Thank you everybody, good afternoon, hopefully we're in there until the end of the day. Thank you guys for coming, this is ICL 38 and we're going to be discussing Neurogenic Thoracic Outlet Primer for the Hand Surgeon, Cesar Bravo from Virginia Tech. We have a great panel of experts and we're excited to share some information and hopefully something applicable to your practice. I do not have any conflicts of interest to declare, first starting off is going to be my partner, Dr. Peter A. Pell, who's going to talk to us about clinical presentation of Neurogenic TOS, is it fact or fiction? We also have our esteemed therapist that's with us, that works with us on a daily basis, she's going to talk to us, Ms. Catherine Larson, she's going to talk to us about non-surgical management of Neurogenic TOS. Then we have Dr. Lee from Wake Forest, who's going to talk to us to resect or keep the first rib for NTOS and give us his wisdom and expertise. Then we have the team from the University of Alabama, Birmingham, Dr. Richard Meyer and Dr. Anne Ransom, and she's going to discuss the treatment algorithm for practice-based experience, which they have a lot of. Last but not least, we do have Dr. Jamie Bertelli, who's going to give us a Brazilian perspective of NTOS. Unfortunately, he did record his session because he has another conjunction, but hopefully towards the end of the ICL, he'll be with us for the question session. One of the things for Thoracic Outlet Syndrome, as we discussed that, is a broad term whose definition is upper extremity symptoms due to compression of the thoracic or bundled vibratory structures in the area between the first rib and behind the clavicle. What we're going to be focusing on is the Neurogenic TOS, which is the main 95 percent of the Thoracic Outlet Syndrome that we tend to see in clinical practice. We're going to be addressing and talking about three anatomical spaces, and the ones that are involved in Neurogenic TOS specifically are the scalene triangle and the pectoralis minor space. Here's the scalene triangle, as well as the pectoralis minor space. Our goal with the ICL is basically that us, as hand upper extremity surgeons, that we recognize this in our practice, that this kind of avoids that long-term sequela of these patients that are undiagnosed, that have seen multiple providers before they see us, and that recognize that this is an otherwise healthy patient population, that it really affects their prime working life. And understand that these patients, if we get to them early, that we're able to respond well with directed therapy dedicated for NTOS. Thank you. So thanks, Dr. Bravo, thanks everybody for being here on a Friday afternoon. So I'm going to talk about the clinical presentation of thoracic outlet syndrome and try to answer is it fact or is it fiction? Here's our team that we have down at Virginia Tech that we approach this with. We have a multidisciplinary team. So in trying to understand thoracic outlet syndrome, it's very hard to put your finger on exactly what it is. And it reminds me of Justice Potter Stewart when discussing a case from the 1960s about obscenity that came to the United States Supreme Court said, I shall not today attempt to further define the term and perhaps I never could in intelligibly doing so. But I know it when I see it. As somebody that treats a lot of thoracic outlet syndrome, that's how I feel about it. It's really hard to define exactly what it is, but I know it when I see it. In the past, we have in our literature this term true neurogenic thoracic outlet syndrome, which is described as atrophy of the APB and the ADM, the Gillott-Sumner hand. Others have talked about there being MABC changes on NCVs. And this represents true neurogenic thoracic outlet syndrome, and the rest is disputed. I would argue that, in fact, those are advanced findings, much like this would be the advanced findings in a rainstorm. If you look closer, you can see the earlier findings, like the raindrops here on the pond. So you don't have to have atrophy in the hand to diagnose thoracic outlet syndrome. There's patterns that we can see that are common and that are going to be much earlier findings. Certainly, in our practice, we should consider it any time we've got a patient with combined neck, shoulder, and arm pain and sensory disturbances, especially when they go down to the ring and small fingers. We see a lot of scapular winging as well. And this combination together should be a clue that this could be thoracic outlet syndrome. But one of the keys that's going to differentiate it from radiculopathy and other symptoms are the positional nature of it. So I'm going to show a quick video of one of our patients that sums up the most common features that we see. So she describes many of the typical findings, right? She's a young female, she's an overhead athlete, she's got the numbness in her fingers. You may not have been able to hear the audio, but she says she feels it in the tips of all of her fingers and then really down the shaft of her pinky. And that's a very typical distribution pattern for the numbness. You'll see in the future videos that she's got scapular dyskinesia and scapular winging. She describes her symptoms of being worse with overhead activity. She talked about driving positionally with getting the arm out. And she even describes some of the sympathetic changes. She says it feels cold. And I think this is why this condition is commonly misunderstood as vascular. Because especially with the lower trunk involvement there's a sympathetic component to it. And that sympathetic component is commonly misinterpreted as being vascular in origin, when in reality it's autonomic in origin. So Sanders did a review, this is now 15 years ago, of his cases describing the different symptoms that were seen in his patients with thoracic outlet syndrome. And you can see that the most common features are paresthesias, trapezius pain, neck pain, shoulder pain, arm pain, supracavicular pain, and occipital headaches. And this is referred pain. Much like in carpal tunnel syndrome, patients have pain in their thumb, index, and long fingers. We know that the thumb, index, and long fingers are normal. That the neurologic pain causes referral. And so with thoracic outlet syndrome it's referred into the occiput because the brain is misunderstanding the origin of it. The pattern of the paresthesias, over half of patients will describe all five fingers. Although more commonly there will be a predominance in the ulnar side of digits, like our patient here described. So we use a template in our clinic. With the advent of the EMR, it's easy to use a template. We'll pull it up as we're going through the exam to make sure we hit all of the components. We ask about each of the specific areas described in the Sanders paper. We go through each of the exam components and perform all of the provocative tests to ensure that everything gets covered. And the advantage of using one of these templates, certainly for us, is you can take a step back and you can look at all the information on the page and say, does this actually fit the pattern of radiculopathy? Does this actually fit the pattern of cubital tunnel syndrome? Or is there something that's going on there that's beyond either of those? And that's how we're able to help come to that diagnosis. We do use PROs in our clinic. We use the QuickDash. We're transitioning to using the Promise. But probably the more beneficial questionnaire that we use is the CBSQ. And so this was described by Jordan et al. And the most beneficial part of it is this diagram that patients use, where they draw where they have numbness and where they have pain. We've modified it to use color. And you can see this is a typical diagram for a patient with thoracic outlet syndrome. And so you see they've got the numbness in the ring and small fingers. But the pain is all in that periscopular region. You have it on the medial border of the scapula and up in the trapezius. And so this pattern with the periscopular pain and the numbness is really the stereotypical pattern we'll see in thoracic outlet syndrome. For us in our brachial plexus clinic, Parsonage-Turner is probably the number one mimic. This is probably the number one referral in that we get that's non-specific numbness and pain that mostly mimics thoracic outlet syndrome. Other diagnoses such as cubital tunnel syndrome and radiculopathy are much easier to differentiate. The one thing, this is not an ICL and Parsonage-Turner syndrome. But simply when the diagnostic for the diagnosis, the history and the pattern of numbness are going to be very different for Parsonage-Turner syndrome versus thoracic outlet syndrome. With Parsonage-Turner having that sudden onset and the pattern of numbness typically being upper trunk rather than lower trunk. So for the physical exam, our patient here is going to demonstrate some of the typical findings. You see that scapular dyskinesia on the right. Dr. Bravo is going to demonstrate in the exam here the winging. Here she's performing the upper limb tension test. By bringing the arms out to the side, she'll progressively bring the wrists up and then tilt the head away from the affected side. Her right side is the affected side here. You'll see as she turns away, that reproduces symptoms. She can turn away no problem from the other side. This is a non-specific test. This is just of brachial plexus irritation. It's not of thoracic outlet syndrome per se. This is Wright's test, which we find to be one of the most helpful positional tests. Just simply bringing the arm up overhead. Some of the legacy tests, the ADSENS and the ROOS, are really, unfortunately, non-specific. That's the arms overhead, opening and closing, and then the turning away. Those are really sort of legacy tests that are not helpful for differentiating neurogenic thoracic outlet syndrome from other more common conditions. So we don't use those in our clinic. We focus on these maneuvers instead. To sum up, really, the key to diagnosis is the high index of suspicion. You'll find that it just doesn't fit anything else. It's not really cubital tunnel syndrome. They've got shoulder complaints. It's not radiculopathy. There's no neck complaints. It's not Parsonage-Turner. It didn't have a sudden onset. It is important, though, to rule out other more common pathology. That's really where the role of nerve conduction studies or EMGs or MRIs come in. Those are helpful only insofar that they're negative and that they rule other things out. There's no serology test. There's no EMG. There's no MRI that's going to be patho-pneumonic for thoracic outlet syndrome. It's a clinical diagnosis of exclusion where everything else has been eliminated. Certainly, I would discourage you from waiting for advanced findings. By early diagnosis and early treatment, you can end up with excellent results. Really, the key to many things that we do in the hand and upper extremity, good indications lead to good results. Even Dr. Bravo is surprised. And she has no neurologic symptoms now with overhead activity. Watch that scapula on the right, which was dyskinetic and winging before, and you can see that's been extinguished. Thanks. Was that a patient after PT or after surgery? That was after surgery. That was four weeks post-op. Does ligamentous laxity have an obvious part of the diagnosis, or none at all, once you see these patients? That's a great question. I have not seen any formal association between ligamentous laxity and the diagnosis. It certainly is more common in females. Hi, I'm Catherine Larson. I'm the CHT, and I'm with the Brachial Plexus Program with these guys. I have the pleasure of working with Dr. Bravo and Dr. Apel. So there is a fair amount of evidence for therapeutic intervention. It really varies in the literature from 39% to 70%. We don't find anything close to 70%, and I wonder if they had sort of cherry-picked their patients to get that kind of result. But just off the top of my head, I'd say around 50%. We have a 12-week program. The goal of the first six weeks is lower pain to get them improved postural awareness, better core strength, lengthen the tight muscles, do some nerve glides, and really look at ergonomic stressors. The next six weeks continue to improve their posture, ergonomics, and go on to more advanced positions, overhead, and hopefully return to their sports and avocational activities. There are some failures in therapeutic intervention. Sometimes the symptoms remain static or worsen. We have been going to 12 weeks, but I'm kind of wanting to scale back to stopping at six weeks if we see no improvement at all. Sometimes the patient pain level is just too high to engage in any kind of therapy, and sometimes the improvements are not significant enough for them to go back to their goal activity. In concomitant diseases or surgeries, I had a patient who had some severe vestibular problems, so she couldn't do anything prone. She couldn't tilt her head. This really kept her from doing a lot of the therapeutic intervention. So during the evaluation, I look at their posture. A lot of times there's cervical lordosis. Of course, because of the pain, they got scapular protraction, elevation. I look at the scapular tilt, winging, and a big part is their work or sports stressors. This is one of our patients, and you can see she's really working that overhead position. We look at muscle tightness and muscle weakness. This is just a quick example of a couple of before and after. This is one of our med students who was our model here, so forward head posture. If they do some chin tucks, it loosens up those middle scalenes. Rounded shoulder, have them do scapular retractions. We start on easy pec minor lengthening as long as they're not getting too symptomatic. Then in the middle, we've got a fairly aggressive middle scalene stretch. Then levators are often very tight, so we have them do levator stretches. There's some evidence that nerve glides can be helpful. These are glides, not stretches. We have them tilt their head towards the symptomatic arm so that they're not stretching the nerve so much as gliding it through those tight spaces. A lot of these patients can't even reach full elbow extension. They kind of get to about here, and we don't push them any further than where they can get to. But a lot of times over the course of therapy, they can eventually reach full motion in their arm without paresthesia. We want to reduce external ergonomic stressors, so backpacks are a big problem. Sometimes we can get people to pull items behind them. Overhead activities, and if they're in competitive sports, we usually like them to just discontinue while they're in therapy. Then workstation, if people are in this kind of posture all day long at a workstation, they're going to just tighten up the already tight muscles and weaken their scapular muscles. Then we progress. In the next six weeks, we want to continue to improve posture and ergonomics. I like to tell people it's like flossing your teeth. You're going to want to do this the rest of your life, because otherwise you will just go right back into those postures that do not help this type of situation. Cell phones are a particular problem, and so a lot of youngsters get that sort of rounded posture, and they're tilting with their head forward and looking at the cell phone. Anyway, then we strengthen the scapular stabilizers. A lot of times that's serratus, rhomboids, lower and middle traps, and often infraspinatus is weak, and that just contributes to the whole dysfunction of the scapula. Developing optimal scapular kinematics, so getting them to engage the proper muscles. Sometimes they have strong muscles. They just can't engage them or haven't learned to engage them when they're doing their activities, and hopefully resume their sports. Here's an in-range pec minor stretch, so we increase the stretch as tolerated. If they haven't a lot of symptoms, we don't increase like this. Strengthening the scapular stabilizers. On the left, this is a serratus. This is a weighted ball, and so we get them started with that. Middle trap exercise, and then just a straightforward external rotator strengthening, just like you would with a rotator cuff repair. Progress to more advanced positions. Now you can see why the patient with vestibular problems didn't continue with this therapy. Middle traps on the left there, and then this guy is doing some lower trap strengthening. You can increase the weights. We do want to improve their use of their arm overhead. Sometimes they have good core strength, but they just don't use their core strength, so they're extending their lumbar instead of moving their arm because they've had so many years or months of arm pain that they have substitution patterns, and they have to relearn how to use those arms properly. He's working on motions, and I'll give verbal or tactile cueing for that. In summary, first phase emphasizes lengthening those tight muscles, ergonomics, posture, a lot of times diaphragmatic breathing, nerve glides, and the second phase emphasizes strengthening those weaker posterior muscles, improving the scapular motion, and resuming functional activities. If they're unable to complete these programs or significant symptoms persist, then surgery should be considered. Thank you. applause That's the question. Definitely so. Excuse me, what was the question? That your therapy program. So when I work with the surgeons that I'm familiar with, of course they say follow the TOS program. If you were to look at the screens where I had the 6 to 12 week, I think that would be enough guidance for a good therapist to go through with that. And I think they would just need to know, look if these symptoms are persisting, there's no improvement at 6 weeks, then send them back to me. I want to reevaluate. Do you think that program may be, I'm just thinking for the everyday patient, that we have episodic cubital tongue symptoms, we're not really thinking about uppercutting everything up. Right. So just where it's limp at night and where it's come out fast. But I'm thinking that program may have significant overlap in value to that everyday cubital tongue patient. It very well may, especially with the nerve glides and postural improvement, yeah, I agree. You know, and one of the things we do have, you know, that's where, you know, with the ICO, the proposal, we do have, this is going to be available for signing then. If any of those are you needed, definitely you can email us what we use. We can share, that's what we want to do, share what we do that we've seen that works and that, because you can easily apply it to your practice and educate your therapist. I'd be happy to talk to any therapist or email or text and give them kind of overview of what I do too. And what we'll do, we'll keep rolling so we can get, because we've got a couple lectures and then definitely at the end, we'll have the panel and we can go through extensive with answers and questions. All right. Thank you for having me. I'm going to give a talk about should we take the rib out or keep the rib? I think that's the most exciting part of this symposium. Yeah, I'm John Lee from Wake Forest. If you don't know Wake Forest, we are from North Carolina. We have a lot of people here, so I have no conflict of interest. So we know there are three types of thoracic outlet syndromes. Arterial, venous, can about 5%. Those patients, typically you need to take the rib out. So we, vascular surgeons, typically working with us together to do the procedure. But 95% of patients are neurogenic. As Dr. Pell discussed about patient's presentation just quickly, most of the time patient come in complains of ulnar, side of hand, forearm numbness, tingling, but it's not unusual. They tell you the whole arm is tingling. And sometimes tingling even radiates to their face. So facial tingling is not unusual. You're worried about is this MS? And a patient oftentimes have neck pain, headaches, periscapular pain. The most characteristic complaint is arm so heavy. All right, so we call it dead arm syndrome. Once they lift it up, they just so feel heavy, they have to put it down. So even brush teeth, brush hair becomes difficult. And so when we examine the patient, look at how good their posture is, and the muscle atrophy. And oftentimes they have tenderness of the supraclavicular area, especially skinny people, especially have cervical rib, you can feel it. You touch it, it's firm and sensitive to touch. We'll still do TNL. We like rules, standard rules test, three minutes, you try to let them squeeze. Most of the time within one minute they have to put down because tingly or heavy or pain. And we feel Edison in the right test are not specific because symmetrical, even the non-symptomatic side have post changes sometimes. But it's most commonly comes to see us that my doctor said my post disappears when we do this. It's not specific. And wasting oftentimes not only affect the hypothermia area, also affects thinner areas. So those are very late stage, as Dr. Appell mentioned. And sensation changes are not only the owner distribution, also medial and tuberculous distribution. So the typical presentation. So the Association of Vascular Surgeons in 2016, they decided to get rid of name of true or disputed or non-specific thoracic outlet syndromes. They proposed four criterias. If we can meet three, it's thoracic outlet syndrome. So it's a clinical diagnosis based on the local symptoms or physical findings, peripheral symptoms, physical findings, throughout other conditions. And they recommended to do scaling block. If you meet three criterias out of four, neurogenic thoracic outlet syndrome. So we routinely get a C-spine x-ray to check, make sure there are no thoracic spine arthritis or stenosis causing reticulopathy. Not unusual to see cervical ribs. We see more cervical ribs than we expect. And I never see a pancreas tumor except one patient actually came to tell me he had pancreas tumor with thoracic outlet. Although it's a common testing question. But we always get a nerve testing. We get an EDX. We tell patients the purpose of EDX is not rule in. We try to rule out other conditions. You know, this is the EMG finding. I show you a classic EMG finding. So neurogenic thoracic outlet syndrome. Those are typically very late stage. So early stage, you don't see much changes. And imaging studies, specifically for those people, you have concerns of possible nerve sheath tumor or soft tissue mass pressing on it. Well, sometimes we'll get a CAT scan. If it has clavicle fractures, you worry about malunion. Bone caries may compress on it. So three zones. We know first rib serves as a floor for the inner scalene triangle and costoclavicular space. So remove the rib, you basically open up the back door for two areas, right? So decompress the inner scalene space and costoclavicular space. So that used to be the standard care. You have to take the rib out. But same time, we wonder, if you release the scalene muscle insertion, you open up the side doors. So the triangle has two sides open. Also, the first rib is going to drop because there's no superior pulling force. So you can open up both space. Why should we take the rib out? And that's one of the reasons we started selectively taking rib out instead of taking rib out for every single patient. And the other debate is approach. We all well know some surgeons use extracellular approach. Some use periclavicular approach. As long as you do it right, and a study showing either way can cure the problem, can treat the problem. And scalene anatomy versus scaleneectomy, we typically just release scalene muscle insertion instead of remove the muscle out. We see some vascular surgeons like cutting the muscle out. And pec minor space release, it's a small percentage of patients in our practice need a pec minor release. So how do we decide to take the rib out or keep the rib in? So we're looking for obvious causes. Soft tissue-wise, scalene muscle could be very, very beefy, hypertrophic, sometimes anterior scalene or sometimes mid-scalene, sometimes both of them. It's not unusual you see tight tenderness portion pressing on the nerve like this patient. That's mid-scalene muscle. You can see here the medial edge of the mid-scalene is tendon. This is a lower praxis, T1, C8 and T1 curved over, so tending on the lower praxis. You can imagine where muscle fires can press even further. So release those muscles or this patient here, this is anterior scalene muscle. We haven't released the transverse cervical artery and veins yet. Very wide, tenderness, tight anterior scalene muscle. And this upper chunk is buried inside the fascia. So a lot of tight fascias you have to release, looking for obvious causes. This is after fascia release. You can see that's the rib behind. We have decided the fate of this rib. Should we cut it out and leave it in? And vascular problems can cause compression. So you see sometimes large vessel ring loop around the nerve root or the chunk. And some occasionally you see aneurysms here. So this upper chunk, suprascapular nerve here, middle chunks are here. Lower chunk is covered by all the venous aneurysms. So if it fills with blood, it can compress it, right? So get rid of all the soft tissue, obvious offenders. Then thinking about bony problems, like this patient had clavicle fracture, now form larger callus on the superior posterior portion of the clavicle, directly pressing on the nerves. So we remove those callus. Patient woke up in the recovery room, they tell you symptoms are gone. Those are very good cases to treat. A cervical rib obviously can cause. So this is, see that, have cervical rib at one side, cervical rib tending on all the nerves. So remove the cervical rib, release the scalings can help those patients. Now, after all, you take care of all those obvious causes. This patient can see here, that's typical patient would do. That's subocclavial artery here. All the nerve roots are out. You make sure there's no fibro bands pressing on the nerve roots. Okay, quite a medial side. Once we're done, we do this maneuver called nutcracker. We just made it up the name. So what we do is slide your index finger underneath the clavicle. Now brachial plexus is behind you. First rib is behind the brachial plexus. Then you abduct the shoulder to 90 degrees and external rotate. If your finger being pinched like nutcracker, the first rib maybe is a troublemaker, have to take it out. If it's loose, we leave the first rib in. And we tell people, you do by yourself. Don't have us one person put a finger there, other people turn this way, your finger may be impinged in between two bony structures. So who needs the rib resection then? As I mentioned, if it's a positive, it's pinching on your finger, we take the rib out. If a rib has a malunion, had people a lot of trauma, may had trauma before, now present with symptoms, we take the rib out. Or if a rib is obviously pushing on the structures, like this patient, before we release it, you can see the subclavial and the nerves being pushing anteriorly. So those patients, we take the rib out. For revision surgeries. So that's an example, after release, after we take care of all the obvious compression, release all the nerve roots here, we did a nutcracker test, it's fine. That's her, came back six weeks, she brought in weights with her. Like, what's going on? So she's showing how strong she is, and her shoulder has no pain. She's very happy, she's stronger than me. After surgery. So that's a typical scar healed six weeks. After six months, they barely can see the scar. There's a small study in 2005, from Hopkins, looking at 54 patients, compare rib sparing versus rib resection. You know, this study's showing rib resection patients do better than rib sparing surgeries. But looking at a small population of patients, they all have severe pain. So it's not a very typical thoracic outlet populations we deal with. Everyone has more than 8 out of 10 pain before the surgery. So there's a recent study by Johnson, reported 504 patients all had a rib sparing procedure. Everyone was confirmed there was a scaling block before the surgery. So 91% of patients reported more than 50% symptom relief. So they believe that not every patient deserves a first rib resection. So this is our current approach. The majority of patients we refer for therapy. We tell them therapy, therapy, therapy. Because most people do well without surgery. And for those who could not tolerate therapy, or refractory to therapy, then we'll do surgery. Then we don't take the rib out easily, because every structure has its purpose. So we do tell patients we may take the rib out, but if you wake up, we'll tell you you can go home, means the rib is still there. So a lot of times patients ask you, did you keep my rib in? They're very happy to hear that, didn't take the rib out. So this is our current approach. If we get rid of scaling attachment, release the fibro bands, if there's cervical rib, resect the cervical rib. Then we do the nutcracker maneuver. If it's negative, we keep the rib in, our patient will go home the same day. If it's a positive, if the rib is prominent, we take it out, and typically stay overnight. We'll make sure there are no pneumothorax. So thank you for attention. APPLAUSE I would say less than 1%. I can recall it's probably one or two patients. Was that difficult for you? No. I just want to state that we've published some data on your nutcracker test. No one. Which I have, and it's in the Annals of Thoracic Surgery. What do you call the name? And what we did is we measured the interstitial pressure between the costo-cavicular space with the arm in an adduct position, abduct and external rotation. And we found a statistically significant difference only and only when you took the first rib out. I think myself, we've been frustrated by recurrence of symptoms. We see that not infrequently. When I first started, I only learned how to do scalenectomies, and that's all I did, and I was frustrated by it. But I would refer you to that, and there's another study that's out there looking at the CT of the costo-cavicular space with the arms positioning, showing significant difficulty with reduction. So my argument for you is I like the nutcracker test. I do that, but I've done it with interstitial pressure measurements using an A-line monitor and a GI balloon, and we've shown you really do need to take the first rib out. So. Where did you put the catheter? We put the balloon, and it's used to dilate the esophagus, and you put it in the costo-cavicular space, and then we inflate it and measure it on an A-line. You get the average pressure, and then abduct and externally rotate. And it's remarkable the difference in pressure. Before you do any scalenectomy, it could be on average about 200 millimeters, but when you take the, just do a scalenectomy, it only drops to about 170, but when you remove the first rib, it drops down to 50. So it's in the anals of thoracic surgery. Thank you. So Dr. Ruse described similar maneuver through the axillary approach. He put a finger there. What the purpose of testing is to determine if a second rib need be removed. So he does the, after first rib removal, then put a finger in. I'd like to mention that both Wrights and Ruse, or both Wrights and Adson's tests, were described before fluoro, and they were the vascular surgeon's impression about what's happening. If you do many of these thoracic outlet cases, you will find that the anterior scalene is inserting on both sides of the subclavian artery very frequently, especially medially. And it's no different than you putting a vessel loop or a tourniquet, just a single thing, around a vessel to control the bleeding. And when you do the nutcracker test, if those bands are still there, they're going to put compression on the subclavian artery and definitely reduce its flow. So any kind of valid, any kind of measurements you make, unless you have totally resected the scalene from way medial on the subclavian artery, you really have no idea what's causing the decreased flow in this situation. All right, so now we're going to talk about a treatment algorithm for neurogenic thoracic outlet syndrome. So at this point, we've diagnosed the patient, we've ruled out other causes, and if they had other causes, we've taken care of those. And we've tried conservative management, and it has failed. So we're going to talk about adjuncts that you can use, both for treatment and to help you make a decision about surgery, and then review some of the decisions that you can make as far as when you're going forward with surgery, except for the first drip, since we just had an excellent talk on that. So injections can be therapeutic or diagnostic, and they're done into the scalene muscles and the pectoralis minor. And our goals for a diagnostic injection, and it's important if you're just starting this out with your anesthesiologist, that it's different than a preoperative block. If you have a sensory or a motor block, then it's a failed injection, and it needs to be repeated. You just want to get it into the muscle belly without any spread outside. And goals for therapeutic injection is you can use it with your therapy to try to help them get through that process. So looking at the diagnostic injection, what's really, you want to separate these out by a couple of days so that you don't get crossover results. And you want to instruct the patient to go perform those activities that really aggravate their symptoms. You don't want them to just go home and sit on the couch after the injection. If they're a pitcher, they need to go throw the ball. So really highlight that when you're counseling them about getting it scheduled and what they're going to go do afterwards. And get them to keep a pain diary after the injection because they'll quickly forget how they felt after one versus the other, and it's important for you for making decisions later. Just looking at some of the results from these blocks, if they have a good response to the block, and 94% of those patients, they have a good response to surgery. And it's similar for if they, if the block's done with Botox, they have a good response with surgery as well. But even if they have a negative block, it doesn't mean that they don't have thoracic outlet syndrome. You haven't ruled it out with a negative block. They're just a little bit, you're a little bit less sure of the results you're going to get from surgery. And you can counsel your patients on that when you're trying to decide whether to move forward with surgery or not. For therapeutic injections, for steroids, it's the same amount of lidocaine, and then you just add steroid as well. And they do have a good reduction in symptoms with this. Botox is a little bit less sure with the results. There's a wide variety in the reduction of symptoms. And then one double-blind randomized control trial did show that there weren't any improvements in their neurogenic patients. And it even delayed their surgery for a couple of years. So you have to be careful with Botox. It's also very difficult to get it covered by insurance. So your surgical indications are going to be an electrically positive with those weakness or atrophy of the muscles. Or if they are electrically negative, they failed their conservative management. And that's when you have to make decisions about which approach are you going to use. Can you do it in a staged approach? And do you want to keep or remove the rib? So one option is the transaxillary approach. And this is midline underneath the axilla. You make an open incision and can remove the scalenes off of the rib and remove the rib through this window. The other main approach that's used is the supraclavicular. And it's an incision right above the clavicle. You remove or take out part of the scalene and any fiber spans just like we talked about. The way I decide where I make my incision is I put my finger right over the clavicle and then I lift up their arm, their in beach chair position, and see where that fold is in their neck to try to put it in a crease to make it more cosmetic. The pectoralis minor release is done through a delta pectoral approach. And similar to one you would use for the shoulder, you just shift it up right over the coracoid so that it's a smaller incision. And if you look at this, see if I can get the pointer to work, this is the conjoined tendon going this way and your pectoralis minor is going this way. And it's important, sometimes there will be a structure back here on the posterior aspect of the coracoid going straight, medial coracocostal ligament to resect directly off the coracoid as well. So this is just showing a couple of pictures after the scalenes have been removed, just looking at for removal of the rib. This is medial and this is lateral. This is the phrenic nerve right here and I do remove the entire scalene. And I think it's easier to remove it off the inferior portion first because then the muscle retracts out of your way to remove it superiorly. I never put vessel loops on the C8 or T1 nerve root. This is just to kind of show it coming above the rib and below the rib. This is the rib right here. Long thoracic nerves here in the back. So don't ever put a vessel loop around them and retract it this way. This is just for the picture. Achilles put up here in the foramen and then the rib is cut right along that most narrow portion of the rib, actually medial to where those nerve roots are coming out. For the anterior cut, this is the plexus right here. The subclavian artery is right here medially and that's retracted there. Achilles put here in the front and the cut is made right here between the plexus and the subclavian artery. And I use a double lumen tube and completely drop the lung during this part so that it's not in your way. And then if you don't have the ability to do that, you can have the anesthesiologist hold their breath. So this is a video of that Kelly going into that neuroforamen. So this is the plexus right here and you can see how it really just drops in after everything's been cleaned off with the periosteal elevator. And then you can rotate it up to really retract everything up so that you can see that area. This is getting ready to take out the rib and you can see that's the C8 and T1 nerve roots above and below which can be retracted out of the way using the sucker tip. And then you can have your assistant hold the sucker tip and then put two hands on the saw to put it going right from that Kelly down and your nerve roots are held out of the way. And then this final picture, for that cut up top, I use a really short saw blade so that there's not as much play in it and then I put a longer one when I go down to do the front cut so that you can see when it's coming down. One technique for taking the rib out so that you don't cause a lot of stress on the nerves. Your rib is going to be curved around this way, and so your first motion you're going to want to do is to actually take your ronger and rotate it upwards like this, and then you want to rotate it out of the body. So you're not strictly pulling it out straight, you're just rotating it out to not put any stress. And this is a video that's actually being done in real time. And I put my non-dominant hand on the clavicle to really brace it as it's coming out to make sure that it's really being smooth coming out. And the more time you spend cleaning muscle off of it by sweeping your finger, the less muscle you have to work around pulling it out and the less force you have to use. So this is just that first maneuver of rotating it up. And then once you get it in that position, if you need to re-grab, you can grab it with a kelly and reposition your ronger, move any of the superior portion of the nerves out of the way, and then really brace your hand up on the chest wall with your non-dominant hand and rotate it out. So there's pros and cons to both of these approaches. I think the biggest is the transaxillary. I just showed you how to do a ribber section with the supraglavicular, but it is potentially easier to remove it transaxillary. The biggest upside to the supraglavicular is that you can really see really superior on those roots and trunks and really take out all those fiber spans, that scalene muscle that's going in between the nerve roots and trunks. But you have to be really careful about your phrenic and your long thoracic nerve. There's other approaches on the horizon. Thibault LaFosse has done some brachial plexus neuralysis using endoscopic techniques, but it's mainly on the lower portion of the plexus at this point. And then there's also endoscopic and robotic techniques that are out there as well. And I think this is the future of where we'll be going eventually. So the other question is, say you have a patient that gets their blocks, they get a great response from their pectoralis minor block and no response from their supraglavicular. Their symptoms on exam are more around that coracoid, so you think it's really more their pectoralis minor that's causing the symptoms. So what do you do in that situation? So if they have symptoms at both levels, then you can go ahead and do a pectoralis minor tonotomy, the first ribber section, supraglavicular decompression, get the whole blue plate special. But if they're mainly at their pectoralis minor, you can consider just doing a pectoralis minor tonotomy. It's a 30-minute procedure. It can be done at a surgery center, and it's a really quick recovery, basically just for the skin to heal, so it's an easy surgery for them to recover from. But you have to counsel a patient that they may end up having to come back and have that other incision to have the full decompression. If you look at patients that are in this scenario, the ones that only had symptoms down there at the pectoralis minor, the majority of them do well with just a pectoralis minor release. If they have symptoms at both levels, then they're more likely to fail and go on to need a full decompression. So all of these in the failed category had symptoms at both levels and went on to have that later decompression. Now, failed sounds really bad, but it's really just an extra surgery, having to do that same surgery they would have had at a later date. So you're delaying their treatment. But some people have a lot of things going on. Thanksgiving's coming up. Their daughter's in a recital. So they may opt to have two surgeries, knowing that that pectoralis minor tonotomy may fail, but it may also just kind of get them by until they can have the big operation based on what's going on in their life. So this is just something to keep in mind when you're counseling your patient about how you want to do things and how you want to go about it. So in summary, injections can be helpful for surgical decision-making and also for treatment as well. There are a lot of different options for surgery, and it's really just important to do what you're most comfortable with in your hands. And then pectoralis minor symptoms can be approached staged or all at once, but just knowing that there's a high risk of needing that secondary surgery when symptoms at both levels fail. And those that went on to need that secondary surgery likely do just as well as if they had had it the first time. They're just having two surgeries. Thank you. I had another question before you start, which is about vascular tests. And I found in my neurogenic thoracic outlet patients, almost 100% of them have positive non-invasive vascular studies. That's not your Roos or your Atsin's test. That's doing peripheral volume recordings, PVRs, and maximum positioning of the arm. You didn't mention that as part of your diagnostic workup. If they're negative on those vascular tests, I'm hesitant to consider surgery, not absolutely. But I think that it has to go along for you to make a diagnosis. Any comment from the panelists? We don't regularly incorporate vascular tests in our clinic. Certainly if the data would indicate that they do well or do poorly with operative and non-operative management, we'd love to include them in those sorts of studies. But we don't routinely get those in our clinic, any vascular studies for that matter, unless they have vascular symptoms, in which case, they go to the vascular surgeon. We have any concerns if we let them see our vascular colleague, they will do Doppler. If there's any concerns, they do a venogram or a teargram as needed. I would say in our clinic, also once a year, we get a patient that has vascular TOS, whether it's arterial or paget-schroder, and then that very quickly goes to the vascular surgeons. I think, like Dr. Meyer pointed out, you can have neurogenic thoracic outlet and still have positional changes in flow in your subclavian artery without there being an actual structural problem in the artery. That can convolute things a little bit more, but if you have any question, we normally send our vascular surgeon, and sometimes they'll completely rule it out and send them back to us. We just do utilize that to help us with the decision. You mean cervical rib? I think the majority, certainly of our operated patients, don't have a cervical rib. So yeah, my understanding, again I don't remember the studies off the top of my head, is that a cervical rib has neither predicted likelihood of neurogenic TOS or been shown to be protective one way or the other. Prevalence in patients with neurogenic TOS is the same as in patients without. Maybe while we're waiting, I can ask one of the other panelists a question. So Erin, in your clinic, do you routinely send everybody for a diagnostic injection in one way, shape, or form? Yes. The one problem that I've had with it is trying to get the anesthesiologist to inject the younger patients, but I typically get those diagnostic injections on everyone, if nothing else just to have a discussion about whether they want to go forward with surgery and how quickly and what's their likely outcome from it. So that's middle scaling, wait a week, pectoralis minor? 24 hours in between the two. Okay. And then come back to see you to discuss the results. And do you require, so that's a diagnostic step. Do you have people go through a therapeutic step with a steroid injection or with Botox or do you just tell them that's an option? I have them go through the same sort of therapy protocol that y'all have. And we don't, our anesthesiologists don't do the diagnostic, I mean the therapeutic injections as much. So it's really just, if they fail that, then they get the diagnostic injection and then we talk about surgery. Got it. So it goes diagnosis, therapy, diagnostic injection, surgery. So really you're using the injection to give them prognostic information on their outcome from surgery. Right. Got it. So what percentage of patients who go to your clinics end up having surgeries? In my clinic it's probably 20% or less. You know, we get a lot of referrals in, just referral to the brachial plexus clinic. You know, Parsonage Turner is probably the most common non-TOS pathology I come across. You know, sometimes we have, you know, psychosomatic pain that comes through. We've got all sorts of other, you know, hodgepods of things that come through that aren't necessarily TOS. And so certainly those don't go on to operations. And then, you know, as Catherine has said, when we have patients who are caught early, are typically the young athletic type, they respond well to therapy. And a lot of those avoid surgery. So to answer your question, it's probably 20% that go on to have surgery overall. Dr. Lee, I'll ask you a question just about therapy while I work on that. So if patients have been seen somewhere else, they've seen a sports therapist or some other physical therapist, do you have them repeat a course of therapy with therapists that you're familiar with, that you know have competency in TOS, or do you give them credit for time served? We typically do. Obviously, most people come to see us, obviously some are already being diagnosed as having threshold, they went through months of therapy. So if someone hasn't been diagnosed, initially treated just for shoulder pathology, it's very commonly treated for scapular dyskinesia or other conditions, so we do tell the patient try a course of good therapy for threshold before we decide to have a surgery. Erin, what about you? I give the patient a quiz, so I ask them what they've been doing in therapy, and if they've been doing mostly things for their shoulder, not for their scapula, but for their shoulder itself, or even if they've been doing some harmful things, like neck strengthening, then I definitely make them go through it again. And I use the same analogy that you used, I teach them the stretches and say, have you been doing these, and they say yes, I ask them, have you been doing it like you brush your teeth? And if they say no, then I make them go through, and I say this is now a part of your everyday life, like brushing your teeth, and make them do that at least. Okay. Well, sorry about that, we'll get going hopefully. Some patients with Kapotanil have signs and symptoms of thoracic omelette, for instance, for the loose manhole. Many patients present numbness and lack of endurance in the gross position. And the other patients complain about numbness in the little finger. But if by any reason you can rule out that this is not a Kapotanil, then this is probably a Covital Tundra Syndrome, because some patients also are going to complain about numbness in the little finger and lack of strength. It's common between these two groups, or to be precise, three groups, thoracic, omelette, median compression, and ulnar compression, that the patients complain about pain. And sometimes the major complaint is pain. To differentiate the origin of pain from being distal or proximal to the elbow, I put a cuff that we use to measure arterial pressure, and I inflate it above the systolic pressure for one to two minutes. The mechanical pressure exerted by the cuff into the peripheral nerve dislocates the axoplasma, and this inhibits momentarily the propagation of the sensory stimulus from the periphery to the central nerve system. Mostly pain because of the susceptibility of pain fibers to compression. And if hand pain subsides, then the first diagnosis should be a Kapotanil. If pain persists, then we have to see proximal causes of the neurologic complaints, and proximally it is a thoracic outlet. If there is no symptoms or no sensory system effect, only motor weakness, then we have to think about pathologies originating from the motor neurons and not from the root of the radial plexus. So if we think that these complaints come from a Kapotanil, the first thing to do is to inject a Kapotanil with a steroid and local anesthesia. If pain did not subside with the inflated cuff, we have to think that this can be a thoracic outlet. A point of interest in the thoracic outlet is that the patient presents atrophy not only of the tinnar immunus, but also on the first dose of enterosis. This means that either the median or the ulnar nerve are affected concomitantly. I like to use this test to show weakness of the abductor of the thumb, the abductor pollicis brevis. You ask the patient to turn the thumb around the tip of the middle finger, and if he or she cannot place the nail in 90 degrees of position, it's because there is a lack of rotation of the first metacarpal, which is exclusively performed by abductor pollicis brevis. Patients with thoracic outlet, they also complain of pain, numbness, or itching in the territory of the T1 or CA foot. It is important to evaluate the strength of the hand in order to check if the muscles are still preserved. So I like to use the gross pin, and I like to use the subterminal key pinch. In the subterminal key pinch, differently from the key pinch or the terminal key pinch, we don't allow the patient to flex the interphalangeal joint. We ask the patient to press the dynamometer with the interphalangeal joint. This is a good gesture to measure the strength of the first dorsal interosseal subterminal abductor. Regarding the image studies, X-rays are enough to see the presence of a cervical rib. MRI is interesting to study the vessels and eventually detect pseudoaneurysm of the subclavian artery. It's also interesting to detect tumors that invade the brachial plexus. However, MRI is not going to give you the diagnosis of thoracic outlet. If the hand strength is preserved, then we can treat our patients conservatively. I like to do first a brachial plexus block with anesthetics and steroids. If there are some symptoms or signs of hand weakness, then I prefer to do Botox injection into the anterior scalenus muscle. If the patient complains a lot of pain, maybe a continuous brachial plexus block is more effective to relieve pain. Then the patient can be under the block for one or two days. The presence of cervical rib is important clue to diagnosis of thoracic outlet. Not the relationship between the lower trunk and the cervical rib. In fact, for me, the pathophysiology of the thoracic outlet syndrome is that the scalenus anterior muscle compresses the subclavian artery that compresses the lower trunk against the cervical rib. So this guides my strategy on the surgical treatment of thoracic outlet syndrome. This is the incision I use to operate and release the subclavian and the lower trunk of the brachial plexus. This is an interoperative view. You can see here the anterior scalenus muscle and the subclavian artery. If you look carefully, we can see that this compresses. And then we release the anterior scalenus muscle, the subclavian artery. In this case, I needed to ligate the dorsal scapular artery in order to move the subclavian artery from the anterior surface of the lower trunk. We can see here the lower trunk of the brachial plexus and the cervical rib. Next, with the help of a carrison holder, I remove the cervical rib. And here, by the end of the surgery, you can see the subclavian artery totally free. Now it's not occupying the space in front of the lower trunk, which is completely released also. Note in this case, clear constriction signs, hourglass signs, that the subclavian artery was affecting or compressing the lower trunk of the brachial plexus. So in those patients with true neurogenic compression of the brachial plexus, if you operate these patients early, you're going to see release of the pain complaints and also the recovery of hand strength. In long-standing cases, you can improve pain, but there will be no improvement on hand strength. That was great. Great perspective. I'll hear as we go in closing arguments and wrap up. So, for a discussion wrap, a lot of excellent talks, excellent points, points of discussion as well. There's been many enteologic factors that have been discussed with NTOS, to name a few, anatomic variations, anomaly, bony trauma, scaling, pectoralis trauma, posterior amenorrhagia, all those things to consider. And one of the things that, for us, is to, when we're thinking of NTOS, it's basically a diagnosis of exclusion. We have to rule out other causes of numbness and tingling of the upper extremities, such as distal entrapment neuropathy, degenerative cervical spine disease, and CRPS, primary shoulder disease, as well. And in summary, for NTOS, as we've seen with these great talks, it's the presence of these, like it was mentioned here, and Dr. Lee mentioned, it's, you know, local findings, peripheral findings, absence of other reasonable diagnosis, and response to diagnostic injections. And three out of four of these is more likely to be a combination of NTOS. And as we have, there's, now the panel's open for discussion and questions to the experts. Thank you. If we can get to the mic. Just one question. Did you ever have, your team ever have to do a combined surgery with vascular surgery, taking out transaxillary, first rib, and then your team doing a scalenectomy, or release of adhesions, like I guess I would say a very comprehensive approach? Any incidences like that, where you had pretty much a severe disease, you had to go two different approaches? Yeah. I answer first. So we have, our vascular surgery has two different teams, two different philosophies. One is transaxillary. So their philosophy is just take the first rib out, most of the time without vascular reconstruction, even with venous occlusion. The other group of vascular surgeons does the supra- and infraclavicular approach. So we typically work together with them. We dissect the nerve out, and help them for the posterior part of the rib, cut the posterior part of the rib, then they cut the anterior part of the rib and take the whole rib out. So we have quite a common to work together for those patients. We do a supra-clavicular decompression and take the rib out that way. We have the vascular set of instruments in the room in case there's ever an injury or a problem, but we don't routinely have them in there. We just call them if there's an issue. We have an approach similar to they do in Birmingham. Dr. Bravo and I actually do all of ours together. These are not easy cases. You know, they're high stress cases, they, you know, unfamiliar areas, and so we do all of them together. But in similar to what Erin said, we have the vascular stuff available, and when we have to, we take the rib out from the supra-clavicular, but we don't do any planned cases with vascular. Usually unplanned cases with vascular. Hi, thank you for your talks. Do you find that obesity is a risk factor for those patients who have symptoms from poor posture, and if they fail a course of therapy, are you more hesitant to operate on them because of their BMI? I'm talking about therapy part of it. Therapy, we typically, the patients I've seen most are not, do not have a high BMI, so very few patients that I've worked with have been extremely obese, and it doesn't seem to have affected anything in terms of their therapy progression. Yeah, we, my personal impression, I don't have scientific data, skinny young girls sometimes do have more symptoms compared to, and the other spectrum is ladies with macromemoral, what's called, you know, big breasts, too heavy, sometimes have to do reduction. Yeah, it really hasn't been shown, like high BMI correlated with NTOS, we tend to see the opposite. We have a lot of chronic biscuit poisoning in Alabama, and they tend to do just as well with surgery as our thinner patients, it just takes a lot longer and is a more difficult surgery, especially if they have a short neck. Thank you for the presentation, I have a question, and I'm from South Korea, and a lot of patients come to me, they suspect themselves as neurogenic TOS, and some of them have experienced that corrective position posture by themselves, or incorrect way, like they say they had rounded shoulder, so they just extend it, adapt it, and sometimes they have forward head, and they tuck, chin tuck, they do that by themselves, and sometimes it makes their symptom worse, or even makes it, like they didn't have any symptom, and after the correction, they develop their symptom, and looks like really similar to TOS, and how about in your country, like America, or what about, do you have any experience about that, and another question is, what do you think of the natural history of TOS, so like I said, some patients had to correct themselves in the wrong way, and they developed their symptoms, so if they do nothing, and I think they will be okay, so what do you think of the natural history of TOS, just doing nothing, or, so. I'm going to see if Dr. Meyer wants to answer the first question there. that the bad posture is secondary to TOS because you're getting a compressive neuropathy. And when you do your shoulders round and move them like this, you're actually increasing the space in the anterior triangle or the posterior triangle, and it somewhat decompresses the nerves. So it's almost a cyclical phenomenon. And the only way to break it is to do whatever surgical correction, and then they can get better posture. But I think the bad posture in most of these comes from them trying to unload their plexus. One other thing that was glossed over, and that is it's almost pathognomonic if you will ask the question. When a girl has TOS, invariably they will modify the way they do their hair. And if you don't ask that question, you won't get it. But if you do ask, you'll find almost 100% of the girls will say, I can't do my hair that way. And that's almost pathognomonic when it's coupled with numbness and pain and the ridiculous stuff. One other thing, when you're looking for causes of this, we've seen a number of patients who have stress fractures of the first rib, and it shows the forces that are across the first rib. And most of the time, this will happen between the middle scalene origin and the insertion of the serratus or the serratus. And it happens right between them. And that's where the plexus goes through. So all of that force is now also directed, or the same forces are directed on your plexus. And you need to stop and think about those forces on the nerves as one of the causes for thoracic outlet. Well, thank you, everybody, for staying late. Great, great lectures and great information. Thank you.

neurogenic thoracic outlet syndrome

upper extremity symptoms

compression

nerves

blood vessels

first rib

clavicle

diagnostic injections

surgical options

physical therapy

individualized treatment plans