Protocol Based Treatment Of Neurogenic Thoracic Outlet Syndrome
Nicholas Russo, MD, Farda Qayyum, MD, Tigran Divanyan, MD, Neil Patel, MD, Benjamin B. Chang, MD, Jeffrey Hnath, MD, R Clement Darling III, MD.
Albany Medical Center / Albany Medical College, Albany, NY, USA.
OBJECTIVES: Neurogenic thoracic outlet syndrome (nTOS) is difficult to diagnose and treatment options may result in a variety of unpredictable results. A protocol was designed to assist in the diagnosis of nTOS and to improve treatment outcomes. The purpose of this study is to evaluate the results of a nTOS treatment protocol. METHODS: All patients with a suspected diagnosis of nTOS in a single vascular group were directed to one vascular surgeon. The protocol was then to refer the patients to physical therapy with scalene muscle block. After the scalene block, there was an option of, continued physical therapy, scalene Botox, or thoracic outlet decompression. Scalene block and Botox injections were performed by a single anesthesia group. Thoracic outlet decompression was performed through a supraclavicular incision and involved scalenectomy, neurolysis, and rib resection. Patient charts were reviewed, and the data was tabulated in standard fashion. RESULTS: 91 patients were seen for nTOS from January 2000-January 2020. 50 patients had consistent follow up and underwent treatment protocol. Mean age was 41 (range 18-59yrs) and 36 were female (72%). 27 (54%) had an inciting trauma and 18 (36%) also had migraine symptoms. 12 (24%) were current tobacco users. 45 patients proceeded to scalene block and the other 5 opted for physical therapy alone. 12 patients underwent Botox with 11(91.6%) symptom resolution, 7 opted for continued physical with only 3 having symptom resolution, 26 opted for thoracic outlet decompression with 24 (92.3%) symptom resolution. Overall, 7 (14%) patients still had symptoms after protocol treatment algorithm. CONCLUSIONS: Neurogenic thoracic outlet syndrome remains a condition that is difficult to diagnose and complex to treat. This single center series demonstrates some of the compliance issues with this patient population. The algorithm-based approach offers a stepwise treatment plan that appears to offer symptomatic benefit while also allowing a degree of patient autonomy.
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