Cervical Proportions in Surgical Thoracic Outlet Syndrome
Emran S. Sheikh, MD1; Michael Zemaitis, MD2; Camille Swain, MD2; Diane Maggio, RN NP1; Renata V Weber, MD1; Ednan S Sheikh, MD3; (1)Multi Disciplinary Specialists, Rutherford, NJ, (2)Carepoint Health, Rutherford, NJ, (3)NJ Pain & Spine, Paterson, NJ
Background:
Originally described by Peet in 1956, thoracic outlet syndrome (TOS) has been a challenging condition to treat. This is significantly related to difficulty in making the diagnosis. Defined as a constellation of symptoms and signs resulting from the compression of the neurovascular structures as they pass through the thoracic outlet, TOS remains a clinical diagnosis. Imaging and nerve testing remain inaccurate. Relationships between the radiographic position of the shoulder girdle position to the thorax (Cho,2012) and even first rib dimensions (Chang,2011) have been suggested in diagnosing TOS. This requires additional patient visits in obtaining the correct imaging technique, radiographic measurements, and follow-up.
Purpose:
We define specific, objective measurements on physical exam of a “longer” neck in patients undergoing surgical treatment of TOS.
Materials and Methods:
A retrospective case control study. Surgically treated cases of TOS were identified between August 2015 and July 2016. A control group of volunteers (patients without TOS) were identified during the dame period. Cervical measurements were obtained by the nurse, independent and prior to the physician exam and clinical discussion with the patient. Measurements were obtained with the patient in repose.
Measurements were compared between the two groups (TOS surgery and non-TOS patients). Unpaired two-tailed t-test was used with significance defined as p- value less than 0.05.
Results:
Seven patients underwent surgery for TOS. Eight control patients were identified.
Superior thyroid notch to sternal notch distance was 8.8 +/- 1.6 cm (TOS) vs 5.8 +/- 0.8 cm (control) with p<0.0006 (significant). Mean difference 2.97 cm [95% Confidence Interval (C.I.) 1.56-4.40]
Acriomioclavicular (AC) joint to contralateral AC joint distance was 30.5 +/- 1.6 cm (TOS) vs 32.6 +/- 2.1 cm (control) with p=0.05 (not significant).
Ratio of notch distance to AC distance was 0.29 +/- 0.05 (TOS) vs 0.18 +/- 0.03 (control) with p<0.0001 (significant) . Mean difference 0.11 [95% Confidence Interval (C.I.) 0.07-.15]
Conclusion:
We define a simple and novel sign on clinical exam which relates to helping identify patients who may need surgical treatment for a challenging and often frustrating diagnosis, TOS. Shoulder width as defined as AC distance was not significantly different between groups. Thyroid notch to sternal notch distance is independently and as a ratio to shoulder width, a significant marker for patients undergoing TOS surgery. TOS surgery patients have “longer” necks (30% of shoulder width) versus non TOS patients (less than 20% of shoulder width).
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