Cases reported "Thoracic Outlet Syndrome"

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1/18. Cervical root stimulation in a case of classic neurogenic thoracic outlet syndrome.

    We performed C8 nerve root stimulation in addition to other electromyographic (EMG) studies in a surgically proven case of classic thoracic outlet syndrome (TOS). The patient was a 19-year-old woman with a 2-year history of right hand cramps and progressive weakness and atrophy of hand muscles, especially the thenar eminence. Routine EMG studies showed evidence for an axon-loss lower trunk brachial plexopathy. Stimulation studies of the C8 nerve roots demonstrated proximal conduction block on the affected side only. The diagnosis was further supported by cervical spine radiographs, which demonstrated a cervical rib, and surgical exploration of the brachial plexus, which demonstrated upward compression and stretching of the lower trunk by a fascial band extending from the anomalous cervical rib to the first thoracic rib. The patient noted a modest improvement in hand function postoperatively. Root stimulation studies can help in the diagnosis of classic TOS by providing more precise localization and information regarding the degree, if any, of proximal motor conduction block.
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2/18. thoracic outlet syndrome caused by first rib hemangioma.

    We report a case of first rib hemangioma that caused thoracic outlet syndrome. A 50-year-ole woman who was admitted to our hospital with a clinical diagnosis of thoracic outlet syndrome presented with fullness and easy fatigue of her right arm. Her right arm discomfort was associated with intermittent engorgement of superficial veins over the shoulder girdle. A chest radiograph revealed an enlargement of the anterior aspect of the first rib with fine bony trabeculations. Computed tomography scan showed contrast enhancement over the enlarged rib. Our tentative preoperative diagnosis was a benign first rib hypertrophic change, such as an old fracture with exuberant callus formation. A right-arm venogram revealed a patent subclavian vein with an extrinsic compression, which occluded on arm abduction. The findings of neural conduction studies of both upper extremities were symmetric and normal. The patient agreed to surgery because of the occlusive condition of the subclavian vein on arm abduction and progressive arm weakness in recent months. Segmental transection of the offending portion of the enlarged first rib was complicated by difficulty in isolating the whole length of the compressed but normal-appearing subclavian vein by our initial transaxillary and infraclavicular approaches because the medial aspect of the subclavian vein was obstructed by the enlarged first rib, which extended medially to the junction of the right jugular and subclavian veins. Successful segmental transection of the enlarged first rib was finally accomplished by combined transaxillary, infraclavicular, and supraclavicular approaches. A moderate amount of rib bleeding from resection ends was noted during segmental resection of the enlarged first rib, resulting in local hematoma formation. A 470-mL bloody discharge was collected from the vacuum ball inserted via the transaxillary route during her 12-day hospitalization. Pathologic examination revealed an intraosseous hemangioma. The patient had a prolonged course to partial recovery of her arm numbness, but signs of venous compression were much improved at 6 months' follow-up. Although hemangioma is benign, its hypervascular nature may cause catastrophic intraoperative bleeding.
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3/18. Hypertrophic non-union of the first rib causing thoracic outlet syndrome: a case report.

    We experienced a rare case of thoracic outlet syndrome caused by hypertrophic nonunion of the first rib. A diagnosis was made mainly upon provocative tests and imaging studies. pain and tingling could be reproduced and the radial pulse obliterated by the hyperabduction test. Abundant callus formation on the posterior aspect of the first rib with fracture line was visible on plain radiograph. Two-dimensional computed tomography showed right thoracic outlet narrowing mainly caused by the mass-effect of the callus. Dynamic arteriographic studies revealed an external compression of the right subclavian artery and duplex ultrasonography demonstrated a reduction in right subclavian artery blood flow when the shoulder is in 90 degrees of abduction. Surgery was performed after the conservative management for three months which failed to relieve the patient of his complaints. Resection of the first rib via transaxillary approach was undergone uneventfully in combination with the myotomy of the scalenus anticus muscle. At postoperative one year follow up, the patient was free of symptoms, and had a full range of motion of the right shoulder with no evidence of arterial insufficiency.
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4/18. Upper plexus thoracic outlet syndrome--case report.

    A 47-year-old right-handed female became aware of proximal ache and muscle weakness in the right shoulder and elbow in 1997. atrophy of the right biceps muscle was recognized and the right deltoid, triceps, supraspinatus, and infraspinatus muscles were weak. The Morley test and elevated arm stress test were positive. Neurolysis of the brachial plexus and anterior scalenectomy were performed via a right supraclavicular approach. An abnormal fibromuscular band was identified passing between the upper and middle trunks and constricting the middle trunk. Another scalene muscle anomaly was found passing between the C-5 and C-6 nerve roots and connecting the anterior and middle scalene muscles. These muscles were resected, and thorough neurolysis was performed around all nerves and the trunks. Postoperatively, all symptoms completely resolved and the patient was discharged 5 days after surgery. thoracic outlet syndrome (TOS) manifests as symptoms of lower cervical nerve involvements with hypesthesia and paresthesia. However, upper plexus TOS manifests as symptoms due to the involvement of the C-5 to C-7 nerve roots, and is relatively rare. Transaxillary first rib resection is performed as the primary operation for TOS, but supraclavicular scalenectomy is effective for upper plexus TOS.
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5/18. Percutaneous mechanical thrombectomy for the management of venous thoracic outlet syndrome.

    PURPOSE: To describe the successful use of percutaneous mechanical thrombectomy as an adjunct to thrombolysis for acute subclavian vein thrombosis due to venous thoracic outlet syndrome. CASE REPORT: A 40-year-old man presented with arm swelling due to acute subclavian vein thrombosis and venous thoracic outlet syndrome. Percutaneous mechanical thrombectomy with the AngioJet device and thrombolysis were used to restore venous patency. Immediately following operative thoracic outlet decompression, the patient experienced rethrombosis, which was successfully treated using percutaneous mechanical thrombectomy. After 6 months, the patient remains symptom-free, with a patent subclavian vein by duplex ultrasonography. CONCLUSIONS: Thrombus debulking or removal with percutaneous mechanical thrombectomy devices may reduce the amount or duration of thrombolytic therapy required, making treatment of venous thoracic outlet syndrome safer. Moreover, patients with recurrent thrombosis after thoracic outlet decompression may be safely treated with percutaneous mechanical thrombectomy, even when thrombolytic therapy is contraindicated.
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6/18. Diagnostic utility of somatosensory and motor evoked potentials in a patient with thoracic outlet syndrome.

    OBJECTIVE: To evaluate the utility of somatosensory and motor evoked potentials in the diagnosis of neurogenic thoracic outlet syndrome (TOS). MATERIALS AND methods: In a female patient with progressive weakness and sensory disturbance, ulnar nerve somatosensory evoked potentials (SSEP), and intraoperative motor evoked potential (MEP) were performed. RESULTS: The SSEPs demonstrated no significant change in latency of major peaks at rest and after abduction of the shoulder. Diminishment of amplitude was noted after dynamic position of the arm. The MEPs demonstrated no significant change in latency after dynamic position. Diminishment of amplitude was noted after the dynamic position. The amplitude returned to normal after repositioning the arm. CONCLUSIONS: Electrophysiologic study is helpful in the diagnosis of neurogenic TOS. Reduced amplitude of cortical SSEP and myogenic MEP is expected during dynamic position of the affected arm.
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7/18. Intraoperative venous balloon angioplasty during surgical thoracic outlet decompression in Paget-Schrotter syndrome.

    The management of primary subclavian-axillary vein thrombosis is controversial. Indications and time of operative or endovascular intervention after successful thrombolysis remain unresolved. To improve the long-term functional outcomes in patients with primary subclavian-axillary vein thrombosis, early reestablishment of venous patency and prevention of recurrent thrombosis are required. We present a case in which, after catheter-directed thrombolysis, positional venography showed costoclavicular compression of the subclavian vein. At the time of surgical thoracic outlet decompression, transluminal venous angioplasty was performed.
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8/18. A novel finding in thoracic outlet syndrome: tachycardia.

    In this case report, we rendered a 22 year old woman with the diagnosis of neurogenic thoracic outlet syndrome. We have evaluated her symptoms of palpitation with Holter monitorization during Roos test before and after surgery where transaxillary first rib resection and scalenectomy were performed. Postoperatively she improved and the tachycardia resolved. We propose that stellate ganglion or postganglionic efferent sympathetic fibers forming the cardiac plexus are exposed to compression while Roos test is being performed. Due to this irritation, there can be an increase in the cardiac sympathetic activity.
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9/18. The rudimentary first rib. A cause of thoracic outlet syndrome with arterial compromise.

    The symptoms of thoracic outlet syndrome are neurologic, not vascular, in more than 95% of cases. subclavian artery compression is usually related to cervical ribs; however, congenitally abnormal first ribs may also produce vascular compromise. We review our two cases of thoracic outlet syndrome associated with significant subclavian artery compression caused by rudimentary first ribs and the prior literature emphasizing the mechanism of injury, diagnostic features, and treatment. Transaxillary resection of the first and second ribs was curative in both cases. The operative specimens demonstrated fusion of the rudimentary first rib to the second rib, with compression of the subclavian artery by a large first-rib exostosis. patients with thoracic outlet syndrome and a rudimentary first rib should be examined for substantial vascular compromise, and, if it is found, the abnormal first and second rib complex should be resected early without prolonged conservative measures.
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10/18. thoracic outlet syndrome secondary to childhood poliomyelitis.

    2 women with acute anterior poliomyelitis affecting the upper limb girdles in early childhood later developed thoracic outlet syndromes, 1 of them bilaterally. It is thought that the poliomyelitis was a contributory factor in each case by allowing undue descent of the shoulder girdles, although cervical ribs were also present in the second case. This association had not been recorded previously. Both patients obtained substantial relief from anterior scalenotomy, indicating that previous involvement of the shoulder girdle by poliomyelitis does not negate the efficacy of this operative procedure.
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