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Trends In The Treatment Of Thoracic Outlet Syndrome At A High-volume Center Within A National Cohort
Mitchell S. Jay, BS
1, Courtenay M. Holscher, MD, PhD
2, Thomas Reifsnyder, MD
2, Joseph M. White, MD, MS
3, Ying Wei Lum, MD, MPH
1.
1Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA,
2Department of Surgery, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,
3Department of Surgery, Suburban Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
OBJECTIVES: Treatment of thoracic outlet syndrome (TOS) includes both nonoperative and operative interventions (botox injections and surgery). However, determining appropriate treatment pathways remains challenging and varies greatly by institution. Here, we identify and compare demographic characteristics and treatment pathways between patients treated at a single high-volume TOS center compared to all centers within the TriNetX Research Network.
METHODS: All patients diagnosed with TOS between January 1st, 2016 and August 30th, 2024 were identified using the TriNetX database. Patients were distinguished between a single high-volume center and nationally within the database. Aggregate cohort demographics, treatment pathways, and outcomes were compared between TOS subtypes. Variables were compared using Fischer’s exact test, Chi-square analysis, unpaired t-tests, and ordinal regression.
RESULTS: 2,510 patients were evaluated for TOS from 2016-2024 at a single high-volume center (2,040 nTOS, 430 vTOS, 40 aTOS). 900 patients ultimately underwent surgical treatment (560 nTOS, 310 vTOS, 30 aTOS). This compared to 17,090 patients evaluated for TOS and 3846 patients who underwent surgery elsewhere nationally( 2457 nTOS, 1233 vTOS, 159 aTOS/mixed). At the high-volume center, 2,040 patients were evaluated for nTOS and 13,635 elsewhere.1,020 patients received botox injections at the high-volume center and 2285 received botox at other centers. Of the patients that ultimately underwent surgery at the high-volume center, 53% received botox before surgery compared to 21% in the national cohort. 37% of patients evaluated at the high-volume center received no procedural intervention, while 72% evaluated elsewhere received no procedures. These treatment pathways were significantly different between the two cohorts(p<0.0001). In nTOS patients at the high-volume center, increasing age, BMI, and black race were significantly higher in the botox-only vs surgical group. In contrast, BMI was not a significant predictor of nonsurgical management in vTOS patients. When comparing 90-day outcomes, there was no significant difference in death, hemothorax, or transfusion, but pneumothorax was significantly lower in the high-volume center compared to elsewhere.
CONCLUSIONS: Our study utilized data from both a single high-volume TOS center and national TOS database to elucidate TOS treatment trends and outcomes. This shed light on the varying characteristics of patients who received nonoperative and operative management, indicating heterogeneity in treatment algorithms and selection of patients for surgical intervention.
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