The Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; The Center for Microbiome and Human Health, Cleveland Clinic, Cleveland, OH.
J Vasc Surg. 2023 Feb;77(2):606-615. doi: 10.1016/j.jvs.2022.10.014. Epub 2022 Oct 20.
Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS.
We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation.
A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88).
Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.
神经源性胸廓出口综合征（NTOS）是胸廓出口综合征中最常见的一种。然而，NTOS 的诊断和成功治疗仍然很困难。本研究的目的是为 NTOS 第一肋切除术（FRR）后的术后结果生成一个预测性临床计算器。
我们对 2016 年至 2020 年期间在一家三级医疗机构接受 FRR 治疗的 NTOS 患者进行了回顾性研究。采用多变量逐步逻辑回归分析评估 FRR 后改善百分比与患者基线特征、相关临床特征和血管外科学会设定的诊断标准之间的关联。主要结果是 FRR 后患者的主观改善。使用向后逐步多元逻辑回归系数开发了预测风险计算器。使用 bootstrap 进行内部验证。
共有 208 例患者（22.2%为男性；平均年龄 35.8±12.8 岁；中位随访时间 44.9 个月）接受了 243 次 FRR。在 208 例患者中，94.7%的患者锁骨上区有症状，97.6%的患者手部有症状。所有患者均有上肢张力试验和上肢紧张试验引起的阳性症状。所有患者均无其他可能的诊断。在接受利多卡因注射的 196 例患者中，180 例（93.3%）NTOS 症状得到改善。在接受肉毒杆菌注射的 95 例患者中，82 例（74.6%）NTOS 症状得到改善。使用受试者工作特征曲线分析评估模型。向后逐步多元逻辑回归模型的曲线下面积为 0.8。多变量逻辑回归分析显示，临床结局恶化的显著预测因素包括手部无力（调整后的优势比 [aOR]，4.28；95%置信区间 [CI]，1.04-17.74）、年龄增长（aOR，0.93；95%CI，0.88-0.99）、工人赔偿或诉讼案件（aOR，0.09；95%CI，0.01-0.82）以及手部优势症状（aOR，0.20；95%CI，0.05-0.88）。
使用单机构数据库的回顾性数据，我们开发了一个具有中等至高度预测能力的预测计算器，曲线下面积为 0.8。该工具（可在：https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/ 获得）是临床决策的重要辅助工具，可以为患者和提供者提供 FRR 治疗 NTOS 后术后结果的现实和个性化期望。本研究的结果加强了血管外科学会设定的诊断标准。该计算器可以帮助医生进行手术规划、转介，并就手术是否进行向患者提供咨询。
