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Obliteration of the Scalene Triangle on Sagittal MRI is Correlated with Intraoperative Findings of Brachial Plexus and Subclavian Artery Compression in Patients with Neurogenic Thoracic Outlet Syndrome (NTOS)
Madi El Haj, MD. MSc.1; Amit Korah, MD2; Ori Wald, MD2; Sofia Anastasia Vorobeitchik, RA2; Yosef Kalish, MD2; Allan I Bloom, MD2
1Hadassah Hebrew University Medical School, Jerusalem, Israel; 2Hadassah Hebrew University Medical Center, Jerusalem, Israel

Objective: Neurogenic thoracic outlet syndrome (NTOS) is caused by dynamic compression of the brachial plexus at the level of the supraclavicular scalene triangle, the sub-coracoid (pectoralis minor) space, or the costoclavicular space. The purpose of this study was to report the correlation between obliteration of the preoperative scalene triangular space on MRI, preoperative symptoms, and intraoperative findings in patient with NTOS.
Methods: A retrospective review was conducted including 26 patients with NTOS between January 2019 to July 2022 (Table 1.). Pre-operative sagittal T1-weighted MRI images were compared with the contralateral normal side and correlated with intraoperative findings in patients who underwent primary TOS decompression with first rib resection. Patients were preoperatively evaluated using composite NTOS Index combining the quick DASH survey, Cervical-Brachial Symptom Questionnaire (CBSQ), a 10-point visual analog scale (VAS) for pain, Pain Rating Index (PRI), Brief Pain Inventory index (BPI) and Pain Catastrophizing scale (PCS).
Results: Preoperative sagittal T1-weighted MRI demonstrated scalene triangular space fat obliteration in all patients with NTOS when compared to the non-affected side (Figure 1). This appearance was well correlated with the intraoperative findings. Including Roos’ bands (8/26) (Figure 2), Scalenus Minimums (SM), (11/26), (Figure 3), fibrotic band at the posterior edge of the anterior scalene (PAS) (12/26) and scalene muscle hypertrophy in the remaining cases. More one lesion was documented in a number of patients. The presence of predominate middle and lower trunk symptoms associated with limited painful shoulder abduction and flexion suggested structural abnormalities (Roos’ bands, SM, PAS) in 61% and 50% of the cases respectively. In all cases brachial plexus root fibrosis and adherence were identified.
Conclusion: Obliteration of the scalene triangle fat on sagittal T1 weighted MRI, is an indicator of compressive plexopathy in NTOS patients. In the presence of appropriate clinical symptoms, failed non operative rehabilitation may support surgical decompression.





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