title: Computed tomography-guided reoperation for neurogenic thoracic outlet syndrome.
abstract: OBJECTIVE
  Persistent or recurrent symptoms after surgical treatment for neurogenic thoracic outlet syndrome (nTOS) is a problem commonly encountered by high-volume referral centers. The mechanical etiology patterns at reoperation include (1) inadequate previous rib resection, (2) rib regrowth, (3) scar tissue formation, or (4) intact scalene muscle. Reoperative TOS surgery has significant potential morbidity, and therefore, careful patient selection and meticulous planning are required. This study evaluated the utility of multidetector computed tomography (CT) in the differential diagnosis of patients with recurrent or persistent nTOS.
  
  
  METHODS
  A retrospective record review was performed of a nTOS referral practice of patients treated from 2003 to 2012 to focus on patients reoperated on for recurrent or persistent symptoms. In 2003, a dedicated high-resolution multidetector TOS CT protocol was established to assist in clinical decision making and reoperative planning. A single designated radiologist interpreted all CT images. Imaging, patient clinical characteristics, interventions, and outcomes were reviewed.
  
  
  RESULTS
  The study group included 20 reoperations for recurrent (n = 15) or persistent (n = 5) symptoms. Mean age was 35 years, and 60% of redo cases were in women. Preoperative CT imaging demonstrated the following anatomic patterns: inadequate previous rib resection in 5 (25%), rib regrowth in 5 (25%), scar tissue formation in 10 (50%), and intact scalene muscle in 3 (15%). Operative findings concurred with preoperative imaging in 85% of patients. There were no neurovascular injuries and no major complications. At a mean follow-up of 43 months, improvement or resolution of symptoms was significant in nine patients (45%), moderate in seven (35%), and minimal in four (20%).
  
  
  CONCLUSIONS
  Recurrent/persistent nTOS is an often-vexing problem with challenging solutions. These results demonstrate the utility of a TOS protocol CT scan in providing correlative objective findings and in assisting with reoperative planning. Positive radiographic findings that correlate with patient symptoms inform the decision to reoperate.
authors.affiliation: Section of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Campus, Aurora, Colo. Electronic address: joshua.greenberg@ucdenver.edu.
authors.forename: Joshua I
authors.initials: JI
authors.lastname: Greenberg
authors.affiliation: Section of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Campus, Aurora, Colo.
authors.forename: Kristen
authors.initials: K
authors.lastname: Alix
authors.affiliation: Section of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Campus, Aurora, Colo.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Nehler
authors.affiliation: Presbyterian/St. Luke's Medical Center, Denver, Colo; Diversified Radiology of Colorado, Lakewood, Colo.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Johnston
authors.affiliation: Section of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Campus, Aurora, Colo; Presbyterian/St. Luke's Medical Center, Denver, Colo.
authors.forename: Charles O
authors.initials: CO
authors.lastname: Brantigan
mesh_terms: D000293:Adolescent; D000328:Adult; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D018579:Patient Selection; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000601:surgery; D011237:Predictive Value of Tests; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D025321:Surgery, Computer-Assisted / Q000009:adverse effects; D013901:Thoracic Outlet Syndrome / Q000000981:diagnostic imaging* / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult