Gregory J. Pearl M.D.

Shutze, W., B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola, A. Young and G. Pearl (2017). “Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome.” J Vasc Surg: 2017 Sep [Epub ahead of print].

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) results from compression of the brachial plexus by the clavicle, first rib, and scalene muscles and may develop secondary to repetitive motion of the upper extremity. Athletes routinely perform repetitive motions, and sports requiring significant arm and shoulder use may put the participant at increased risk for NTOS. Competitive athletes who develop NTOS may require first rib resection and scalenectomy (FRRS) for symptomatic relief. However, the effectiveness of FRRS has not previously been studied in this vulnerable population. METHODS: This is a cross-sectional study of competitive athletes with NTOS who received FRRS by the senior author between 2009 and 2014. Eligible patients were contacted by phone and invited to complete a nine-item survey assessing the long-term effects of FRRS on pain medication use, postoperative physical therapy duration, patient satisfaction, symptom relief, activities of daily living, athletic performance, time to return of athletic performance, and need for other operations. Multivariate analyses of the following risk factors were performed: age, pectoralis minor release, preoperative narcotic use, athletic shutdown, and involvement in a throwing sport. RESULTS: There were 232 competitive athletes who met the inclusion criteria, and 67 of these (age, 14-48 years; 35 male; 99% white) responded to the survey. The average time between surgery and survey completion was 3.9 years (range, 2.2-7.0 years). The most frequent sports conducted by this group were baseball and softball (n = 44 [66%]), volleyball (n = 7 [10%]), and cheerleading and gymnastics (n = 5 [7%]), ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%. Multivariate regression analysis identified younger age as a predictor of the length of physical therapy and preoperative narcotics use as a predictor of symptom resolution. CONCLUSIONS: At our center, >40% of patients requiring FRRS for NTOS are competitive athletes. The results of this study show that the majority of them are able to return to their precompetitive state after FRRS, and few experience limitations in their daily living activities. Half can return to competition at or exceeding their premorbid ability level within 6 months of surgery. The majority are pleased with their decision to undergo FRRS. Further investigation is needed to identify predictive factors for successful return to competitive athletics.

Thompson, R. W., C. Dawkins, C. Vemuri, M. W. Mulholland, T. D. Hadzinsky and G. J. Pearl (2016). “Performance metrics in professional baseball pitchers before and after surgical treatment for neurogenic thoracic outlet syndrome.” Ann Vasc Surg: 2016 Aug [Epub ahead of print].

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BACKGROUND: High-performance throwing athletes may be susceptible to the development of neurogenic thoracic outlet syndrome (NTOS). This condition can be career-threatening but the outcomes of treatment for NTOS in elite athletes have not been well characterized. The purpose of this study was to utilize objective performance metrics to evaluate the impact of surgical treatment for NTOS in Major League Baseball (MLB) pitchers. METHODS: Thirteen established MLB pitchers underwent operations for NTOS between July 2001 and July 2014. For those returning to MLB, traditional and advanced (PitchF/x) MLB performance metrics were acquired from public databases for various time-period scenarios before and after surgery, with comparisons made using paired t-tests, Wilcoxon matched-pair signed rank tests, and Kruskal-Wallis analysis of variance. RESULTS: Ten of 13 pitchers (77%) achieved a sustained return to MLB, with a mean age of 30.2 +/- 1.4 years at the time of surgery and 10.8 +/- 1.5 months of postoperative rehabilitation before the return to MLB. Pre- and post-operative career data revealed no significant differences for 15 traditional pitching metrics, including earned-run-average (ERA), fielding-independent-pitching (FIP), walks-plus-hits-per-inning-pitched (WHIP), walks-per-9-innings (BB/9), and strikeouts-to-walks-ratio (SO/BB). There were also no significant differences between the 3 years before and the 3 years after surgical treatment. Using PitchF/x data for 72 advanced metrics and 25 different time-period scenarios, the highest number of significant relationships (n = 18) was observed for the 8-weeks-before/12-weeks-after scenario. In this analysis, 54 (75%) measures were unchanged (including ERA, WHIP, and SO/BB) and 14 (19%) were significantly improved, while only 4 (6%) were significantly decreased (including hard pitch maximal velocity, 93.1 +/- 1.0 vs 92.5 +/- 0.9 miles per hour, P = 0.047). Six pitchers remained active in MLB during the study period, while the other 4 had retired due to factors or injuries unrelated to NTOS. CONCLUSIONS: Objective performance metrics demonstrate that pitchers returning to MLB after surgery for NTOS have had capabilities equivalent to or better than before treatment. Thoracic outlet decompression coupled with an ample period of postoperative rehabilitation can provide effective treatment for professional baseball pitchers with career-threatening NTOS.