Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Interventional Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
Ann Vasc Surg. 2023 Oct;96:347-356. doi: 10.1016/j.avsg.2023.05.009. Epub 2023 May 24.
The optimal diagnostic and treatment algorithm for patients with suspected thoracic outlet syndrome (TOS) remains challenging. Botulinum toxin (BTX) muscle injections have been suggested to shrink muscles in the thoracic outlet reducing neurovascular compression. This systematic review evaluates the diagnostic and therapeutic value of BTX injections in TOS.
A systematic review of studies reporting BTX as a diagnostic or therapeutic tool in TOS (or pectoralis minor syndrome as TOS subtype) was conducted in PubMed, Embase, and CENTRAL databases on May 26, 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. Primary end point was symptom reduction after primary procedure. Secondary end points were symptom reduction after repeated procedures, the degree of symptom reduction, complications, and duration of clinical effect.
Eight studies (1 randomized controlled trial [RCT], 1 prospective cohort study, and 6 retrospective cohort studies) were included reporting 716 procedures in at least 497 patients (at minimum 350 primary and 25 repeated procedures, residual unclear) diagnosed with presumably only neurogenic TOS. Except for the RCT, the methodological quality was fair to poor. All studies were designed on an intention to treat basis, one also investigated BTX as a diagnostic tool to differentiate pectoralis minor syndrome from costoclavicular compression. Reduction of symptoms was reported in 46-63% of primary procedures; no significant difference was found in the RCT. The effect of repeated procedures could not be determined. Degree of symptom reduction was reported by up to 30-42% on the Short-form McGill Pain scale and up to 40 mm on a visual analog scale. Complication rates varied among studies, no major complications were reported. Symptom relief ranged from 1 to 6 months.
Based on limited quality evidence, BTX may provide short-lasting symptom relief in some neurogenic TOS patients but remains overall undecided. The role of BTX for treatment of vascular TOS and as a diagnostic tool in TOS is currently unexploited.
对于疑似胸廓出口综合征（TOS）患者，最佳的诊断和治疗方案仍然具有挑战性。肉毒毒素（BTX）肌肉注射已被建议用于缩小胸廓出口处的肌肉，以减少神经血管压迫。本系统评价评估了 BTX 在 TOS 中的诊断和治疗价值。
我们于 2022 年 5 月 26 日在 PubMed、Embase 和 CENTRAL 数据库中对报告 BTX 作为 TOS（或 TOS 亚型胸小肌综合征）诊断或治疗工具的研究进行了系统评价。我们遵循了系统评价和荟萃分析的首选报告项目声明。主要终点是初次治疗后症状的缓解。次要终点是重复治疗后症状的缓解、症状缓解的程度、并发症和临床效果的持续时间。
纳入了 8 项研究（1 项随机对照试验[RCT]、1 项前瞻性队列研究和 6 项回顾性队列研究），至少 497 例患者（至少 350 例初次治疗和 25 例重复治疗，其余情况不清楚）接受了至少 716 次治疗，这些患者被诊断为可能只有神经性 TOS。除 RCT 外，其余研究的方法学质量均为中等至较差。所有研究均基于意向治疗设计，其中 1 项研究还将 BTX 作为一种诊断工具，用于区分胸小肌综合征与肋锁挤压。初次治疗后症状缓解率为 46-63%；RCT 中未发现显著差异。重复治疗的效果无法确定。在 Short-form McGill 疼痛量表上，症状缓解程度的报告高达 30-42%，在视觉模拟量表上高达 40 毫米。各研究的并发症发生率不同，未报告重大并发症。症状缓解持续时间为 1 至 6 个月。
基于有限的质量证据，BTX 可能会为一些神经性 TOS 患者提供短暂的症状缓解，但总体而言仍不确定。BTX 在治疗血管性 TOS 和作为 TOS 的诊断工具方面的作用目前尚未得到充分利用。
