guidelines for neurologic thoracic outlet syndrome · • 1x brachial vein thrombosis • 1x...
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Guidelines for neurologic thoracic outlet syndrome
Guidelines of NTOS and an institutional series with a dedicated care pathway
Philippe Cuypers and Joep Teijink
J. Goeteyn, N. Pesser, A. Bode, M. van Sambeek, B. van Nuenen,
Disclosure
Speaker name:
Philippe Cuypers
I have no potential conflicts of interest to report
NTOS - Presentation
Are of compression: – Scalene triangle
– Costoclavicular
– Pectoralis minor space
Which structure is compressed ?– NTOS (95%)
– VTOS (4%)
– ATOS (1%)
– Mixed TOS (%?)
NTOS - Controverse
2014
“One of the most controversial clinical entities in medicine”
Peet 1956: Term thoracic outlet syndrome
1960-1970: A popular operation
– 1962: Claggett: first rib resection
– 1966: Roos: trans-axillair first rib resection
– 1979: Sanders: Supraclavicular scalenectomy for recurrent TOS
1980-1990: Discouraging results…
NTOS - Controverse
Multiple publications (Dale, Horowitz, Wilbourn, … )
– Brachial plexus lesions 10 – 30%
– Recurrent TOS up to 26%
– Mortality +++
NTOS – “discouraging results”
NTOS – Controversy at three levels
SVS Reporting Standards 2016
Diagnosis of NTOS requires at least 3 of the following :
1. Symptoms and history consistent with NTOS2. Physical examination consistent with NTOS3. No plausible differential diagnosis4. Positive result on test injection
NTOS – Reporting Standards
Step by step instructions are provided:
- History taking- Symptoms- Prior treatment- History of trauma- Occupation, hobbies
- Clinical examination with provocation tests
NTOS: Provocation tests
Elevated Arm Stress Test (EAST)
Issue: lack of standardisation
Standardised EAST measurement
Lack of objective outcome parameters
Three instruments recommended for reporting outcome:
1. (Quick)DASH: Disabilities of the arm, Shoulder and Hand Questionnaire
2. CBSQ: Cervical-Brachial Symptom Questionnaire
3. TOS disability scale
NTOS – Reporting Standards
(Quick) DASH
1. Provides a scale for DISABILITY
2. Is not highly dicriminatory for NTOS, does not differentiate from other diagnoses
NTOS – Reporting Standards
NTOS – Reporting Standards
CBSQ
1. Provides a scale for SYMPTOMS
2. Seems more dicriminatory for NTOS than QuickDASH
3. Helps differentiate from other diagnoses
NTOS – Reporting Standards
When is TOD successful?
QuickDASH and CBSQ are supposed to show around 30% improvement
NTOS – Care pathway
Catharina Hospital, Eindhoven
• Prospective cohort study January 2017 – December 2019• Diagnosis and treatment according to reporting standards
• TOS disability scale• Cervical-Brachial Symptom Questionnaire (CBSQ)• Disabilities of the arm, Shoulder and Hand (DASH) questionnaires
Referred patients
10 3 9 14 12 28 45
140
339 350
0
50
100
150
200
250
300
350
400
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Referred patients
Results 2017-2019
2015 2016 2017 2018 2019
212
30
65
142
49 10 6
20
1 0 1 3 1
TOD proceduresNTOS VTOS ATOS
surgeon
assistant 2
assistant 1
assistant 3
Aversion against procedure among residents
Trimano shoulder holder
Trimano
Results 2017-2019
6,51
4,13
3,09 3,333,44
0
1
2
3
4
5
6
7
Baseline (n=168) 3 months (n=99)(p<0.001)
6 months (n=124)(p<0.001)
12 months (n=94)(p<0.001)
24 months (n=15)
TOS disability scale scores
Results 2017-2019
73
38 37 35 38
0
10
20
30
40
50
60
70
80
Baseline (n=168) 3 months (n=99) (p<0.001) 6 months (n=124)(p<0.001)
12 months (n=94)(p<0.001)
24 months (n=15)
CBSQ scores
Results 2017-2019
52,82
38,68
33,5834,81
33,05
0
10
20
30
40
50
60
Baseline (n=168) 3 months (n=99)(p<0.001)
6 months (n=124)(p<0.001)
12 months (n=94)(p<0.001)
24 months (n=15)
DASH scores
Results 2017-2019
Results 2017-2019
• Mean hospital stay: 1.39 days• Complications over 363 TOD procedures:
• 1x pneumonia• 1x pulmonary embolism• 2x Horner’s syndrome• 2x Winged scapula• 1x Brachial vein thrombosis• 1x pneumothorax (10-days after surgery)• 3x post-operative bleeding, 2 with re-intervention• 1x chylous leakage (resolved w/ MCT)• 1x wound infection• NO: brachial plexus injury, NO major intraoperative bleeding
Conclusion
• SVS gudelines provide a useful tool for managing and reporting NTOS
• Systematic work-up according to NTOS pathway provides good guidance on diagnostics and treatment.
• These first results are promissing, long term results have to be awaited
• Thoracic outlet decompression surgery performed in a high-volume center is safe.