Robotic Transthoracic First Rib Resection for Neurogenic Thoracic Outlet Syndrome

Purpose: Neurogenic Thoracic Outlet Syndrome accounts for over 95% of patients with TOS. We report a single institution experience with robotic first rib resection in patients with Neurogenic TOS. Methods: The diagnosis of NTOS was made in patients in whom all specific localizing and diagnostic orthopedic and neurologic conditions were ruled out. Preoperative diagnostic tests included a comprehensive history and physical exam, Chest X-ray, Chest CT, MRI if the cervical spine, Nerve conduction studies, and Magnetic Resonance angiography of the Thoracic outlet with arm maneuvers (MRA). Patients with NTOS who underwent robotic first rib resection with disarticulation of the costosternal joint and scalenectomy. Results: There were 137 patients (47 men and 90 women). Mean age was 34 ± 9.5 years. Operative time was 93 minutes ± 10.3 minutes. There were no intraoperative complications. There was no injury to the subclavian vessels during the dissection. There were no neurovascular complications. There was no 30 or 90 day mortality. Quick DASH Scores (Mean ± SEM) decreased from 60.3+/2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period, and 3.5+/1.1 at 6 months. (P < 0.01) Immediate relief of symptoms was seen in all patients (100%). Complete relief of symptoms was seen in 133/137 (97%) of patients. Conclusions: Robotic resection of the medial aspect of the first rib with disarticulation of the costo-sternal joint is associated with excellent relief of neurologic symptoms in patients with Neurogenic Thoracic Outlet Syndrome.

Essentials of thoracic outlet syndrome:A narrative review

Thoracic outlet syndrome(TOS)is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region.TOS results in pain,numbness,paresthesia,and motor weakness in the affected upper limb.We reviewed the pathophysiology,clinical evaluation,differential diagnoses,and treatment of TOS.TOS is usually classified into three types,neurogenic,venous,and arterial,according to the primarily affected structure.Both true neurogenic and disputed TOS are considered neurogenic TOS.Since identifying the causative lesions is complex,detailed history taking and thorough clinical investigation are needed.Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS.The existence of a disputed TOS remains controversial.Neuromuscular physicians tend to be skeptical about the existence of disputed TOS,but thoracic surgeons argue that disputed TOS is under-diagnosed.Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.

Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome

Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.

Costoclavicular Syndrome and MRI Evaluation, Our Experience at Tertiary Care Hospital, SKIMS Srinagar, J&K

Introduction: Cervical rib is a supernumerary rib springing from one of the cervical vertebrae, usually the seventh. About 1 in 200 people are born with cervical rib. About 1 in 10 people who have a cervical rib develop symptoms of thoracic outlet syndrome (TOS). Aims: The aim of this study was to identify normal and abnormal anatomy of thoracic outlet using MRI in symptomatic costoclavicular compression syndrome and to plan them for surgery thereafter. Methods: This was a prospective hospital based study. All the symptomatic cases of cervical rib syndrome admitted in the department of Cardiovascular and thoracic surgery SKIMS, Srinagar from May 2011 to May 2015 were taken up for the study. Results: A total of 40 cases of symptomatic cervical rib syndrome were reported from May 2011 to May 2015. Mean age of presentation was 26.3. The most prevalent age group was 21 - 30 years (47%). Majority of patients were females (83%) with male female ratio of 1:5. 67% had bilateral cervical rib, more in females (72%) than males (40%). 97% had neurogenic thoracic outlet syndrome and 3% had vascular thoracic outlet syndrome. 35% of cases with neurogenic thoracic outlet syndrome had subclavian artery compression on MR Angio of thoracic outlet after subjecting them to postural maneuvers. All the patients with subclavian artery compression were subjected to surgery. Conclusion: Costoclavicular compression syndrome affects mainly young females. MR Angio is complementary in finding vascular compression in cases presenting mainly with neurogenic symptoms of thoracic outlet syndrome.

Upper extremity deep vein thrombosis:An intensivist’s perspective

Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities.