasive approaches through enhanced 3D visualization, wristed instrumentation, and tremor filtration. This review synthesizes current evidence on robotic applications in vascular surgery, including aortic, visceral, venous, and endovascular interventions. Feasibility of robotic vascular surgery has been demonstrated in over 1500 patients across aortic, visceral, venous, and decompression procedures. Reported outcomes include pooled conversion rates of ~5%, 30-day mortality of 1–3%, and long-term patency rates exceeding 90% in aortoiliac occlusive disease. Similarly favorable outcomes have been observed in AAA repair, visceral artery aneurysm repair, IVC reconstructions, renal vein transpositions, and minimally invasive decompression procedures such as median arcuate ligament and thoracic outlet syndromes. Endovascular robotics enhances catheter navigation precision and reduces operator radiation exposure by 85–95%, with multiple series demonstrating consistent benefit compared to manual techniques. Despite these advantages, adoption is limited by high costs, lack of dedicated vascular instruments, absent haptic feedback on most platforms, and the need for standardized training. Most available evidence is observational and from high-volume centers, highlighting the need for multicenter randomized trials. Future directions include AI-enabled planning and augmented-reality navigation, which are the most feasible near-term technologies since they rely largely on software integration with existing systems. Other advances such as microsurgical robotics, soft-robotic platforms, and telesurgery remain longer-term developments requiring new hardware and regulatory pathways. Overcoming barriers through collaborative innovation, structured training, and robust evidence generation is essential for robotics to become a new standard in vascular care. Full article

Background: First rib stress fractures (FRSFs) are exceptionally rare in skeletally immature athletes and are frequently overlooked because their symptoms mimic more common scapular conditions such as scapular dyskinesis or thoracic outlet syndrome. Early and accurate identification is critical to avoid delayed union, prolonged disability, and misdirected management. Case Presentation: We report a 12-year-old elite baseball pitcher with progressive scapular winging and audible snapping during pitching. Unlike typical posterior-type fractures near the costotransverse joint, imaging revealed a cortical discontinuity precisely at the serratus anterior enthesis, consistent with repetitive traction enthesopathy. High-resolution musculoskeletal ultrasound (MSK-US) identified cortical disruption with periosteal edema, and dynamic ultrasound reproduced the patient’s snapping and pain in real time, establishing a direct clinical–imaging correlation. Conservative three-phase rehabilitation (scapular stabilization, serratus anterior activation, and structured return-to-throwing) led to complete union and pain-free return to sport within 12 weeks. Discussion: This case highlights the superior diagnostic efficacy of MSK-US for FRSFs in adolescents. The posterior scanning approach facilitated bilateral comparison and growth plate assessment. Dynamic examination provided a functional correlation beyond static imaging, identifying a novel snapping mechanism. This underscores the value of MSK-US in visualizing not just anatomy but also pathophysiology. Conclusions: This is among the youngest documented cases of first rib stress fracture diagnosed with dynamic ultrasound. Its novelty lies in the following: (1) occurrence at the serratus anterior enthesis, (2) reproduction of snapping during provocative maneuvers, and (3) expansion of the etiological spectrum of scapular dyskinesis to include rib pathology. Dynamic ultrasound should be considered a frontline modality for adolescent throwers with unexplained periscapular pain. Full article

Background/Objectives: Thoracic outlet syndrome (TOS) is a rare and difficult-to-diagnose condition in children, characterized by the compression of neurovascular structures in the thoracic outlet. Neurogenic TOS (nTOS) often presents with nonspecific symptoms such as paresthesia, weakness, and upper extremity discomfort. While anterior scalene muscle block (ASMB) has been used in adults as a diagnostic adjunct, its role in pediatric patients remains underreported. Methods: We present two adolescent female patients with suspected neurogenic thoracic outlet syndrome (nTOS) who were referred to the acute pain service for further evaluation. Both patients underwent ultrasound-guided ASMB. Results: Following the block, both patients experienced rapid and marked relief of symptoms. Subsequently, each underwent first rib resection with brachial plexus neurolysis. At follow-up, both patients reported a complete resolution of symptoms and a return to baseline function. Conclusions: These cases suggest that ASMB may serve as a functional diagnostic tool and short-term therapeutic test in pediatric nTOS patients. It also helps guide surgical decision-making for invasive treatment. However, as ASMB is not without risk, its role should be considered supportive rather than confirmatory. Further studies are needed to better define its utility and safety in the pediatric population. Full article

Objective: Neurogenic thoracic outlet syndrome (nTOS) is a rare compression neuropathy, and establishing a firm diagnosis can be challenging. Interscalene nerve blocks with Ropivacaine and Dexamethasone have been proposed in cases with typical symptoms and without evident pathology of the thoracic outlet (i.e., disputed nTOS) to establish the diagnosis. The aim of this study was to evaluate the effectiveness of interscalene nerve block for long-term pain relief in patients with true and disputed nTOS. Methods: Patients between 18 and 90 years of age with either true or disputed nTOS were prospectively included in the study. All patients received an interscalene nerve block with Ropivacaine and Dexamethasone. At baseline, 2, 6, 12, and 24 weeks after infiltration, minimum and maximum pain levels were assessed using the numeric rating scale (NRS 0–10). Furthermore, arm function was assessed using the Quick-DASH, and health-related quality of life was assessed by means of the SF-12 questionnaire. Statistical analysis was performed with SPSS version 29.0 using the Wilcoxon signed rank test and t-test for paired samples. A p-value below 0.05 was considered statistically significant. Results: A total of 21 patients were included in the study. There was a significant decrease in the minimum (Pmin) and maximum (Pmax) mean pain levels at 2 and 6 weeks after the baseline. Thereafter, 12 patients dropped out of the study due to surgery. In the remaining nine patients, pain levels remained significantly lower than baseline at 12 and 24 weeks after infiltration. Quick-DASH scores as well as the physical domain of the SF-12 showed significant improvement compared to baseline. Conclusions: In patients with true and disputed nTOS, long-term pain relief can be achieved with the interscalene nerve block with Ropivacaine and Dexamethasone. Additionally, the study indicated an improvement in arm function and health-related quality of life. In patients with disputed nTOS, the interscalene nerve block may be a useful tool to establish the diagnosis of clinically relevant true nTOS. Key points: Question: Does a scalene nerve block with Ropivacaine and Dexamethasone lead to long-term pain relief in patients with a neurogenic thoracic outlet syndrome (nTOS)? Findings: A scalene nerve block with Ropivacaine and Dexamethasone leads to significant pain relief, as well as an improvement in arm function and health-related quality of life for patients with a neurogenic TOS. Meaning: This study provides new insights into the diagnostic of neurogenic TOS and may be used as a short- and long-term pain therapy. Full article

Background and Clinical Significance: The levator claviculae muscle (also known as cleidocervicalis) is a vestigial muscle located in the posterior triangle of the neck, extending from the upper cervical transverse processus to the clavicle. It has been detected in ~2% of humans, but is rarely documented in the radiologic or anatomic literature. When found on physical exam, it is usually mis-identified as lymphadenopathy, metastasis, cysts, an aneurysm, or other masses. It has been implicated in a few cases of thoracic outlet syndrome. Case Presentation: Herein, we describe a 25-year-old man with a weightlifting history, who was found to have a right levator claviculae muscle in the setting of unilateral mixed neurovascular thoracic outlet syndrome. The patient presented with right-sided extremity paresthesias, pain in the neck, shoulder, and arm, and symptom exacerbation with overhead activities. He also described intermittent unilateral pulsatile tinnitus during strenuous exercise. On physical exam, he was found to have a right carotid bruit, unequal systolic blood pressures, and positive Roos and Adson’s testing. The variant muscle was identified with a modified exam maneuver, and was further characterized with sonography and MRI. Symptoms were managed with activity restriction and NSAIDs. We reviewed 17 cases of levator claviculae variant muscles in patients. Conclusions: The presence of levator claviculae muscles has been detected in patients with thoracic outlet syndrome, but never in a patient with an audible bruit and pulsatile tinnitus. This physical exam maneuver, used in conjunction with multimodal imaging, successfully aided diagnosis and direct medical management in this case. Full article

Background: Thoracic outlet syndrome (TOS) is an uncommon condition defined by the compression of neurovascular structures within the thoracic outlet. When conservative management strategies fail to alleviate symptoms, surgical decompression becomes necessary. The purpose of this study is to evaluate and compare the efficacy and safety of regional anesthesia (RA) using spontaneous breathing in contrast to general anesthesia (GA) for patients undergoing surgical intervention for TOS. Methods: We conducted a retrospective comparative study involving 68 patients who underwent trans-axillary first rib resection for TOS. The patient cohort was divided into two groups: 29 patients in the GA group and 39 patients in the RA group. The RA technique employed consisted of supraclavicular brachial plexus (SBP) and pectoral nerve (PECS II) blocks, accompanied by deep sedation. Key outcome measures such as pain scores, opioid consumption, and various perioperative parameters were systematically analyzed. Results: Postoperative pain levels recorded in the recovery room were significantly lower in the RA group, with a median numerical rating scale (NRS) score of zero compared to two in the GA group (p = 0.0443). Additionally, both intraoperative and postoperative opioid consumption showed a marked reduction in the RA group, with p-values of less than 0.001 and 0.0418, respectively. The RA approach was associated with shorter surgical durations (p = 0.0008), a decrease in the incidence of postoperative nausea and vomiting (PONV) (p = 0.0312), and a lower occurrence of intraoperative lung injuries (p < 0.0001). Furthermore, the length of hospital stay was significantly reduced for patients in the RA group. Conclusions: Although both groups reported low postoperative pain scores, the regional anesthesia approach exhibited distinct advantages in terms of opioid consumption, surgical duration, and overall perioperative outcomes. The utilization of SBP and PECS II blocks facilitated surgical procedures and mitigated complications, thereby positively influencing the postoperative recovery trajectory. Future prospective studies are essential to validate these findings further and to investigate long-term outcomes associated with the use of regional anesthesia in TOS surgery. Full article

Thoracic outlet syndrome (TOS) is a group of symptoms caused by the compression of neurovascular structures of the superior thoracic outlet. The knowledge of its clinical presentation with specific symptoms, as well as proper imaging examinations, ranging from plain radiographs to ultrasound, computed tomography and magnetic resonance imaging, may help achieve a precise diagnosis. Once TOS is recognized, proper treatment may comprise a conservative or a surgical approach. Full article

We present the case of a 23-year-old woman who reported weakness in the left upper limb, decreased warmth, numbness in the fingers, pain in the clavicular region, and a severe cold sensation in the limb. A thermal imaging camera examination was performed for diagnostic purposes, which guided further diagnostic and therapeutic management towards arterial thoracic outlet syndrome (aTOS). Following surgery and rehabilitation procedures, significant remission of symptoms was achieved and the patient’s condition improved. This is the first report on the diagnosis of aTOS using thermal imaging, paving the way for further clinical research into this effective, rapid, and radiation-free method of diagnostic imaging. Conclusion: Thermal imaging is one of the most effective, readily available, and patient-safe methods for diagnosing vascular disease associated with flow disruption. Full article

Thoracic outlet syndrome (TOS) is recognised in approximately 8% of the population. Vascular presentation is rare and diagnosis is often elusive due to its rarity. As episodes of TOS in the upper extremities are rare, proven protocols for rehabilitation management are lacking. The purpose of our article is to present a clinical examination protocol and a treatment protocol for patients after an episode of venous thrombosis in the upper limb (VTOS). We report the case of a middle-aged woman with right venous TOS with pain in the right upper extremity, accompanied by oedema and mild violet discolouration. The results after 10 sessions of physiotherapy were as follows: a reduction in symptoms of approximately 40%, an improvement of approximately 15% in sports performance, and an improvement of approximately 25% in work. There was also an improvement in the results of TOS provocation tests, i.e., a 50–100% improvement in pulse rate and about 30% less discolouration in the extremity. Additionally, there was a significant improvement in posture between the two sides of the upper quadrant. The results after 10 physiotherapy sessions are surprising due to chronic disease after the thrombosis episode. It appears that even after a long period of time since diagnosis, improvement is possible. Full article