False-negative upper extremity ultrasound in the initial evaluation of patients with suspected subclavian vein thrombosis due to thoracic outlet syndrome (Paget-Schroetter syndrome)

OBJECTIVE: To assess the utilization and consequences of upper extremity Duplex ultrasound in the initial diagnostic evaluation of patients with suspected subclavian vein (SCV) thrombosis and venous thoracic outlet syndrome (VTOS). METHODS: A retrospective single-center review was conducted for patients that underwent primary surgical treatment for VTOS between 2008 and 2017, in whom an upper extremity ultrasound had been performed as the initial diagnostic test (n = 214). Clinical and treatment characteristics were compared between patients with positive and false-negative ultrasound studies. RESULTS: There were 122 men (57%) and 92 women (43%) that had presented with spontaneous idiopathic arm swelling, including 28 (13%) with proven pulmonary embolism, at a mean age of 30.7 ± 0.8 years (range 14-69). Upper extremity ultrasound had been performed 23.8 ± 12.2 days after the onset of symptoms, with confirmation of axillary-SCV thrombosis in 169 patients (79%) and negative results in 45 (21%). Of the false-negative ultrasound study reports, only 8 (18%) acknowledged limitations in visualizing the central SCV. Definitive diagnostic imaging (DDI) had been obtained by upper extremity venography in 175 (82%), computed tomography angiography in 24 (11%), and magnetic resonance angiography in 15 (7%), with 142 (66%) undergoing catheter-directed axillary-SCV thrombolysis. The mean interval between initial ultrasound and DDI was 48.9 ± 14.2 days with no significant difference between groups, but patients with a positive ultrasound were more likely to have DDI within 48 hours than those with a false-negative ultrasound (44% vs 24%; P = .02). At the time of surgical treatment, the SCV was widely patent following paraclavicular decompression and external venolysis alone in 74 patients (35%). Patch angioplasty was performed for focal SCV stenosis in 76 (36%) and bypass graft reconstruction for long-segment axillary-SCV occlusion in 63 (29%). Patients with false-negative initial ultrasound studies were significantly more likely to require SCV bypass reconstruction than those with a positive ultrasound (44% vs 25%; P = .02). CONCLUSIONS: Duplex ultrasound has significant limitations in the initial evaluation of patients with suspected SCV thrombosis, with false-negative results in 21% of patients with proven VTOS. This is rarely acknowledged in ultrasound reports, but false-negative ultrasound studies have the potential to delay definitive imaging, thrombolysis, and further treatment for VTOS. Initial false-negative ultrasound results are associated with progressive thrombus extension and a more frequent need for SCV bypass reconstruction at the time of surgical treatment

Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome

OBJECTIVE: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. METHODS: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and χ RESULTS: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean ± standard error degree of local tenderness to palpation (1.7 ± 0.1 vs 2.0 ± 0.1; P = .032), the number of positive clinical diagnostic criteria (9.0 ± 0.3 vs 10.1 ± 0.1; P = .001), Cervical-Brachial Symptom Questionnaire scores (68.0 ± 4.1 vs 78.0 ± 2.7; P = .045), and Short-Form 12-item physical quality-of-life scores (35.6 ± 1.5 vs 32.0 ± 0.8; P = .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was -15.6 ± 3.0 (-29.5% ± 5.7%) compared with -29.8 ± 2.4 (-47.9% ± 3.6%) for surgery (P = .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P \u3c .0001). CONCLUSIONS: The present study has demonstrated contemporary outcomes for physical therapy and surgery in a well-studied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for ∼90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery

Reoperative brachial plexus neurolysis after previous anatomically complete supraclavicular decompression for neurogenic thoracic outlet syndrome: A 10-year single-center case series

BACKGROUND: Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge. OBJECTIVE: To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS. METHODS: From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively. RESULTS: The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P \u3c .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P \u3c .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P \u3c .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%. CONCLUSION: Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations