Two new studies from Washington University School of Medicine in St. Louis suggest ways to improve surgical treatment for a debilitating condition caused by compressed nerves in the neck and shoulder. The condition, neurogenic thoracic outlet syndrome, causes pain, numbness or tingling in the shoulder, arm or hand and is perhaps best known for affecting baseball pitchers and other elite athletes. Patients often describe pain and tension in the neck and upper back, numbness and tingling in the fingers, headaches and perceived muscle weakness in the affected limb.
Treatment begins with physical therapy and sometimes medications such as anti-inflammatory drugs and muscle relaxants. When these treatments fail to improve symptoms and there is substantial disability in the use of the affected upper extremity, surgery can help relieve pressure on the nerves, often by removing the first rib and other structures thought to be causing the compression.
According to the summary in Science Daily, one of the studies showed that certain patients may do just as well with a minimally invasive procedure done on an outpatient basis as those who require the traditional surgery. The traditional procedure has an average five-day hospital stay. This study looked at 200 patients treated for neurogenic thoracic outlet syndrome from 2008 through 2011. To determine the best surgical approach for each patient, the doctor examined two locations of potential nerve compression — the side of the neck above the collarbone and the upper chest just below the collarbone, near the shoulder.
If patients experienced pain and tenderness in both places, they were offered the traditional procedure that includes removing the first rib and scalene muscles in the neck and detaching the tendon of the pectoralis minor muscle, which connects to the top and front of the shoulder blade. Of the 200 patients, 143 underwent this procedure.
When symptoms occurred exclusively under the collarbone, patients only received detachment of the pectoralis minor tendon as a minimally invasive procedure. The remaining 57 participants in the study underwent this outpatient procedure.
To determine outcomes, the researchers compared various measures of the patients’ arm and shoulder function before surgery and again three months after surgery. Both sets of patients improved significantly after surgery, and the extent of their improvement was not statistically different. At the three-month mark, about 75 percent of patients in both groups demonstrated improved function in the affected areas.
“The ideal candidate for the minimally invasive procedure would be a patient with characteristic and debilitating symptoms, no response to physical therapy and clinical exam findings that were completely localized to the pectoralis minor tendon,” Thompson says. “That’s the really exciting subset of patients. You might be able to have a big impact with a minor outpatient procedure. The trick is to properly identify these patients. We still have to rely primarily on the experience of the physician and old-fashioned diagnosis by physical exam — knowing the anatomy, knowing what we’re feeling and what elicits symptoms.”