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Boney Abnormalities Cause Arterial, Venous, and/or Neurogenic Thoracic Outlet Syndrome
Lydia L Faber, Gabriela Velazquez-Ramirez, Randolph Geary, Kevin Z Chang, Matthew P Goldman, Julie Freischlag
Wake Forest Baptist Medical Center, Winston-Salem, NC

Background:
Thoracic Outlet Syndrome (TOS) is a disease due to compression of the neurovascular bundle in the first rib space. This bundle contains the brachial plexus nerve, artery, and venin and as a result the syndrome can present as neurogenic, venous, and arterial. Boney abnormalities can impinge on the thoracic outlet resulting in TOS symptom presentation. First rib resection, anterior scalenectomy, and removal of the boney abnormality are performed as treatment of TOS
Objective:
To examine the presentations and outcomes of thoracic outlet syndrome patients whose cause is a boney abnormality.
Methods:
A total of 73 patients who underwent thoracic outlet surgery between 2016 -2021 were retrospectively reviewed via electronic medical records. Twelve (16%) patients demonstrated boney abnormalities on presentation causing their symptoms. The patients with boney abnormalities were analyzed based on venous, arterial, or neurogenic TOS diagnosis.
Results:
41.6% of patients presented with venous thrombosis and 20% had concomitant neurogenic symptoms. There were 3 males and 2 females with an average age of 27 (16-37). The bony abnormalities in this group included 3 clavicular fractures, 1 non-fused congenital clavicle, and 1 residual rib. Four patients underwent a transaxillary first rib resection followed by a venogram two weeks later. One patient underwent a simultaneous infraclavicular first rib resection and venogram. Three patients had their veins dilated and one patient had lysis followed by dilatation. 100% of patients had patent veins at an average follow up length of 10.2 months (5 25). One female patient presented with a fused first and second rib with arterial compression and embolization and she underwent a transaxillary first and second rib resection. An angiogram was performed two weeks later that demonstrated a patent subclavian artery. She remained on oral anticoagulation for 6 months to treat her distal embolization and has returned to normal activities of daily living.
50% of patients presented with neurogenic symptoms and 83.3% had evidence of arterial compression on arm elevation. 50% of the patients had a fractured first rib, 16.6% had a fractured clavicle, and 33.3% had cervical ribs. There were 3 males and 3 females with an age range between 14 and 60 years old. All patients underwent transaxillary first rib resection and anterior scalenectomy and the two patients with cervical ribs underwent transaxillary removal of
both the cervical and first rib. All patients did physical therapy following surgery which continued their symptom improvement.
There were no artery, vein, or nerve injuries in these patients. Five patients had a pneumothorax treated over night with a chest tube and one patient had a superficial wound infection. The mean hospital stay was 1.08 days.
Conclusions:
Patients with bony abnormalities can present with all three forms of thoracic outlet syndrome: neurogenic, arterial, and venous and some will have more than one of these presentations. Results in patients undergoing surgery with bony abnormalities causing thoracic outlet syndrome are excellent with symptoms resolution and without substantial complications.


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