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American Association for Hand Surgery

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Trends in Thoracic Outlet Syndrome Surgical Treatment
Tariq Ziad Issa, BA, Northwestern University, Chicago, IL, Puneet Gupta, BS, George Washington University, Washington, DC, DC, Ivy Chen, MS, Boston University, Boston, MA, Fernando Herrera, MD, Division of Plastic Surgery, Medical University of South Carolina, Charleston, SC and Brian A Mailey, MD, Southern Illinois University School of Medicine, Springfield, IL

Introduction
The operative treatment for thoracic outlet syndrome (TOS) varies in the United States. This is partially due to differences in specialty training of the treating provider. We sought to identify which procedures are primarily performed in the U.S. by specialty.
Materials and Methods
Patients treated for TOS between 2016 - 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient cohorts were stratified by type of operative intervention (transthoracic rib resection vs. supraclavicular scalene division with or without rib resection vs brachial plexus exploration) and by treating specialty (vascular surgery, cardiothoracic surgery, orthopedic surgery, general surgery, neurosurgery, and plastic surgery).
Results
Of the 1023 patients treated for TOS, the majority were performed by vascular surgeons (87%, N=893), followed by cardiothoracic (5.0%, N=52), general surgery (4.6%, N= 47), orthopedic surgery (1.3%, N=13), neurosurgery (1.2%, N=12), and plastic surgery (0.002%, N=3). Excision of a first rib with was the most common procedure performed for TOS relief (46.7%). However, division of the scalene muscles with first rib resection and brachial plexus exploration with decompression were the next most common procedures, representing 23.9% and 19.4% of cases, respectively. Brachial plexus exploration with decompression was both the most time-consuming procedure (169 minutes) and was associated with the longest total length of hospital stay (3.3 days). These procedures were of relatively low morbidity to the patients with a 3.5% (N=36) complication rate. The most common complications were surgical site infections and deep vein thrombosis. Overall unplanned readmission rate was 2.5%.
Conclusions
Transthoracic first rib resection performed by vascular surgeons remains the most common surgical treatment for patients with TOS in the U.S. Recognition of TOS as a compressive neuropathy has led to an increase in treatment by peripheral nerve surgeons and subsequently brachial plexus exploration and direct scalene division through a supraclavicular approach. Still, although most TOS symptoms are neurogenic in nature, less than 10% of operations are performed by peripheral nerve specialists, highlighting a need for greater incorporation of TOS surgical repair into clinical practice.


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