A clinical case of a combined endoscopic treatment: brachial plexus decompression in the thoracic aperture and subacromial spacer implantation

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Abstract

Background: Thoracic outlet syndrome — compression of the brachial plexus in the area between the clavicle and the first rib — is a commonly spread and important pathology. It occurs, as usual, after a trauma or due to an anatomical malformation of this area. Thoracic outlet syndrome can be combined with a shoulder joint pathology. In the case of a conservative treatment's failure, the standard surgical procedure is decompression of the brachial plexus in the thoracic aperture. This procedure is usually done via an open approach. The development of the endoscopic surgical technique of decompression allows reducing the risk of complications and recurrences, improving the cosmetic result and relieving the rehabilitation period. Clinical case description: A 73-year-old female patient with a clinical picture of posttraumatic brachial plexopathy and a massive shoulder rotator cuff tear. The patient underwent a conservative treatment for 6 months after the trauma without a significant improvement. To confirm the diagnosis, ENMG and an ultrasound investigation of the brachial plexus, as well as MRI of the shoulder joint were performed. Simultaneous shoulder joint arthroscopy with subacromial spacer implantation and brachial plexus decompression in the thoracic aperture were performed to the patient. According to the VAS-scale (Visual Analogue Scale), the severity of pain syndrome before the surgery was 10 cm, while 6 months after the surgery, it decreased to 1 cm. According to the DASH scale (Disabilities of the Arm, Shoulder, and Hand), the dysfunction of the of shoulder joint before the surgery was 76 points, while 6 months after the surgery, it decreased to 12 points. The range of motion in the shoulder joint before the surgery was as follows: flexion 105°, abduction 95°, external rotation 15°, which increased to 160°, 165°, and 45°, respectively, 6 months after the surgery. Conclusion: The results allow us to characterize the method of simultaneous shoulder joint arthroscopy and endoscopic decompression of the brachial plexus in the thoracic aperture as a low-traumatic and effective technique. The technique provides complete brachial plexus decompression in the thoracic aperture which promotes restoration of the function of the upper extremity and shoulder joint, and elimination of pain syndrome from the upper extremity area.

About the authors

Evgeniy A. Belyak

Peoples’ Friendship University of Russia; Moscow City Clinical Hospital in honor of V.M. Buyanov

Email: belyakevgen@mail.ru
ORCID iD: 0000-0002-2542-8308
SPIN-code: 7337-1214

MD, PhD

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198; Moscow

Dmitry L. Paskhin

Moscow City Clinical Hospital in honor of V.M. Buyanov

Email: yas-moe@mail.ru
ORCID iD: 0000-0003-3915-7796
SPIN-code: 8930-1390
Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198

Fedor L. Lazko

Peoples’ Friendship University of Russia; Moscow City Clinical Hospital in honor of V.M. Buyanov

Email: fedor_lazko@mail.ru
ORCID iD: 0000-0001-5292-7930
SPIN-code: 8504-7290

MD, PhD

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198; Moscow

Aleksey P. Prizov

Peoples’ Friendship University of Russia; Moscow City Clinical Hospital in honor of V.M. Buyanov

Email: aprizov@yandex.ru
ORCID iD: 0000-0003-3092-9753
SPIN-code: 6979-6480

к.м.н.

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198; Moscow

Maxim F. Lazko

Peoples’ Friendship University of Russia; Moscow City Clinical Hospital in honor of V.M. Buyanov

Email: maxim_lazko@mail.ru
ORCID iD: 0000-0001-6346-824X

MD, PhD

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198; Moscow

Nikolay V. Zagorodniy

Peoples’ Friendship University of Russia

Email: zagorodniy51@mail.ru
ORCID iD: 0000-0002-6736-9772
SPIN-code: 6889-8166

MD, PhD, correspondent member of RAS

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198

Sarkis A. Asratyan

Moscow City Clinical Hospital in honor of V.M. Buyanov

Email: dr.sako@mail.ru
ORCID iD: 0000-0001-8472-4249
SPIN-code: 1037-4232

MD, PhD

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198

Alexander A. Akhpashev

Peoples’ Friendship University of Russia

Author for correspondence.
Email: akhpashev@yandex.ru
ORCID iD: 0000-0002-2938-5173
SPIN-code: 9965-1828

MD, PhD

Russian Federation, 6, Miklukho-Maklaya street, Moscow, 117198

References

  1. Kuhn JE, Lebus GF, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015;23(4):222–232. doi: 10.5435/JAAOS-D-13-00215
  2. Куцай Н.В., Головина Е.Р., Аджисалиев Г Р. Современные методы лечения синдрома верхней апертуры грудной клетки // Инновации. Наука. Образование. 2020. № 24. С. 1933–1939. [Kutsyy NV, Golovina ER, Adjisaliev GR. Modern methods of treatment of upper chest aperture syndrome. Innovations. The science. Education. 2020;(24):1933–1939. (In Russ).]
  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
  4. Магомедов Р.К., Цуладзе И.И., Древаль О.Н., Чапандзе Г.Н. Клинико-диагностические особенности нейроваскулярного компрессионного синдрома в области верхней грудной апертуры // Российский нейрохирургический журнал им. проф. А.Л. Поленова. 2021. Т. 13, № S1. С. 106. [Magomedov RK, Tsuladze II, Dreval ON, Kapanadze GN. Clinical and diagnostic features of neurovascular compression syndrome in the upper thoracic aperture. Russ Neurosur J named after Professor A.L. Polenov. 2021;13(S1):106. (In Russ).]
  5. 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
  6. Collins E, Orpin M. Physical therapy management of neurogenic thoracic outlet syndrome. Thorac Surg Clin. 2021;31(1):61–69. doi: 10.1016/j.thorsurg.2020.09.003
  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
  8. Boglione M, Ortíz R, Teplisky D, et al. Surgical treatment of thoracic outlet syndrome in pediatrics. J Pediatr Surg. 2022;57(9):29–33. doi: 10.1016/j.jpedsurg.2021.08.017
  9. Магомедов Р.К., Муин Р.А. Нейроваскулярный компрессионный синдром в области верхней грудной апертуры: клинико-диагностические аспекты и хирургическое лечение // Вестник неврологии, психиатрии и нейрохирургии. 2015. № 7. С. 55–64. [Magomedov RK, Musin RA. Neurovascular compression syndrome in the upper thoracic aperture: clinical and diagnostic aspects and surgical treatment. Bulletin Neurol Psychiatry Neurosur. 2015;(7):55–64. (In Russ).]
  10. Гаибов А.Д., Кахоров А.З., Садриев О.Н., Юнусов Х.А. Хирургическое лечение синдрома верхней грудной апертуры // Вестник хирургии им. И.И. Грекова. 2015. Т. 174, № 1. С. 78–83. [Gaibov AD, Zakharov AZ, Sadriev ON, Yunusov HA. Surgical treatment of upper thoracic aperture syndrome. Bulletin Sur named after I.I. Grekov. 2015;174(1):78–83. (In Russ).] doi: 10.24884/0042-4625-2015-174-1-78-83
  11. 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
  12. Кахоров А.З., Гаибов А.Д., Султонов Д.Д. Осложнение хирургического лечения синдрома верхней грудной апертуры // Вестник Таджикского национального университета. Серия естественных наук. 2015. № 1–4. С. 243–246. [Kakharov AZ, Gaibov AD, Sultanov DD. Complication of surgical treatment of upper thoracic aperture syndrome. Bulletin Tajik National University. Series Natural Sci. 2015;(1–4):243–246. (In Russ).]
  13. George RS, Milton R, Chaudhuri N, et al. Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome. Ann Thorac Surg. 2017;103(1):241–245. doi: 10.1016/j.athoracsur.2016.06.075
  14. Lafosse T, Le Hanneur M, Lafosse L. All-endoscopic brachial plexus complete neurolysis for idiopathic neurogenic thoracic outlet syndrome: surgical technique. Arthrosc Tech. 2017;10;6(4):e967–e971. doi: 10.1016/j.eats.2017.03.006
  15. Патент РФ № 2637616 C1. Суфианов А.А., Гизатуллин М.Р., Якимов Ю.А. Способ эндоскопической ревизии, невролиза и декомпрессии плечевого сплетения. [Patent RF No 2637616 C1. Sufianov AA, Gizatullin MR, Yakimov YuA. Method of endoscopic revision, neurolysis and decompression of the brachial plexus. (In Russ).] Режим доступа: https://yandex.ru/patents/doc/RU2637616C1_20171205. Дата обращения: 17.03.2022.
  16. Furushima K, Funakoshi T. Endoscopic-assisted transaxillary approach for first-rib resection and neurolysis in thoracic outlet syndrome. Arthrosc Tech. 2021;10(1):e235–e240. doi: 10.1016/j.eats.2020.09.034
  17. Vanti C, Natalini L, Romeo A, et al. Conservative treatment of thoracic outlet syndrome. A review of the literature. Eura Medicophys. 2007;43(1):55–70.
  18. Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am. 1995;20(4):542–548. doi: 10.1016/S0363-5023(05)80264-3
  19. Mailis A, Papagapiou M, Vanderlinen RG, et al. Thoracic outlet syndrome after motor vehicle accidents in a canadian pain clinic population. Clin J Pain. 1995;11:316–324.
  20. Lafosse T, Masmejean E, Bihel T, Lafosse L. Brachial plexus endoscopic dissection and correlation with open dissection. Chir Main. 2015;34(6):286–293. doi: 10.1016/j.main.2015.08.007
  21. Mitták M, Tulinský L, Martínek L. Our technique of thoracoscopic first rib resection — case report. Rozhl Chir. 2022;101(4): 176–179. doi: 10.33699/PIS.2022.101.4.176-179
  22. Candia-de la Rosa RF, Pérez-Rodríguez A, Candia-García R, Palacios-Solís JM. Endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe surgical option. Cir Cir. 2010;78(1):53–59. (In English, Spanish).
  23. Nuutinen H, Riekkinen T, Aittola V, et al. Thoracoscopic versus transaxillary approach to first rib resection in thoracic outlet syndrome. Ann Thorac Surg. 2018;105(3):937–942. doi: 10.1016/j.athoracsur.2017.10.004
  24. Ojanguren A, Krueger T, Gonzalez M. First rib resection by VATS for thoracic outlet syndrome. Multimed Man Cardiothorac Surg. 2020;2020. doi: 10.1510/mmcts.2020.027

Supplementary files

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2. Fig. 1. Marking of anatomical landmarks and endoscopic portals before surgery.

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3. Fig. 2. Schematic view of placement of arthroscope and instrument during approach to thoracic aperture: 1 — upper cord of brachial plexus; 2 — median cord of brachial plexus; 3 — inferior cord of brachial plexus; 4 — subclavian artery; 5 — medial branch of brachial plexus; 6 — superior branch of median nerve; 7 — musculocutaneous nerve; 8 — suprascapular nerve; 9 — working instrument (ablator); 10 — arthroscope; 11 — anterior working portal; 12 — antero-lateral working portal; 13 — coracoid process; 14 — clavicle; 15 — acromial process of scapula; 16 — first rib; 17 — subclavian muscle.

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4. Fig. 3. Placement of arthroscope and working instrument during approach to thoracic aperture.

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5. Fig. 4. Axillary nerve (1) and radial nerve (2) after performing neurolysis.

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6. Fig. 5. Detachment of pectoralis minor muscle (*) from medial margin of coracoid process.

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7. Fig. 6. Musculocutaneous nerve (*) after performing neurolysis.

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8. Fig. 7. Co-position of axillary artery (1) and musculocutaneous nerve (2).

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9. Fig. 8. Detachment of lateral portion of subclavian muscle from clavicle: 1 — detached part of subclavian muscle; 2 — clavicle.

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10. Fig. 9. Components of brachial plexus in thoracic aperture area: 1 — upper trunk; 2 — division from the upper trunk; 3 — suprascapular nerve.

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11. Fig. 10. Components of brachial plexus after decompression: 1 — upper trunk; 2 — median trunk; 3 — suprascapular nerve.

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12. Fig. 11. Components of brachial plexus after decompression: 1 — upper trunk; 2 — division from upper trunk.

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13. Fig. 12. Subclavian artery (1); upper trunk of brachial plexus shifted posteriorly (2).

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14. Fig. 13. Introducing of subacromial spacer: а — spacer (*) in folded position introduced into a shoulder joint; б — spacer (*) after dilatation.

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15. Fig. 14. External view of the shoulder area after endoscopic surgery.

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Copyright (c) 2022 Belyak E.A., Paskhin D.L., Lazko F.L., Prizov A.P., Lazko M.F., Zagorodniy N.V., Asratyan S.A., Akhpashev A.A.

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