- Email: [email protected]
Differences in quality of life outcomes after paraclavicular decompression for thoracic outlet syndrome
Differences in quality of life outcomes after paraclavicular decompression for thoracic outlet syndrome Zain Al Rstum, MD,a Akiko Tanaka, MD, PhD,a Harleen K. Sandhu, MD, MPH,a Charles C. Miller III, PhD,a Naveed U. Saqib, MD,a Joseph M. Besho, MD,a Kristofer M. Charlton-Ouw, MD,a and Ali Azizzadeh, MD,b Houston, Tex; and Los Angeles, Calif
ABSTRACT Background: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms. However, little is known about long-term function and quality of life (QoL) from a patient’s perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach. Methods: A prospectively maintained database was used to conduct a retrospective review of patients who underwent thoracic outlet decompression between August 2004 and August 2018. We excluded patients without complete followup data. Functional outcomes were assessed by the Derkash classification (poor, fair, good, excellent) using contingency table methods, and QoL was assessed by the 12-Item Short Form Health Survey (SF-12) using general linear models. SF-12 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). Secondary outcomes included mortality, complications, and duration of hospital stay. Results: We performed 105 operations for TOS, and 100 patients with complete follow-up data were included in the study. Five patients were lost to follow-up. Median age was 35 (interquartile range, 24-47) years, and 58 (58%) were female. The median duration of hospital stay was 4 (interquartile range, 3-5.5) days. Of these patients, 46 had venous etiology, 8 arterial, 42 neurogenic, and 4 mixed vascular and neurogenic. Good or excellent Derkash results were reported in 77 (77%) patients, 46 of 54 (85%) of those with vascular TOS vs 31 of 46 (67%) of those with neurogenic etiology (P < .036). SF-12 score was obtained in 93 of 100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic TOS (NTOS) reported significantly lower aggregate mental health QoL than patients with vascular-only TOS (57 vs 59; P < .016). This effect persisted across the entire duration of follow-up and was unaffected by time from surgery (regression P for time ¼ .509). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P ¼ .303), and all patients improved linearly with time (0.5 scale unit/y; P < .009). Three patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n ¼ 6), neurapraxia (n ¼ 6), and lymph leak (n ¼ 2) treated with tube thoracostomy. Conclusions: NTOS is associated with significantly worse functional outcome assessed by the Derkash classification. NTOS also demonstrated worse composite mental health QoL, which did not improve over time. In contrast, composite physical health QoL improved linearly with time from surgery regardless of etiology of TOS. (J Vasc Surg 2020;-:1-6.) Keywords: Thoracic outlet syndrome; TOS; Quality of life; QoL; Paraclavicular decompression
Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular bundle in the thoracic outlet.1 Structures in the outlet include the brachial plexus, subclavian vein, and subclavian artery. Depending on etiology, TOS can be divided into neurogenic (NTOS), vascular, and mixed. Vascular TOS can be
further subdivided into arterial (ATOS) and venous (VTOS). The symptoms and signs of TOS depend on the anatomic structure that is being compressed. Whereas several approaches exist, we prefer a supraclavicular approach for NTOS and ATOS. For VTOS, we perform a
From the Department of Cardiothoracic and Vascular Surgery, McGovern Med-
The editors and reviewers of this article have no relevant financial relationships to
ical School at The University of Texas Health Science Center at Houston
disclose per the JVS policy that requires reviewers to decline review of any
(UTHealth), Houstona; and the Department of Surgery, Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles.b Author conflict of interest: A.A. and K.C.O. are consultants for W. L. Gore & Associates and Medtronic.
manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2020 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.12.037
Correspondence: Kristofer M. Charlton-Ouw, MD, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, 6400 Fannin St, Ste 2850, Houston, TX 77030 (e-mail: [email protected]).
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paraclavicular (supraclavicular and infraclavicular) approach. The additional infraclavicular incision is required to resect the anterior segment of the first rib. We find that the paraclavicular approach provides good exposure for effective decompression of and potential intervention on all the neurovascular structures.1-4 Based on our previous experience with TOS patients, most patients report excellent or good functional outcomes postoperatively, as defined by the Derkash classification.3 However, little is known about long-term quality of life (QoL) from a patient’s perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach.
METHODS Population of patients. The Committee for the Protection of Human Subjects, our local Institutional Review Board, approved this study. We retrospectively reviewed all patients undergoing paraclavicular surgical decompression of the thoracic outlet at our center between August 2004 and 2018. Data were compiled regarding clinical presentation, diagnostic workup, procedures performed, postoperative care, and outcomes. Based on history, physical examination, and imaging findings, TOS etiology was characterized as NTOS, VTOS, ATOS, or mixed. Preoperative and postoperative variables were entered either during the hospital stay or after discharge. Postoperatively, clinical evaluations and questionnaires were assessed as part of the clinical pathway and were performed either over the phone or in the clinic with the patient. Short-term functional outcome was assessed according to the Derkash classification.1 An excellent result is no pain, with easy return to preoperative professional and leisure daily activities; a good result is intermittent pain well tolerated, with possible return to preoperative professional and leisure daily activities; a fair result is intermittent or permanent pain with poor tolerance and difficult return to preoperative professional and leisure daily activities; and a poor result is symptoms not improved or aggravated. Health-related QoL was assessed by the 12-Item Short Form Health Survey (SF-12) generic questionnaire,2 which consists of 12 questions that address the physical components (functional capacity and limitation due to physical aspects) and the mental components (pain, vitality, social aspects, limitation due to emotional aspects, and mental health). The SF-12 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 6 10 in the general population for this age group. SF-12 assessments were not made preoperatively, and those measures were not made repetitively over time within patients. Rather, patients were
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Type of Research: Retrospective cohort study Key Findings: Vascular and neurogenic thoracic outlet syndrome (TOS) decompression in 100 patients provided relief of TOS symptoms. Neurogenic TOS was associated with significantly worse functional outcomes and composite mental health quality of life (QoL) compared with vascular TOS. Take Home Message: Surgical decompression of TOS provides relief and improvement in physical QoL, regardless of etiology. However, neurogenic TOS might need special consideration, especially with regard to mental health aspects and mental health QoL.
surveyed cross-sectionally at a single point in time after surgery, and this varied considerably across cohort time, depending on how remotely in the past patients had undergone surgery. Secondary outcomes included mortality, complications, and duration of hospital stay. Surgical technique. All patients underwent surgical decompression by a paraclavicular approach. Patients with NTOS and ATOS were usually decompressed through a supraclavicular incision only, whereas all the patients with VTOS required an additional infraclavicular incision for complete resection of the first rib or for additional intervention. In all, 50% of patients with TOS had vascular etiology; the rest were neurogenic. Of all the neurogenic patients seen in clinic, a few do improve with physical therapy alone. The majority are managed surgically. This could be due to the fact that those patients already underwent extensive workup and trial of physiotherapy by the referring physicians without improvement in symptoms before they were referred to us. Our surgical technique has been previously described.3 Under general endotracheal anesthesia, the patient is placed in the supine position. The neck is extended with a shoulder roll and rotated away from the operative side. A transverse incision is made about 1 fingerbreadth above and parallel to the clavicle. Superior and inferior platysmal flaps are developed, and the clavicular head of the sternocleidomastoid muscle and omohyoid muscle are retracted or divided, if needed. Dissection continues parallel and lateral to the internal jugular vein, and the scalene fat pad is retracted laterally. The lymphatics and the thoracic duct are carefully divided. The anterior scalene and scalenus minimus (if present) are circumferentially dissected and radically resected after identifying the phrenic nerve and the subclavian artery. Neurolysis of the brachial plexus with nerve roots from C5 to T1 is performed. The middle scalene is partially resected, with care taken to preserve the long
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thoracic and scapular nerves that traverse this muscle. Then, the first rib is identified and the posterior portion from the transverse process of the cervical spine to the tubercle is resected. The cervical rib is also removed, if present. In patients with VTOS, the anteromedial portion of the first rib is then resected through a small infraclavicular incision. The subclavian vein is mobilized from the supraclavicular approach and venolysis is performed, followed by intraoperative ipsilateral venography. For a significant stenosis or occlusion of the subclavian vein, reconstruction is performed using endovenectomy with a great saphenous vein patch, as needed. Completion venography is routinely performed after the reconstruction. In patients with ATOS, a subclavian artery aneurysm or occlusion was sometimes present and was replaced with an autogenous conduit, when possible. When completion angiography demonstrated poor distal runoffs, especially in patients with a history of embolism, open thrombectomy was performed through a brachial artery approach. After placement of a drain or tube thoracostomy and closure of the incision, the decision to place a chest tube is surgeon dependent. In general, we place chest tubes with pre-emptive opening of the apical pleura in patients with high risk of bleeding, for example, vascular TOS patients who underwent thrombolysis and received anticoagulation. Otherwise, we usually place a JP drain. Patients are extubated in the operative suite and taken to the recovery room. Most patients had the drains or chest tubes removed on day 2 or 3 before discharge. Anticoagulation therapy was initiated on postoperative day 2 or 3 before discharge. Anticoagulation therapy was initiated on postoperative day 2 in ATOS patients with previous distal arterial embolization or VTOS patients who had venous reconstructions. Patients are seen in the clinic for the first postoperative follow-up in 2 to 4 weeks and then at 3, 6, and 12 months and yearly thereafter. Statistical analysis. Continuous data are reported as mean 6 one standard deviation for normally distributed data or median and interquartile range (IQR) for skewed data. Categorical variables are expressed as number and percentage. Univariate data analyses were conducted by contingency table methods for categorical variables and by unpaired t-test or Wilcoxon rank sum test for continuous variables, depending on the distribution of the data. SF-12 overall mental and physical health QoL ratings and subscales were computed and modeled with clinical variables. General linear models were developed to assess the impact of TOS etiology and time elapsed from surgery to survey on the SF-12 scale scores. Interactions by time and TOS etiology were assessed. P value of <.05 was determined to be significant. All computations were performed using SAS 9.4 software (SAS Institute, Cary, NC).
RESULTS We performed 105 paraclavicular TOS decompressions during the study period. We excluded five patients because of incomplete follow-up or unavailable questionnaire results. Median age was 35 years (IQR, 24-47 years), and 58 (58%) were female. There were 38 (38%) procedures on the left side and 62 (62%) on the right side. The underlying etiology was vascular in 54 (54%), neurogenic in 42 (42%), and mixed vascular and neurogenic in 4 (4%; Table I). Of note, 100% of VTOS patients initially presented with acute effort thrombosis, whereas 70% of vascular TOS patients had adjunctive arterial or venous interventions. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion and hemothorax requiring evacuation (n ¼ 6) by either chest tube placement or video-assisted thoracoscopic surgery. Temporary weakness or altered sensation in the surgical limb was noted in six patients (6%) because of traction neurapraxia, which resolved spontaneously within 1 to 6 months. Two lymph leaks were identified (n ¼ 2) and treated conservatively, with resolution of leak at the first postoperative follow-up. The median duration of hospital stay was 4 (IQR, 3-5.5) days. The duration of hospital stay varied from 3 (IQR, 3-4) days for NTOS to 4 (IQR, 3-6) days in VTOS and 3 (IQR, 3-4) days in ATOS. Three patients with NTOS had incomplete relief of symptoms after paraclavicular decompression and underwent pectoralis minor decompression. This was done through a small incision in the deltopectoral groove. Functional outcome: Derkash classification. Most patients reported a Derkash classification of good or excellent (n ¼ 77 [77%]); the rest (23%) reported either fair or poor. Of note, vascular TOS patients reported significantly superior Derkash results (excellent or good in 46/54 [85%]) compared with the neurogenic or mixed etiology patients, of whom 31 of 46 (67%) reported excellent or good results (P < .036; Tables II and III). There was no statistically significant difference in outcomes based on sex or age. The patients with vascular TOS who reported poor or fair results composed 15% of the patients with vascular TOS who underwent decompression. Their reported poor outcomes are mostly related to incisional pain and overall function. Of note, all those patients had some form of imaging to assess patency; all were patent except for one patient, who underwent repeated revascularization. She was later found to be positive for hypercoagulable state. Health-related QoL: SF-12. Overall physical and mental health scores were assessed by SF-12 as a measure of health-related QoL. This was obtained cross-sectionally in time in 93 of 100 patients (93%) with a median duration from surgery of 6.1 (IQR, 3.3-9.3) years. Mean physical component summary score and mental component
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Table I. Patients grouped by etiology Etiology
No. (%)
Vascular
54 (54)
Venous
46 (46)
Arterial
8 (8)
Neurogenic
42 (42)
Mixed vascular and neurogenic
4 (4)
Table II. Thoracic outlet syndrome (TOS) etiology and the Derkash classification Derkash score
VTOS ATOS NTOS Mixed (n ¼ 46) (n ¼ 8) (n ¼ 42) (n ¼ 4)
Excellent
P value
20 (44)
5 (63)
15 (36)
1 (25)
.026
Good
15 (33)
2 (25)
16 (39)
2 (50)
.031
Fair
10 (21)
1 (12)
7 (16)
1 (25)
.001
Poor
1 (2)
0
4 (9)
0
.041
ATOS, Arterial thoracic outlet syndrome; Mixed, mixed vascular and neurogenic thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome. Categorical variables are expressed as number (%).
Table III. Derkash classification in pure vascular vs pure neurogenic/mixed etiology
Derkash score Excellent or good Fair or poor
Pure neurogenic/ mixed (n ¼ 46)
P value
46 (85)
31 (67)
<.036
8 (15)
15 (33)
<.043
Pure vascular (n ¼ 54)
Categorical variables are expressed as number (%).
summary score were slightly higher (better QoL) than the general population norm of 50. Patients with NTOS reported significantly lower aggregate mental health QoL than patients with vascular TOS (VTOS and ATOS; 57 vs 59; P < .016). Multivariable regression analysis demonstrated that this effect was not altered by time elapsed from surgery (P ¼ .509; Fig, a). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P ¼ .303), and all patients improved linearly as a function of time from surgery (0.5 scale unit/y, P < .009; Fig, b). We also used the SF-12 questionnaire to assess QoL as a long-term outcome with good length of followup at a median of 6.1 years.
DISCUSSION TOS refers to disorders characterized by compression of one or more of the neurovascular structures, including brachial plexus, subclavian artery, and subclavian vein, in the thoracic outlet. Depending on which structures are affected, a TOS patient can present with a single symptom or a constellation of upper extremity symptoms, such as weakness, pain, numbness, and tingling of the fingers, and symptoms of impaired circulation.3
Fig. a, Mental health quality of life (QoL; y-axis) vs time between surgery and 12-Item Short Form Health Survey (SF-12) administration (x-axis). Multivariable P for neurogenic thoracic outlet syndrome (TOS), P < .019; for time, P ¼ .509. b, Physical health QoL (y-axis) vs time between surgery and SF-12 administration (x-axis). Multivariable P for neurogenic TOS, P ¼ .303; for time, P < .009.
TOS is commonly characterized by its etiology or the causative anatomic abnormality: neurogenic, venous, arterial, and mixed. In our study, the most common type of TOS encountered is the venous type. This might be due to the nature of the referral pattern as more vascular TOS is referred to vascular surgeons, whereas NTOS can be managed by other surgeons in different specialties with comparable results.3,4 All patients with vascular (ATOS, VTOS) and mixed TOS are offered surgical decompression. For NTOS, however, initial conservative management with a trial of physical therapy and avoidance of triggering activities or motions is common. Failure of conservative treatment is an indication for surgical decompression of the thoracic outlet. In our data, because of the referral pattern, we have approximately 50% of patients with TOS who have vascular etiology; the rest are neurogenic. Of all the neurogenic patients seen in clinic, only a few improve with physical therapy
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alone. The majority are managed surgically. This could be due to the fact that those patients already underwent extensive workup and trial of physiotherapy by the referring physicians without improvement in symptoms before they were referred to our clinic. The two most common surgical approaches for decompression are the transaxillary and the supraclavicular (paraclavicular).1,3 All patients in our series underwent paraclavicular decompression. As reported previously,3 the paraclavicular approach to TOS offers excellent exposure of the neurovascular bundles and affords easy accessibility to cervical and aberrant first ribs or excessive bands. It permits complete resection of the scalene muscles and associated scar tissue and allows full brachial plexus neurolysis. In addition, arterial and venous reconstruction can be performed with ease under direct visualization. We used the Derkash classification to evaluate shortterm functional outcome of TOS patients after the decompression procedure. Nearly three-fourths of our patients reported good or excellent outcome. Vascular TOS patients were rated to have good to excellent functional outcome after surgery in the short term compared with NTOS patients (good/excellent: 85% vs 67%; P < .036). This closely mirrors our previous results.3 Of note, 40 of 100 TOS decompressions in this series are included in our previous analysis published in 2014.3 QoL results in TOS patients using the Derkash classification were reported elsewhere, including by Azakie et al5 after the supraclavicular approach in TOS patients and by Degeorges et al6 after the transaxillary approach. A meta-analysis comparing the outcomes and major complications after TOS decompression published by Peek et al7 showed that the majority of patients reported improvement of symptoms after TOS decompression. In addition to the Derkash classification, there are other methods to evaluate and to predict success and to measure the effectiveness of surgery in improving QoL and physical functioning. These include validated questionnaires, such as the Disabilities of the Arm, Shoulder, and Hand questionnaire; the SF-12 health survey8; and the more extended 36-Item Short Form Health Survey and EuroQoL-5 Dimension questionnaire. After analyzing SF-12 data in our series, we found that patients with NTOS reported significantly lower aggregate mental health QoL than patients with vascular-only TOS. In addition, the mental aspect of QoL in NTOS patients did not improve or worsen over time. On the contrary, aggregate physical health QoL between NTOS and VTOS or ATOS was similar, and regardless of the etiology, all TOS patients in our series showed improvement over time. Other studies showed similar results regarding physical and mental QoL in patients with NTOS. Chang et al9 reported a baseline mean SF-12 physical component summary score of 33.8 and mental component summary score of 44.5 with improvements of 0.24 point (P < .001) and 0.15
point (P ¼ .01) per month, respectively, during the first 2 postoperative years. However, this effect was lost thereafter. Similarly, Rochlin et al10 reported mean scores in NTOS patients that are slightly lower (worse QoL) than in our series. Last, we do not have patency data of all the vascular TOS patients postoperatively unless they complained of persistent symptoms or had positive findings on physical examination (eg, swelling or decreased pulses). For those patients who have persistence of symptoms, a duplex ultrasound examination in the office is usually the first step. Interestingly, among all the VTOS patients who had persistent symptoms, all but one had patent vascular repair. The one patient who had symptoms underwent multiple revascularizations and had underlying hypercoagulable disease. In terms of follow-up, the decision to obtain a routine postoperative study is surgeon dependent. Some of those patients with vascular TOS, especially venous, did not undergo any venous reconstruction if the intraoperative venogram showed improvement of external compression after decompression. Limitations. Our study has several limitations. First, the data were analyzed retrospectively from a single center, which is associated with intrinsic biases. Also, the physical and mental health composite scale scores derived from SF-12 have little intuitive meaning as the range of possible scores varies considerably by patient. Mental and physical health composite scale scores tend to vary over the life span for different age groups as physical wellness tends to decrease with age. A physical health composite score of 55 in a 22-year-old is not equivalent to a score of 55 in a 70-year-old. Last, our study lacks baseline physical or mental health composite scale QoL data, thus precluding a comparison of preoperative and postoperative QoL in TOS patients. Also, we did not have a preoperative QoL evaluation for comparison to better ascertain the degree of improvement after intervention. Another limitation lies in the timing of the survey administration. The mean time to SF-12 administration is 6 years. The length of time between intervention and assessment may allow too many confounding variables that could have an impact on the results.
CONCLUSIONS NTOS was associated with worse short-term functional outcomes and long-term mental health QoL compared with vascular TOS (VTOS or ATOS). In contrast, composite physical health QoL scores were similar in both NTOS and vascular TOS and improved linearly with time from surgery, regardless of etiology of TOS.
AUTHOR CONTRIBUTIONS Conception and design: ZAR, AT, HS, CM, NS, JB, KCO, AA Analysis and interpretation: HS, CM, KCO, AA Data collection: ZAR, AT, HS, CM, NS, JB, KCO, AA
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Writing the article: ZAR, AT, KCO Critical revision of the article: ZAR, AT, HS, CM, NS, JB, KCO, AA Final approval of the article: ZAR, AT, HS, CM, NS, JB, KCO, AA Statistical analysis: HS, CM, KCO Obtained funding: Not applicable Overall responsibility: KCO
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REFERENCES 1. Ellison DW, Wood VE. Trauma-related thoracic outlet syndrome. J Hand Surg Br 1994;19:424-6. 2. Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33. 3. Desai SS, Toliyat M, Dua A, Charlton-Ouw KM, Hossain M, Estrera AL, et al. Outcomes of surgical paraclavicular thoracic outlet decompression. Ann Vasc Surg 2014;28: 457-64. 4. Cronenwett JL, Johnston KW, editors. Rutherford’s vascular surgery. 7th ed. Philadelphia: Saunders Elsevier; 2010. 5. Azakie A, McElhinney DB, Thompson RW, Raven RB, Messina LM, Stoney RJ. Surgical management of
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subclavian-vein effort thrombosis as a result of thoracic outlet compression. J Vasc Surg 1998;28:777-86. Degeorges R, Reynaud C, Becquemin JP. Thoracic outlet syndrome surgery: long-term functional results. Ann Vasc Surg 2004;18:558-65. Peek J, Vos GC, Ünlü C, van de Pavoordt HD, van den Akker PJ, de Vries JP. Outcome of surgical treatment for thoracic outlet syndrome: systematic review and metaanalysis. Ann Vasc Surg 2017;40:303-26. Vilagut G, Forero CG, Pinto-Meza A, Haro JM, de Graaf R, Bruffaerts R, et al. The mental component of the short-form 12 health survey (SF-12) as a measure of depressive disorders in the general population: results with three alternative scoring methods. Value Health 2013;16:564-73. Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg 2009;49:630-5. Rochlin DH, Gilson MM, Likes KC, Graf E, Ford N, Christo PJ, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013;57:436-43.
Submitted Sep 5, 2019; accepted Dec 6, 2019.
ABSTRACT Background: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms. However, little is known about long-term function and quality of life (QoL) from a patient’s perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach. Methods: A prospectively maintained database was used to conduct a retrospective review of patients who underwent thoracic outlet decompression between August 2004 and August 2018. We excluded patients without complete followup data. Functional outcomes were assessed by the Derkash classification (poor, fair, good, excellent) using contingency table methods, and QoL was assessed by the 12-Item Short Form Health Survey (SF-12) using general linear models. SF-12 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). Secondary outcomes included mortality, complications, and duration of hospital stay. Results: We performed 105 operations for TOS, and 100 patients with complete follow-up data were included in the study. Five patients were lost to follow-up. Median age was 35 (interquartile range, 24-47) years, and 58 (58%) were female. The median duration of hospital stay was 4 (interquartile range, 3-5.5) days. Of these patients, 46 had venous etiology, 8 arterial, 42 neurogenic, and 4 mixed vascular and neurogenic. Good or excellent Derkash results were reported in 77 (77%) patients, 46 of 54 (85%) of those with vascular TOS vs 31 of 46 (67%) of those with neurogenic etiology (P < .036). SF-12 score was obtained in 93 of 100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic TOS (NTOS) reported significantly lower aggregate mental health QoL than patients with vascular-only TOS (57 vs 59; P < .016). This effect persisted across the entire duration of follow-up and was unaffected by time from surgery (regression P for time ¼ .509). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P ¼ .303), and all patients improved linearly with time (0.5 scale unit/y; P < .009). Three patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n ¼ 6), neurapraxia (n ¼ 6), and lymph leak (n ¼ 2) treated with tube thoracostomy. Conclusions: NTOS is associated with significantly worse functional outcome assessed by the Derkash classification. NTOS also demonstrated worse composite mental health QoL, which did not improve over time. In contrast, composite physical health QoL improved linearly with time from surgery regardless of etiology of TOS. (J Vasc Surg 2020;-:1-6.) Keywords: Thoracic outlet syndrome; TOS; Quality of life; QoL; Paraclavicular decompression
Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular bundle in the thoracic outlet.1 Structures in the outlet include the brachial plexus, subclavian vein, and subclavian artery. Depending on etiology, TOS can be divided into neurogenic (NTOS), vascular, and mixed. Vascular TOS can be
further subdivided into arterial (ATOS) and venous (VTOS). The symptoms and signs of TOS depend on the anatomic structure that is being compressed. Whereas several approaches exist, we prefer a supraclavicular approach for NTOS and ATOS. For VTOS, we perform a
From the Department of Cardiothoracic and Vascular Surgery, McGovern Med-
The editors and reviewers of this article have no relevant financial relationships to
ical School at The University of Texas Health Science Center at Houston
disclose per the JVS policy that requires reviewers to decline review of any
(UTHealth), Houstona; and the Department of Surgery, Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles.b Author conflict of interest: A.A. and K.C.O. are consultants for W. L. Gore & Associates and Medtronic.
manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2020 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.12.037
Correspondence: Kristofer M. Charlton-Ouw, MD, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, 6400 Fannin St, Ste 2850, Houston, TX 77030 (e-mail: [email protected]).
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paraclavicular (supraclavicular and infraclavicular) approach. The additional infraclavicular incision is required to resect the anterior segment of the first rib. We find that the paraclavicular approach provides good exposure for effective decompression of and potential intervention on all the neurovascular structures.1-4 Based on our previous experience with TOS patients, most patients report excellent or good functional outcomes postoperatively, as defined by the Derkash classification.3 However, little is known about long-term quality of life (QoL) from a patient’s perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach.
METHODS Population of patients. The Committee for the Protection of Human Subjects, our local Institutional Review Board, approved this study. We retrospectively reviewed all patients undergoing paraclavicular surgical decompression of the thoracic outlet at our center between August 2004 and 2018. Data were compiled regarding clinical presentation, diagnostic workup, procedures performed, postoperative care, and outcomes. Based on history, physical examination, and imaging findings, TOS etiology was characterized as NTOS, VTOS, ATOS, or mixed. Preoperative and postoperative variables were entered either during the hospital stay or after discharge. Postoperatively, clinical evaluations and questionnaires were assessed as part of the clinical pathway and were performed either over the phone or in the clinic with the patient. Short-term functional outcome was assessed according to the Derkash classification.1 An excellent result is no pain, with easy return to preoperative professional and leisure daily activities; a good result is intermittent pain well tolerated, with possible return to preoperative professional and leisure daily activities; a fair result is intermittent or permanent pain with poor tolerance and difficult return to preoperative professional and leisure daily activities; and a poor result is symptoms not improved or aggravated. Health-related QoL was assessed by the 12-Item Short Form Health Survey (SF-12) generic questionnaire,2 which consists of 12 questions that address the physical components (functional capacity and limitation due to physical aspects) and the mental components (pain, vitality, social aspects, limitation due to emotional aspects, and mental health). The SF-12 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 6 10 in the general population for this age group. SF-12 assessments were not made preoperatively, and those measures were not made repetitively over time within patients. Rather, patients were
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Type of Research: Retrospective cohort study Key Findings: Vascular and neurogenic thoracic outlet syndrome (TOS) decompression in 100 patients provided relief of TOS symptoms. Neurogenic TOS was associated with significantly worse functional outcomes and composite mental health quality of life (QoL) compared with vascular TOS. Take Home Message: Surgical decompression of TOS provides relief and improvement in physical QoL, regardless of etiology. However, neurogenic TOS might need special consideration, especially with regard to mental health aspects and mental health QoL.
surveyed cross-sectionally at a single point in time after surgery, and this varied considerably across cohort time, depending on how remotely in the past patients had undergone surgery. Secondary outcomes included mortality, complications, and duration of hospital stay. Surgical technique. All patients underwent surgical decompression by a paraclavicular approach. Patients with NTOS and ATOS were usually decompressed through a supraclavicular incision only, whereas all the patients with VTOS required an additional infraclavicular incision for complete resection of the first rib or for additional intervention. In all, 50% of patients with TOS had vascular etiology; the rest were neurogenic. Of all the neurogenic patients seen in clinic, a few do improve with physical therapy alone. The majority are managed surgically. This could be due to the fact that those patients already underwent extensive workup and trial of physiotherapy by the referring physicians without improvement in symptoms before they were referred to us. Our surgical technique has been previously described.3 Under general endotracheal anesthesia, the patient is placed in the supine position. The neck is extended with a shoulder roll and rotated away from the operative side. A transverse incision is made about 1 fingerbreadth above and parallel to the clavicle. Superior and inferior platysmal flaps are developed, and the clavicular head of the sternocleidomastoid muscle and omohyoid muscle are retracted or divided, if needed. Dissection continues parallel and lateral to the internal jugular vein, and the scalene fat pad is retracted laterally. The lymphatics and the thoracic duct are carefully divided. The anterior scalene and scalenus minimus (if present) are circumferentially dissected and radically resected after identifying the phrenic nerve and the subclavian artery. Neurolysis of the brachial plexus with nerve roots from C5 to T1 is performed. The middle scalene is partially resected, with care taken to preserve the long
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thoracic and scapular nerves that traverse this muscle. Then, the first rib is identified and the posterior portion from the transverse process of the cervical spine to the tubercle is resected. The cervical rib is also removed, if present. In patients with VTOS, the anteromedial portion of the first rib is then resected through a small infraclavicular incision. The subclavian vein is mobilized from the supraclavicular approach and venolysis is performed, followed by intraoperative ipsilateral venography. For a significant stenosis or occlusion of the subclavian vein, reconstruction is performed using endovenectomy with a great saphenous vein patch, as needed. Completion venography is routinely performed after the reconstruction. In patients with ATOS, a subclavian artery aneurysm or occlusion was sometimes present and was replaced with an autogenous conduit, when possible. When completion angiography demonstrated poor distal runoffs, especially in patients with a history of embolism, open thrombectomy was performed through a brachial artery approach. After placement of a drain or tube thoracostomy and closure of the incision, the decision to place a chest tube is surgeon dependent. In general, we place chest tubes with pre-emptive opening of the apical pleura in patients with high risk of bleeding, for example, vascular TOS patients who underwent thrombolysis and received anticoagulation. Otherwise, we usually place a JP drain. Patients are extubated in the operative suite and taken to the recovery room. Most patients had the drains or chest tubes removed on day 2 or 3 before discharge. Anticoagulation therapy was initiated on postoperative day 2 or 3 before discharge. Anticoagulation therapy was initiated on postoperative day 2 in ATOS patients with previous distal arterial embolization or VTOS patients who had venous reconstructions. Patients are seen in the clinic for the first postoperative follow-up in 2 to 4 weeks and then at 3, 6, and 12 months and yearly thereafter. Statistical analysis. Continuous data are reported as mean 6 one standard deviation for normally distributed data or median and interquartile range (IQR) for skewed data. Categorical variables are expressed as number and percentage. Univariate data analyses were conducted by contingency table methods for categorical variables and by unpaired t-test or Wilcoxon rank sum test for continuous variables, depending on the distribution of the data. SF-12 overall mental and physical health QoL ratings and subscales were computed and modeled with clinical variables. General linear models were developed to assess the impact of TOS etiology and time elapsed from surgery to survey on the SF-12 scale scores. Interactions by time and TOS etiology were assessed. P value of <.05 was determined to be significant. All computations were performed using SAS 9.4 software (SAS Institute, Cary, NC).
RESULTS We performed 105 paraclavicular TOS decompressions during the study period. We excluded five patients because of incomplete follow-up or unavailable questionnaire results. Median age was 35 years (IQR, 24-47 years), and 58 (58%) were female. There were 38 (38%) procedures on the left side and 62 (62%) on the right side. The underlying etiology was vascular in 54 (54%), neurogenic in 42 (42%), and mixed vascular and neurogenic in 4 (4%; Table I). Of note, 100% of VTOS patients initially presented with acute effort thrombosis, whereas 70% of vascular TOS patients had adjunctive arterial or venous interventions. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion and hemothorax requiring evacuation (n ¼ 6) by either chest tube placement or video-assisted thoracoscopic surgery. Temporary weakness or altered sensation in the surgical limb was noted in six patients (6%) because of traction neurapraxia, which resolved spontaneously within 1 to 6 months. Two lymph leaks were identified (n ¼ 2) and treated conservatively, with resolution of leak at the first postoperative follow-up. The median duration of hospital stay was 4 (IQR, 3-5.5) days. The duration of hospital stay varied from 3 (IQR, 3-4) days for NTOS to 4 (IQR, 3-6) days in VTOS and 3 (IQR, 3-4) days in ATOS. Three patients with NTOS had incomplete relief of symptoms after paraclavicular decompression and underwent pectoralis minor decompression. This was done through a small incision in the deltopectoral groove. Functional outcome: Derkash classification. Most patients reported a Derkash classification of good or excellent (n ¼ 77 [77%]); the rest (23%) reported either fair or poor. Of note, vascular TOS patients reported significantly superior Derkash results (excellent or good in 46/54 [85%]) compared with the neurogenic or mixed etiology patients, of whom 31 of 46 (67%) reported excellent or good results (P < .036; Tables II and III). There was no statistically significant difference in outcomes based on sex or age. The patients with vascular TOS who reported poor or fair results composed 15% of the patients with vascular TOS who underwent decompression. Their reported poor outcomes are mostly related to incisional pain and overall function. Of note, all those patients had some form of imaging to assess patency; all were patent except for one patient, who underwent repeated revascularization. She was later found to be positive for hypercoagulable state. Health-related QoL: SF-12. Overall physical and mental health scores were assessed by SF-12 as a measure of health-related QoL. This was obtained cross-sectionally in time in 93 of 100 patients (93%) with a median duration from surgery of 6.1 (IQR, 3.3-9.3) years. Mean physical component summary score and mental component
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Table I. Patients grouped by etiology Etiology
No. (%)
Vascular
54 (54)
Venous
46 (46)
Arterial
8 (8)
Neurogenic
42 (42)
Mixed vascular and neurogenic
4 (4)
Table II. Thoracic outlet syndrome (TOS) etiology and the Derkash classification Derkash score
VTOS ATOS NTOS Mixed (n ¼ 46) (n ¼ 8) (n ¼ 42) (n ¼ 4)
Excellent
P value
20 (44)
5 (63)
15 (36)
1 (25)
.026
Good
15 (33)
2 (25)
16 (39)
2 (50)
.031
Fair
10 (21)
1 (12)
7 (16)
1 (25)
.001
Poor
1 (2)
0
4 (9)
0
.041
ATOS, Arterial thoracic outlet syndrome; Mixed, mixed vascular and neurogenic thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome. Categorical variables are expressed as number (%).
Table III. Derkash classification in pure vascular vs pure neurogenic/mixed etiology
Derkash score Excellent or good Fair or poor
Pure neurogenic/ mixed (n ¼ 46)
P value
46 (85)
31 (67)
<.036
8 (15)
15 (33)
<.043
Pure vascular (n ¼ 54)
Categorical variables are expressed as number (%).
summary score were slightly higher (better QoL) than the general population norm of 50. Patients with NTOS reported significantly lower aggregate mental health QoL than patients with vascular TOS (VTOS and ATOS; 57 vs 59; P < .016). Multivariable regression analysis demonstrated that this effect was not altered by time elapsed from surgery (P ¼ .509; Fig, a). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P ¼ .303), and all patients improved linearly as a function of time from surgery (0.5 scale unit/y, P < .009; Fig, b). We also used the SF-12 questionnaire to assess QoL as a long-term outcome with good length of followup at a median of 6.1 years.
DISCUSSION TOS refers to disorders characterized by compression of one or more of the neurovascular structures, including brachial plexus, subclavian artery, and subclavian vein, in the thoracic outlet. Depending on which structures are affected, a TOS patient can present with a single symptom or a constellation of upper extremity symptoms, such as weakness, pain, numbness, and tingling of the fingers, and symptoms of impaired circulation.3
Fig. a, Mental health quality of life (QoL; y-axis) vs time between surgery and 12-Item Short Form Health Survey (SF-12) administration (x-axis). Multivariable P for neurogenic thoracic outlet syndrome (TOS), P < .019; for time, P ¼ .509. b, Physical health QoL (y-axis) vs time between surgery and SF-12 administration (x-axis). Multivariable P for neurogenic TOS, P ¼ .303; for time, P < .009.
TOS is commonly characterized by its etiology or the causative anatomic abnormality: neurogenic, venous, arterial, and mixed. In our study, the most common type of TOS encountered is the venous type. This might be due to the nature of the referral pattern as more vascular TOS is referred to vascular surgeons, whereas NTOS can be managed by other surgeons in different specialties with comparable results.3,4 All patients with vascular (ATOS, VTOS) and mixed TOS are offered surgical decompression. For NTOS, however, initial conservative management with a trial of physical therapy and avoidance of triggering activities or motions is common. Failure of conservative treatment is an indication for surgical decompression of the thoracic outlet. In our data, because of the referral pattern, we have approximately 50% of patients with TOS who have vascular etiology; the rest are neurogenic. Of all the neurogenic patients seen in clinic, only a few improve with physical therapy
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alone. The majority are managed surgically. This could be due to the fact that those patients already underwent extensive workup and trial of physiotherapy by the referring physicians without improvement in symptoms before they were referred to our clinic. The two most common surgical approaches for decompression are the transaxillary and the supraclavicular (paraclavicular).1,3 All patients in our series underwent paraclavicular decompression. As reported previously,3 the paraclavicular approach to TOS offers excellent exposure of the neurovascular bundles and affords easy accessibility to cervical and aberrant first ribs or excessive bands. It permits complete resection of the scalene muscles and associated scar tissue and allows full brachial plexus neurolysis. In addition, arterial and venous reconstruction can be performed with ease under direct visualization. We used the Derkash classification to evaluate shortterm functional outcome of TOS patients after the decompression procedure. Nearly three-fourths of our patients reported good or excellent outcome. Vascular TOS patients were rated to have good to excellent functional outcome after surgery in the short term compared with NTOS patients (good/excellent: 85% vs 67%; P < .036). This closely mirrors our previous results.3 Of note, 40 of 100 TOS decompressions in this series are included in our previous analysis published in 2014.3 QoL results in TOS patients using the Derkash classification were reported elsewhere, including by Azakie et al5 after the supraclavicular approach in TOS patients and by Degeorges et al6 after the transaxillary approach. A meta-analysis comparing the outcomes and major complications after TOS decompression published by Peek et al7 showed that the majority of patients reported improvement of symptoms after TOS decompression. In addition to the Derkash classification, there are other methods to evaluate and to predict success and to measure the effectiveness of surgery in improving QoL and physical functioning. These include validated questionnaires, such as the Disabilities of the Arm, Shoulder, and Hand questionnaire; the SF-12 health survey8; and the more extended 36-Item Short Form Health Survey and EuroQoL-5 Dimension questionnaire. After analyzing SF-12 data in our series, we found that patients with NTOS reported significantly lower aggregate mental health QoL than patients with vascular-only TOS. In addition, the mental aspect of QoL in NTOS patients did not improve or worsen over time. On the contrary, aggregate physical health QoL between NTOS and VTOS or ATOS was similar, and regardless of the etiology, all TOS patients in our series showed improvement over time. Other studies showed similar results regarding physical and mental QoL in patients with NTOS. Chang et al9 reported a baseline mean SF-12 physical component summary score of 33.8 and mental component summary score of 44.5 with improvements of 0.24 point (P < .001) and 0.15
point (P ¼ .01) per month, respectively, during the first 2 postoperative years. However, this effect was lost thereafter. Similarly, Rochlin et al10 reported mean scores in NTOS patients that are slightly lower (worse QoL) than in our series. Last, we do not have patency data of all the vascular TOS patients postoperatively unless they complained of persistent symptoms or had positive findings on physical examination (eg, swelling or decreased pulses). For those patients who have persistence of symptoms, a duplex ultrasound examination in the office is usually the first step. Interestingly, among all the VTOS patients who had persistent symptoms, all but one had patent vascular repair. The one patient who had symptoms underwent multiple revascularizations and had underlying hypercoagulable disease. In terms of follow-up, the decision to obtain a routine postoperative study is surgeon dependent. Some of those patients with vascular TOS, especially venous, did not undergo any venous reconstruction if the intraoperative venogram showed improvement of external compression after decompression. Limitations. Our study has several limitations. First, the data were analyzed retrospectively from a single center, which is associated with intrinsic biases. Also, the physical and mental health composite scale scores derived from SF-12 have little intuitive meaning as the range of possible scores varies considerably by patient. Mental and physical health composite scale scores tend to vary over the life span for different age groups as physical wellness tends to decrease with age. A physical health composite score of 55 in a 22-year-old is not equivalent to a score of 55 in a 70-year-old. Last, our study lacks baseline physical or mental health composite scale QoL data, thus precluding a comparison of preoperative and postoperative QoL in TOS patients. Also, we did not have a preoperative QoL evaluation for comparison to better ascertain the degree of improvement after intervention. Another limitation lies in the timing of the survey administration. The mean time to SF-12 administration is 6 years. The length of time between intervention and assessment may allow too many confounding variables that could have an impact on the results.
CONCLUSIONS NTOS was associated with worse short-term functional outcomes and long-term mental health QoL compared with vascular TOS (VTOS or ATOS). In contrast, composite physical health QoL scores were similar in both NTOS and vascular TOS and improved linearly with time from surgery, regardless of etiology of TOS.
AUTHOR CONTRIBUTIONS Conception and design: ZAR, AT, HS, CM, NS, JB, KCO, AA Analysis and interpretation: HS, CM, KCO, AA Data collection: ZAR, AT, HS, CM, NS, JB, KCO, AA
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Writing the article: ZAR, AT, KCO Critical revision of the article: ZAR, AT, HS, CM, NS, JB, KCO, AA Final approval of the article: ZAR, AT, HS, CM, NS, JB, KCO, AA Statistical analysis: HS, CM, KCO Obtained funding: Not applicable Overall responsibility: KCO
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subclavian-vein effort thrombosis as a result of thoracic outlet compression. J Vasc Surg 1998;28:777-86. Degeorges R, Reynaud C, Becquemin JP. Thoracic outlet syndrome surgery: long-term functional results. Ann Vasc Surg 2004;18:558-65. Peek J, Vos GC, Ünlü C, van de Pavoordt HD, van den Akker PJ, de Vries JP. Outcome of surgical treatment for thoracic outlet syndrome: systematic review and metaanalysis. Ann Vasc Surg 2017;40:303-26. Vilagut G, Forero CG, Pinto-Meza A, Haro JM, de Graaf R, Bruffaerts R, et al. The mental component of the short-form 12 health survey (SF-12) as a measure of depressive disorders in the general population: results with three alternative scoring methods. Value Health 2013;16:564-73. Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg 2009;49:630-5. Rochlin DH, Gilson MM, Likes KC, Graf E, Ford N, Christo PJ, et al. Quality-of-life scores in neurogenic thoracic outlet syndrome patients undergoing first rib resection and scalenectomy. J Vasc Surg 2013;57:436-43.
Submitted Sep 5, 2019; accepted Dec 6, 2019.