Abstract
Background:
The operative treatment for thoracic outlet syndrome (TOS) varies in the United States. This may be due to differences in specialty training of the provider. We sought to identify which procedures are primarily performed by specialty, identify patient characteristics presenting for different neurogenic TOS surgical interventions, and describe the safety of TOS surgery.
Methods:
Patients treated for neurogenic TOS between 2016 and 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient characteristics, surgeon details, intraoperative variables, and complication outcomes were abstracted. Patient cohorts were stratified by type of operative intervention and by treating specialty.
Results:
Transthoracic first rib resection was the most common procedure performed for TOS relief (46.1%), followed by division of the scalene muscles with rib resection (23.9%) and brachial plexus exploration with decompression (19.4%). Vascular surgeons performed 87% of TOS repairs. Thirty-day complication rate was 3.5%. Addition of scalenectomy to first rib resection was common and resulted in increased operative time but did not increase early complication rate or readmission rate.
Conclusion:
Patient characteristics and dispositions are similar between the various TOS operative approaches. All major surgical treatments for TOS have low complication rates. Transthoracic first rib resection performed by vascular surgeons remains the most common surgical treatment for patients with TOS in the United States. Despite neurogenic symptoms representing most cases, less than 10% of operations are performed by peripheral nerve specialists, highlighting a potential need for greater incorporation of TOS release into peripheral nerve practices.
Keywords: thoracic outlet syndrome, nerve compression, nerve, diagnosis, NSQIP, first rib resection, scalene division, TOS, scalene triangle syndrome
Introduction
Thoracic outlet syndrome (TOS) refers to a collection of signs and symptoms that arise from compression of the subclavian artery, subclavian vein, and nerves of the brachial plexus. These structures are susceptible to compression as they traverse the scalene triangle and the area immediately between the first rib and the clavicle. 1 Recent data suggest a yearly incidence of neurogenic and vascular TOS of 3 and 1 per 100 000 per year, respectively. However, these rates likely underestimate the true incidence, as this diagnosis is frequently missed. 2 Neurogenic TOS is estimated to account for more than 90% of all TOS cases.1,3 However, aspects of TOS remain controversial, including the nomenclature of the syndrome itself, making it difficult to study its prevalence, diagnosis, and treatment. Historically, prominent sources reported an overdiagnosis of neurogenic TOS, 4 unacceptable complication rates, 5 and have even called for a moratorium on surgery for TOS. 6 Cases are thus infrequently reported due to disagreement regarding the diagnostic criteria, and epidemiologic reports are prone to significant inconsistencies.
Surgical treatments are also varied. Multiple operative approaches have been described, including transaxillary, supraclavicular, and infraclavicular. The anatomic dissection influences how the compressed structures are addressed with variable efficacy depending on the etiologic subtype. The choice of approach can be influenced by the specific site of neurovascular compromise, but can also be a result of surgeon preference, training background, and familiarity with the individual vital structures.7,8 Surgical thoracic outlet decompression is indicated for symptomatic vascular TOS patients and for neurogenic TOS patients with symptoms refractory to conservative management.
In this study, we primarily seek to describe recent trends in neurogenic TOS surgical management and to determine whether patient risk factors or surgeon specialty affects surgical approach. We secondarily seek to describe the safety of neurogenic TOS surgical management.
Materials and Methods
American College of Surgeons National Surgical Quality Improvement Program
The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is a multi-institutional quality improvement registry representing more than 700 participating sites that collects perioperative data and follows patients for 30 days after major surgical procedures. The hospitals participating in the NSQIP database are the source of the data used herein.
The NSQIP is a validated national database that annually compiles more than 150 variables, including preoperative patient demographics and risk factors, operative variables, and 30-day postoperative outcomes. In the year 2018, there were 722 participating centers providing data for more than 1 million cases in both the outpatient and inpatient setting. The ACS has implemented regular auditing and training procedures to ensure accurate data reporting by participating institutions with excellent reliability and inter-reporting. Audits have yielded data with extremely low disagreement rates on data. 9
Patient Population
Patients who had TOS were identified through the International Classification of Diseases (ICD)-10 codes G54.0 between January 1, 2016, and December 31, 2018. The transition from ICD-9 to ICD-10 was effective as of October 1, 2014. Our study dates were selected to accurately capture TOS diagnostic data reflective of the ICD-10 changes and allowed for a buffer period after the ICD-10 implementation to reduce data collection errors. This study was deemed institutional review board (IRB)-exempt due to the nature of reviewing previously collected and deidentified data. Patients between 18 and 80 years of age were included to study. Current Procedural Terminology (CPT) codes with less than 10 cases were excluded from this study, ensuring that all cases included in the study were for primary TOS procedures rather than other simultaneous operations. The following preoperative variables were recorded and reported for each patient: demographic information (age, sex, race, body mass index [BMI]), American Society of Anesthesiologists (ASA) class, smoking history, and history of comorbid medical conditions. Procedure-specific data were collected including measures of operative time, inpatient status, length of stay, and primary surgeon specialty. The incidence of several 30-day complications, including unplanned readmission and reoperation were collected. Major complications, defined as Clavien-Dindo classification grade 3 or 4 disease requiring invasive intervention with risk of organ failure or death, were collected. These included pulmonary embolism, cardiac arrest requiring cardiopulmonary resuscitation, sepsis, and cerebrovascular accidents. However, several other complications were also collected and reported as well.
Statistical Analysis
The primary objective of this study was to report the classification of neurogenic TOS procedure type and surgeon specialty. The secondary objective was to determine an association between surgical approach and patient characteristics, provider training, and safety outcomes. The third objective was to determine the safety of TOS procedures. Patient demographics and characteristics were compared across groups using χ2 analyses. Surgical specialty volume and patient demographics were reported from these data. The incidence of 30-day complications was reported as a percentage of the entire cohort.
For statistical comparison, patients were categorized based on their surgical procedure: first rib excision alone or first rib excision with scalene division. These represented the 2 most common procedures in our cohort. Review of the secondary CPT codes for concurrent procedures was then performed to account for variations in primary CPT code assignment at institutional levels. The authors conducted analysis in this manner to achieve proper statistical power on which relevant conclusions may be drawn. Categorical variables were compared using χ2 or Fisher exact test, as appropriate, and reported as frequencies or proportions. Continuous variables were compared using a Student t test or univariate analysis of variance (as appropriate), with median and interquartile ranges (IQRs) reported. All statistical tests where 2-sided, with a P < .05 predetermined to represent statistical significance. All statistical tests were completed using Stata SE, Release 17 (Stata Statistical Software, College Station, Texas).
Results
American College of Surgeons NSQIP
The NSQIP query identified 64 CPT codes, of which 56 were excluded. In this patient cohort, 8 primary CPT codes were identified for primary neurogenic TOS treatment: 23405, 32900, 64713, 21600, 21616, 21615, 21700, and 21705 (Table 1). Excluded CPT codes reflected both nonstandard procedures, of which less than 10 cases were performed; codes performed for other simultaneous procedures; and others performed for vascular symptom etiologies. Excision of a first or cervical rib alone was the most common procedure performed for neurogenic TOS relief (46.1%), followed by division of the scalene muscles with rib resection (23.9%) and brachial plexus exploration with decompression (19.4%).
Table 1.
CPT Codes for Identified Thoracic Outlet Syndrome Procedures.
| CPT code | Procedure name |
|---|---|
| 21600 | Rib excision partial |
| 21615 | Excision first/cervical rib |
| 21616 | Rib excision with sympathectomy |
| 21700 | Division scalene without rib resection |
| 21705 | Division scalene with rib resection |
| 23405 | Tenotomy |
| 32900 | Extrapleural rib resection |
| 64713 | Brachial plexus decompression |
Note. CPT = Current Procedural Terminology.
Patient Cohort
A total of 1023 patients underwent thoracic surgery repair and met the study’s inclusion criteria. Of those, 61.7% were women, mean age was 36.4 years, and mean BMI was 27.4 kg/m2. The most prevalent comorbidities were smoking (15.7%) and medically treated hypertension (11.9%). Moreover, most patients were assigned an ASA class II (65.1%). Nearly all patients were functionally independent (99.8%). Preoperative demographics and clinical characteristics are presented in Table 2.
Table 2.
Patient Characteristics and Operative Details.
| Category | Partial rib excision, n (%) | Excision first/cervical rib, n (%) | Rib excision with sympathectomy, n (%) | Scalene division without rib resection, n (%) | Scalene division with rib resection, n (%) | Tenotomy, n (%) | Extrapleural rib resection, n (%) | Brachial plexus decompression, n (%) | Total, n (%) |
|---|---|---|---|---|---|---|---|---|---|
| Age, y | 36.1 (14.4) | 36.3 (12.9) | 32.6 (10.8) | 37.7 (11.7) | 36.1 (11.8) | 40.1 (12.8) | 39.7 (10.2) | 36.4 (13.1) | 36.4 (12.6) |
| Sex (female) | 10 (62.5) | 277 (58.7) | 7 (53.8) | 21 (60) | 167 (68.2) | 11 (50) | 15 (68.2) | 124 (62.6) | 632 (61.8) |
| BMI, kg/m2 | 26.8 (5.3) | 27.2 (5.7) | 28.4 (8.6) | 26.7 (8.8) | 27.6 (6.9) | 27.7 (6.6) | 29.1 (6.0) | 27.8 (7.2) | 27.4 (6.5) |
| Diabetes | 2 (12.5) | 15 (3.2) | 1 (7.7) | 1 (2.9) | 4 (1.6) | 0 | 1 (4.5) | 3 (1.5) | 27 (2.6) |
| Smoking history | 1 (6.3) | 64 (13.6) | 3 (23.1) | 4 (11.4) | 50 (20.4) | 5 (22.7) | 5 (22.7) | 29 (14.6) | 161 (15.7) |
| COPD | 0 | 5 (1.1) | 0 | 0 | 5 (2.4) | 0 | 2 (9.1) | 3 (1.5) | 15 (14.7) |
| CHF | 0 | 0 | 0 | 0 | 1 (0.41) | 0 | 0 | 1 (0.51) | 2 (0.20) |
| Hypertension | 2 (12.5) | 55 (11.7) | 3 (23.1) | 4 (11.4) | 28 (11.4) | 2 (9.1) | 3 (13.7) | 29 (14.6) | 126 (12.3) |
| Renal failure | 0 | 1 (0.21) | 0 | 0 | 0 | 0 | 1 (4.5) | 0 | 2 (0.20) |
| ESRD | 0 | 4 (0.85) | 1 (7.7) | 0 | 2 (0.82) | 0 | 1 (4.5) | 1 (0.51) | 9 (0.88) |
| ASA class | |||||||||
| Class I | 2 (12.5) | 90 (19.1) | 3 (23.1) | 6 (17.1) | 28 (11.4) | 3 (13.6) | 1 (4.5) | 4 (2.0) | 137 (13.4) |
| Class II | 10 (62.5) | 293 (62.1) | 8 (61.5) | 27 (77.1) | 176 (71.8) | 13 (59.1) | 15 (68.2) | 124 (62.6) | 666 (65.1) |
| Class III | 4 (25) | 81 (61.5) | 2 (15.4) | 2 (5.7) | 37 (15.1) | 6 (27.3) | 6 (27.3) | 3 (1.5) | 141 (13.8) |
| Class IV | 0 | 8 (1.7) | 0 | 0 | 3 (1.2) | 0 | 0 | 0 | 11 (1.1) |
| Inpatient procedures | 12 (0.75) | 357 (75.6) | 12 (92.3) | 24 (68.6) | 176 (71.8) | 12 (54.5) | 21 (95.5) | 172 (86.9) | 786 (76.8) |
| General anesthesia | 16 (100) | 468 (99.2) | 13 (100) | 35 (100) | 244 (99.6) | 22 (100) | 22 (100) | 197 (99.5) | 1018 (99.5) |
| Independent functional status | 16 (100) | 470 (99.6) | 13 (100) | 35 (100) | 245 (100) | 22 (100) | 22 (100) | 197 (99.5) | 1021 (99.8) |
| Operative time, min | 113.6 (53.3) | 126.5 (65.2) | 110.7 (36.0) | 128 (76.9) | 136.2 (70.0) | 50.7 (26.5) | 134.4 (86.5) | 169.4 (80.3) | 135.8 (72.7) |
| Length of stay, d | 2.8 (3.1) | 2.1 (1.7) | 2.7 (2.5) | 1.2 (1.0) | 1.8 (6.7) | 1.7 (1.9) | 2.4 (1.9) | 3.3 (2.2) | 2.1 (4.9) |
Note. Categorical variables reported as n (%). Continuous variables reported as mean (standard deviation). BMI = body mass index; COPD = chronic obstructive pulmonary disease; CHF = congestive heart failure; ESRD = end-stage renal disease; ASA = American Society of Anesthesiologists.
Vascular surgeons performed 87% of all TOS repairs, followed by thoracic surgeons (5.1%) and general surgeons (4.6%), respectively. Plastic surgeons, orthopedic surgeons, neurosurgeons, and cardiac surgeons combined to perform the remaining 3.1% (Table 3). Almost all procedures were performed with general anesthesia (99.7%), and 76.4% were performed as inpatient procedures. Thoracic outlet syndrome operations had a mean operative time of 135.8 minutes. Brachial plexus exploration with decompression was the most time-consuming procedure (169 minutes), while tenotomies were the shortest procedure (50 minutes). Rib resection alone was the most common procedure (n = 472, 46.1%), followed by division of the scalene muscles with simultaneous rib resection (n = 245, 23.9%) and brachial plexus exploration (n = 198, 19.4%; Table 4).
Table 3.
Thoracic Outlet Syndrome Treatment by Surgical Specialty.
| Surgical specialty | Procedural volume, n (%) |
|---|---|
| Vascular surgery | 893 (87.3) |
| Orthopedic surgery | 14 (1.5) |
| Thoracic surgery | 52 (5.1) |
| Plastic surgery | 3 (0.3) |
| Neurosurgery | 13 (1.3) |
| General surgery | 47 (4.6) |
| Cardiac surgery | 1 (0.1) |
Table 4.
Thoracic Outlet Syndrome Treatment by Procedure.
| Procedure approach | Volume, n (%) |
|---|---|
| Partial rib excision | 16 (1.6) |
| Excision first/cervical rib | 472 (46.1) |
| Rib excision with sympathectomy | 13 (1.3) |
| Scalene division without rib resection | 35 (3.4) |
| Scalene division with rib resection | 245 (23.9) |
| Tenotomy | 22 (2.2) |
| Extrapleural rib resection | 22 (2.2) |
| Brachial plexus decompression | 198 (19.4) |
There was a total of 36 procedural complications, resulting in a 3.5% 30-day complication rate. The most common complications were deep vein thrombosis, postoperative pneumonia, and superficial skin infections. Thirty-day unplanned readmission rate was 2.5% (n = 27) with a total of 24 (2.3%) reoperations within those 30 days. Only 5 (0.49%) major complications occurred in this population, as described by Clavien-Dindo classification grade 3 or 4 disease. These included 2 pulmonary embolisms, 1 cardiac arrest, and 2 occurrences of sepsis (Table 5).
Table 5.
Thirty-Day Complication Rates.
| Thirty-day outcome | Number of patients (%) |
|---|---|
| Superficial surgical site infection | 6 (0.5) |
| Pneumonia | 7 (0.6) |
| Unplanned intubation | 2 (0.02) |
| Pulmonary embolism | 2 (0.02) |
| Urinary tract infection | 2 (0.02) |
| Stroke/cerebrovascular accident | 0 (0) |
| Cardiac arrest | 1 (0.01) |
| Myocardial infarction | 0 (0) |
| Bleeding transfusions | 4 (0.39) |
| Deep vein thrombosis | 10 (0.97) |
| Sepsis | 2 (0.2) |
| Total complication | 30 (3.5) |
| Reoperations | 24 (2.3) |
| Unplanned readmissions | 27 (2.5) |
Division of the scalene muscles with rib excision was analyzed against complete rib excision procedures without division of the scalene muscles (CPT codes 21615 and 21616). Sixty procedures primarily coded as rib excision procedures had concurrent division of the scalene muscles; so, these were pooled with CPT code 21700 to account for variations in primary CPT code assignment. We identified 425 cases of partial or complete rib excision without scalene muscle division and 319 cases with scalene division. Addition of scalene division increased procedure time by approximately 14 minutes (138 vs 124 minutes; P = .0045). However, it did not increase total length of hospital stay (P = .2) or unplanned readmission or reoperation rate (P = .18 and P = .17, respectively). Overall complication rate did not differ between the 2 procedures. Vascular surgeons were more likely to perform rib excision only than general surgeons (P = .001). Female patients were significantly more likely to undergo first rib excision plus scalene division (66.8%) rather than rib excision alone (57.4%; P = .009). However, BMI, race, age, and medical comorbidities did not differ between cohorts (Table 6).
Table 6.
Rib Resection Versus Rib Resection and Scalene Division.
| Rib resection (n = 425) |
Rib resection with scalene division (n = 319) | P value | |
|---|---|---|---|
| Age, y | 36.2 (12.2) | 36 (11.9) | .73 |
| BMI, kg/m2 | 27.2 (5.7) | 27.4 (6.7) | .66 |
| Female sex | 244 (57.4) | 213 (66.8) | .009* |
| Race | .72 | ||
| • White | 371 (87.3) | 279 (87.5) | |
| • Black | 18 (4.2) | 15 (4.7) | |
| • Other | 3 (0.71) | 4 (1.3) | |
| Diabetes | 15 (3.5) | 6 (1.9) | .18 |
| Smoking history | 60 (14.1) | 58 (18.2) | .13 |
| COPD | 4 (0.94) | 6 (1.9) | .27 |
| CHF | 0 | 1 (0.31) | .43 |
| Hypertension on medication | 55 (12.9) | 35 (11) | .42 |
| ESRD receiving dialysis | 5 (1.2) | 2 (0.63) | .36 |
| Cancer | 0 | 1 (0.31) | .43 |
| Chronic steroid use | 15 (3.5) | 9 (2.8) | .59 |
| ASA class | .55 | ||
| • Classes I and II | 347 (81.6) | 265 (83.1) | |
| • Classes III and IV | 78 (18.4) | 53 (16.6) | |
| Surgeon | .001* | ||
| • Cardiac | 0 | 1 (0.31) | |
| • General | 33 (7.8) | 6 (1.9) | |
| • Neurosurgery | 0 | 2 (0.63) | |
| • Thoracic | 26 (6.1) | 13 (4.1) | |
| • Vascular | 366 (86.1) | 297 (93.1) | |
| Inpatient | 322 (75.7) | 236 (74) | .58 |
| Operative time, min | 123.8 (63.1) | 138 (72.3) | .005* |
| Length of stay, d | 2.06 (1.7) | 1.54 (1.4) | .20 |
| Reoperation | 8 (1.9) | 11 (3.4) | .18 |
| Unplanned readmission | 7 (1.6) | 10 (3.1) | .17 |
| Superficial skin infection | 0 | 2 (0.63) | .18 |
| Pneumonia | 3 (0.71) | 1 (0.31) | .42 |
| Deep vein thrombosis | 6 (1.4) | 3 (9.4) | .41 |
Note. BMI = body mass index; COPD = chronic obstructive pulmonary disease; CHF = congestive heart failure; ESRD = end-stage renal disease; ASA = American Society of Anesthesiologists.
Indicates statistical significance P < .05.
Discussion
In this study, we sought to understand trends in the surgical management of neurogenic TOS, including commonly performed procedures, surgeon subspecialty, and operative times by procedure type. We also sought to clarify the overall safety of neurogenic TOS surgery by both quantifying complication rates and identifying the most frequent types of complications.
The neurovascular structures traversing the thoracic outlet may be compressed in several distinct spaces, including the costoclavicular space (the area bounded by the first rib, clavicle, and scapula), the pectoralis minor space (the area between the pectoralis minor and chest wall), and the scalene triangle (the area bounded by the anterior scalene muscle, middle scalene muscle, and first rib). 10 By far the most common site of neurologic compromise is the scalene triangle; therefore, it is intuitive that direct scalene muscle division would be effective for patients suffering from compression at this site. 10 Roos and Owens defined the varied anatomic anomalies in patients with TOS, which frequently included a scalene medius muscle that traverses through the brachial plexus divisions and may not be completely released in transthoracic first rib resection alone. 11 Moreover, techniques were developed to target this pathophysiology surgically via scalene muscle decompression and scalenectomy. 10 Similarly, removal of the first thoracic rib further decompresses the costoclavicular space and space of the scalene triangle. This procedure indirectly releases the compression on the brachial plexus by the scalene muscles.
In our population, vascular surgeons performed 87% of all TOS repairs, consistent with the existing literature. 12 We were also able to identify the surgeons performing the remaining portion of procedures as thoracic surgeons, general surgeons, orthopedic surgeons, neurosurgeons, plastic surgeons, and cardiac surgeons (in descending order of frequency). The finding that vascular surgeons are performing most TOS repairs is particularly surprising given that venous and arterial TOS only account for 3% and 1%, respectively, of all TOS cases, while the rest of TOS cases are neurogenic. 13 Moreover, peripheral nerve and hand surgeons only comprised a very small portion of those performing TOS repair in our cohort. Yet orthopedic surgeons, plastic surgeons, and neurosurgeons often serve as the primary surgeons treating many pathologies frequently confused with TOS, including carpal tunnel release, brachial plexus exploration, and ulnar nerve decompression, among others.14-16 Explanations for these findings remain unclear. The diagnosis of vascular etiologies of TOS remains straightforward, as vascular symptoms include signs of upper limb vein thrombosis or phlebitis, particularly when extremities are raised. 17 This may represent elevated likelihood of rapid referral to vascular surgery for arterial and venous TOS. However, the diagnosis of neurogenic TOS remains disputed because the symptoms are often nonspecific and frequently present in other upper extremity pain syndromes, including nerve tunnel syndromes, cervical pain, degenerative disk disease, and noncompressive neuropathies. 17 Moreover, conservative treatments or surgical treatments may continue managing more common pathways in efforts to address patient-reported pain. Further investigation may help determine whether historic trends result in increased TOS referrals to vascular surgeons. We believe the nomenclature of the diagnosis contributes to the confusion and prevents TOS referral to brachial plexus and peripheral nerve surgeons. The term scalene triangle syndrome has been proposed to reflect the most common presentation of this disease more accurately. 18
First rib resection represented 60% of primary operations in our cohort. Many studies have reported that the most common surgical treatment for neurogenic TOS involves rib excision.13,19,20 Most patients undergoing TOS surgery were women, consistent with previous literature. 21 Women are significantly more likely to be affected to neurogenic TOS than men who are more likely to suffer from vascular TOS. However, other patient characteristics, comorbidities, and overall disposition assessed via ASA class were similar between surgical cohorts. Therefore, it does not appear that surgeons use these characteristics to select surgical approach.
Our analysis found that the mean operative time of TOS operations was 135.8 minutes, with brachial plexus exploration with decompression being the most time-consuming procedure (169 minutes) and pectoralis tenotomies being the shortest (50 minutes). This number is substantially lower than what has been reported in other recent studies, which report a mean length of surgery of 215.7 minutes. 19 Maqbool et al found rib resection was associated with significantly longer operative times compared with rib-sparing scalenectomy (221.7 vs 154.1 minutes, respectively). We also identified that addition of scalene division increased procedural times. Even when analyzing the same database, our measured increase in operative time was only 14 minutes, suggesting less differences in recent years than previously reported. 19
In this analysis, we also reviewed the safety of TOS operations. Overall, TOS operations had a 3.5% 30-day complication rate. A recent systematic review identified that previously reported complication rates varied from less than 5% to almost 40%. 7 However, the latest study that was included in that systematic review was published in 2014. A recent analysis by Maqbool et al 19 reported a 3.6% complication rate from patients in the NSQIP database from 2005 to 2013, similar to our complication rate. In contrast, we identified a major complication of 0.49%, much lower than their identified major complication rate of 2.2%. 19 Another analysis of TOS patients from 2005 to 2014 reported that readmission and reoperation rates were 8.6%. 12 This is significantly greater than the 2.5% readmission rate in our cohort. Recent advances in robotic and endoscopic surgical treatments may contribute to lower complication rates.22-25 We therefore believe that these lower complications and readmission rates in our contemporary cohort suggest that the safety of TOS surgery has markedly improved. Thus, our data support our impression that TOS surgery is safe, and that severe complications and death are rare.
Our study was subject to various limitations as a retrospective database study. Because NSQIP only collects data on outcomes for 30 days postoperatively, any complications after 30 days are not accounted for in our analysis. The NSQIP also does not collect functional outcomes or pain scores for patients. Given that TOS is largely a functional disease, our study is unable to accurately assess the clinical success of TOS procedures after 30 days. However, this database has the advantage of being one of the largest surgical databases and provides important safety outcomes and intraoperative details. Furthermore, although NSQIP includes more than 700 centers, it is still not necessarily representative of the whole United States, only participating institutions. However, we were willing to accept this limitation given that NSQIP collects data directly from patient charts and can account for differences between hospitals with strong interhospital validity. Last, although this is one of the largest scale studies to date reporting on TOS, the relative infrequency of this diagnosis lends to a limited patient population.
Our study revealed that surgical management of TOS is subject to significant flexibility in surgeon approach and experience and that all major surgical treatments for TOS yield low complication rates. First rib excisions with or without scalenectomy remain the most performed procedures for TOS, and addition of scalenectomy does not increase 30-day complications. Importantly, we identified that peripheral nerve and hand subspecialists perform less than 5% of all surgical repairs, while vascular surgeons continue to be the primary surgeons managing TOS. Future analysis should concentrate on examining surgical provider trends in their approach to both operative and nonoperative management of TOS and in their presenting patient populations to explain why brachial plexus and peripheral nerve surgeons are not routine referrals for TOS surgical care.
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. This article does not contain any studies with human or animal subjects.
Statement of Informed Consent: Informed consent was obtained from all patients for being included in the study.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Tariq Z. Issa 
https://orcid.org/0000-0002-0978-5225
Jasmine S. Lin
https://orcid.org/0000-0003-2478-1668
Brian Mailey
https://orcid.org/0000-0002-2846-7556
References
- 1. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007;46(3):601-604. doi: 10.1016/j.jvs.2007.04.050. [DOI] [PubMed] [Google Scholar]
- 2. Illig KA, Rodriguez-Zoppi E, Bland T, et al. The incidence of thoracic outlet syndrome. Ann Vasc Surg. 2021;70:263-272. doi: 10.1016/j.avsg.2020.07.029. [DOI] [PubMed] [Google Scholar]
- 3. Masocatto NO, Da-Matta T, Prozzo TG, et al. Thoracic outlet syndrome: a narrative review. Rev Col Bras Cir. 2019;46(5):e20192243. doi: 10.1590/0100-6991e-20192243. [DOI] [PubMed] [Google Scholar]
- 4. Wilbourn AJ. The thoracic outlet syndrome is overdiagnosed. Arch Neurol. 1990;47(3):328-330. doi: 10.1001/archneur.1990.00530030106024. [DOI] [PubMed] [Google Scholar]
- 5. Urschel HC, Razzuk MA. Neurovascular compression in the thoracic outlet: changing management over 50 years. Ann Surg. 1998;228(4):609-617. doi: 10.1097/00000658-199810000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Cherington M. Surgery for thoracic outlet syndrome? N Engl J Med. 1986;314(5):322-322. [DOI] [PubMed] [Google Scholar]
- 7. Peek J, Vos CG, Ünlü Ç, et al. Outcome of surgical treatment for thoracic outlet syndrome: systematic review and meta-analysis. Ann Vasc Surg. 2017;40:303-326. doi: 10.1016/j.avsg.2016.07.065. [DOI] [PubMed] [Google Scholar]
- 8. Illig KA, Rodriguez-Zoppi E. How common is thoracic outlet syndrome? Thorac Surg Clin. 2021;31(1):11-17. doi: 10.1016/j.thorsurg.2020.09.001. [DOI] [PubMed] [Google Scholar]
- 9. Shiloach M, Frencher SK, Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16. doi: 10.1016/j.jamcollsurg.2009.09.031. [DOI] [PubMed] [Google Scholar]
- 10. Hooper TL, Denton J, McGalliard MK, et al. Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip Ther. 2010;18(2):74-83. doi: 10.1179/106698110X12640740712734. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Roos DB, Owens JC. Thoracic outlet syndrome. Arch Surg. 1966;93(1):71-74. doi: 10.1001/archsurg.1966.01330010073010. [DOI] [PubMed] [Google Scholar]
- 12. Rinehardt EK, Scarborough JE, Bennett KM. Current practice of thoracic outlet decompression surgery in the United States. J Vasc Surg. 2017;66(3):858-865. doi: 10.1016/j.jvs.2017.03.436. [DOI] [PubMed] [Google Scholar]
- 13. Yin ZG, Gong KT, Zhang JB. Outcomes of surgical management of neurogenic thoracic outlet syndrome: a systematic review and Bayesian perspective. J Hand Surg Am. 2019;44(5):416.e1-416.e17. doi: 10.1016/j.jhsa.2018.06.120. [DOI] [PubMed] [Google Scholar]
- 14. D’Auria JL, Montanez A, Toirac A, et al. Accuracy of surgeon diagnosis in predicting carpal tunnel syndrome. Hand. 2021;16(2):179-182. doi: 10.1177/1558944719856105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Sears ED, Lu YT, Wood SM, et al. Diagnostic testing requested before surgical evaluation for carpal tunnel syndrome. J Hand Surg Am. 2017;42(8):623-629. doi: 10.1016/j.jhsa.2017.05.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Hill JR, Lanier ST, Rolf L, et al. Trends in brachial plexus surgery: characterizing contemporary practices for exploration of supraclavicular plexus [published online ahead of print May 21, 2021]. Hand. doi: 10.1177/15589447211014613. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Laulan J, Fouquet B, Rodaix C, et al. Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. J Occup Rehabil. 2011;21(3):366-373. doi: 10.1007/s10926-010-9278-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Gage M, Parnell H. Scalenus anticus syndrome. Am J Surg. 1947;73(2):252-268. [DOI] [PubMed] [Google Scholar]
- 19. Maqbool T, Novak CB, Jackson T, et al. Thirty-day outcomes following surgical decompression of thoracic outlet syndrome. Hand. 2019;14(1):107-113. doi: 10.1177/1558944718798834. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Johansen K. Rib-sparing scalenectomy for neurogenic thoracic outlet syndrome: early results. J Vasc Surg. 2021;73(6):2059-2063. doi: 10.1016/j.jvs.2020.12.052. [DOI] [PubMed] [Google Scholar]
- 21. Ciampi P, Scotti C, Gerevini S, et al. Surgical treatment of thoracic outlet syndrome in young adults: single centre experience with minimum three-year follow-up. Int Orthop. 2011;35(8):1179-1186. doi: 10.1007/s00264-010-1179-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Soukiasian HJ, Shouhed D, Serna-Gallgos D, et al. A video-assisted thoracoscopic approach to transaxillary first rib resection. Innovations. 2015;10(1):21-26. doi: 10.1097/IMI.0000000000000120. [DOI] [PubMed] [Google Scholar]
- 23. Kocher GJ, Zehnder A, Lutz JA, et al. First rib resection for thoracic outlet syndrome: the robotic approach. World J Surg. 2018;42(10):3250-3255. doi: 10.1007/s00268-018-4636-4. [DOI] [PubMed] [Google Scholar]
- 24. Gharagozloo F, Meyer M, Tempesta B, et al. Robotic first rib resection for thoracic outlet syndrome. Surg Technol Int. 2020;36:239-244. [PubMed] [Google Scholar]
- 25. Abdellaoui A, Atwan M, Reid F, et al. Endoscopic assisted transaxillary first rib resection. Interact Cardiovasc Thorac Surg. 2007;6(5):644-646. doi: 10.1510/icvts.2007.151423. [DOI] [PubMed] [Google Scholar]