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International Physician Update
Thoracic Outlet Surgery: Who Should Have It?
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| We're good at selecting the patients who will benefit most from the procedure, notes surgeon Julie Freischlag. |
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Patients describe pain and swelling so severe in their arm that all they can do is sit there and hold it. Others say they feel tingling and numbness, like their arm is a dead weight. Often, doctors can’t make sense of it. Ah hah, you’ve got thoracic outlet syndrome, one patient’s physician says. It’s all in your head, says another.
“Thoracic outlet syndrome is a disease of varied distinctions throughout the medical community,” says anesthesiologist Peter Staats. “Some people believe that everyone with a sore arm has it; others believe it doesn’t exist at all.”
Indeed, thoracic outlet syndrome, or TOS, is one of the most difficult-to-diagnose conditions. Suspected causes include accidents and repetitive motions like brushing one’s hair, or simply being born with an extra rib, the “cervical rib.” In physical terms, the syndrome occurs when the artery, vein and nerves that run down the arm from the thoracic outlet behind the collarbone are compressed. But if you can’t determine whether painful symptoms are biological or psychological, how do you treat them?
That’s the critical question when it comes to thoracic outlet syndrome, says Hopkins’ new chief of surgery, Julie Freischlag, who should know. Before coming to Hopkins, she was chief of vascular surgery at UCLA, a center of excellence in treating the disorder. Freischlag not only developed an improved, safer surgery for TOS, but as part of a team that was evaluating some 800 cases a year, she learned that selecting the right patients for surgery was more important than the surgery itself.
“If you pick patients improperly, they won’t get better,” Freischlag says. “They’ll continue to have pain and emotional symptoms that become even more devastating, because they were looking forward to the operation and getting better.”
The good news is that Freischlag brings a 90 percent success rate in treating patients because of what she’s learned about preoperative assessment of TOS. She’s brought that same approach to Hopkins, working with pain specialists like Staats to identify surgical candidates through innovative techniques in numbing nerves in the neck and brachial plexus, or armpit.
“We’re very good at doing diagnostic, therapeutic nerve blocks to pinpoint sources of pain,” says Staats, director of Hopkins’ multidisciplinary Division of Pain Medicine. “Working closely with psychiatry, we’re also good at teasing out the emotional dimensions of the pain.”
In one nerve-blocking technique he developed, Staats uses CT guidance to inject a small amount of botulinum toxin between certain nerves and muscles. That not only helps determine what structures to operate on and whether the patient will benefit from surgery, but the therapy also may alleviate spasms associated with TOS.
“If the nerve block works, you know what kind of operation will work best for the patient,” Freischlag says. “It also can provide temporary relief.”
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