Differential Impact of Etiology on Long-Term Functional Outcomes of Patients with Thoracic Outlet Syndrome
Zain Al Rstum, MD1, Harleen Sandhu1, Charles Miller, PhD1, Naveed Saqib, MD1, Gordon Martin, MD1, Joseph Besho, MD1, Kristofer Charlton-Ouw, MD1, Ali Azizzadeh, MD2.
1McGovern Medical School, UTHealth, Houston, TX, USA, 2Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
Objective:Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms, but little is known about long-term function and quality of life (QOL) from a patient perspective. The purpose of this study is to evaluate surgical and QOL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach.
Methods: We reviewed our prospectively maintained database of patients who underwent thoracic outlet decompression. Short-term outcomes were assessed by Derkash classification, using contingency table methods, and long-term outcomes including SF12 QoL using multiple regression. SF12 was scored by published criteria, and scale-specific and aggregate mental and physical health-related QoL scores were computed. Aggregate QoL scores range from 0 (terrible) to 100 (perfect), and, for context, average 50±10 in the general population for this age group. Secondary outcomes included mortality, complications, and duration of hospital stay.
Results:Between August 2004 and August 2018, we performed 100 decompression procedures. Median age was 35 (IQR 24-47), and 58 (58%) were female. The mean duration of hospital stay was 4.48 days. The etiology of TOS was venous in 46, arterial in 8, neurogenic in 42 and and mixed vascular and neurogenic in 4. Good or excellent Derkash results were reported in 77 (77%) patients; 46/54 (85%) of those with vascular TOS vs. 31/46 (67%) of those with neurogenic etiology (p<0.036). Long-term QoL was obtained in 93/100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic-TOS reported significantly lower aggregate mental-health QOL than vascular- TOS patients (57 vs 59, p<0.016). This effect persisted across the entire duration of follow-up and was unaffected by time out from surgery (regression p for time=0.509). In contrast, aggregate physical-function QOL was unaffected by neurogenic etiology (p=0.303), and all patients improved linearly with time (0.5 scale units/yr, p<0.009). There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n=6), phrenic nerve palsy (n=6), and lymph leak (n=2) treated with tube thoracostomy.
Conclusion:Neurogenic TOS is associated with significantly reduced short-term Derkash score. Patient-reported physical-health QOL improves linearly with time from surgery regardless of etiology of TOS, while mental-health QOL is severely affected in neurogenic-TOS, and this effect does not improve over time.
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