Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 22 - Neurological and Neuromuscular Disorder Medical Treatment Guidelines
Subchapter B - Thoracic Outlet Syndrome
Section I-2227 - Therapeutic Procedures-Operative

Universal Citation: LA Admin Code I-2227

Current through Register Vol. 50, No. 9, September 20, 2024

A. Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All patients being considered for surgical intervention should first undergo a comprehensive neuro-musculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention.

1. Non-vascular Diagnostic Criteria for Surgical Procedures

a. True or Classic Neurogenic TOS

i. Clinical-at least two consistent clinical sign plus symptoms consistent with TOS (refer to initial diagnostic procedures).

ii. Neurophysiologic-meets criteria for neurogenic TOS (refer to follow-up diagnostic imaging and testing procedures).

b. Non-specific Neurogenic TOS (also called disputed)

i. Clinical-at least three consistent clinical signs plus symptoms consistent with TOS refer to discussion in Initial Diagnostic Procedures and alternative diagnoses have been explored and tests are negative.

ii. Neurophysiologic-may have normal EMG/NCV or a pattern not meeting criteria in EMG section.

c. Pectoralis Minor Syndrome without TOS

i. Compression of the Neurovascular Bundle by the Pectoralis Muscle. This syndrome, described by a few authors, is usually caused by neck or shoulder trauma and generally resolves with physical therapy.

ii. Clinical. Patients do not meet criteria for non-specific or true TOS. They generally have pain over the anterior chest wall near the pectoralis minor and into the axilla, arm, and forearm. They may complain of paresthesia or weakness, and have fewer complaints of headache, neck or shoulder pain. On physical exam there is tenderness with palpation over the pectoralis minor and in the axilla which reproduces the patient's symptoms in the arm. Disabling symptoms have been present for more than three months despite active participation in an appropriate therapy program and alternative diagnoses have been explored and tests are negative.

iii. Neurophysiologic and other Diagnostic Tests. EMG/NCV studies may show medial antebrachial cutaneous nerve changes compared to the normal side. The axillary vein may show some occlusion. Pectoralis minor block should be positive.

d. Non-surgical Diagnosis for Possible TOS

i. Clinical-inconsistent clinical signs plus symptoms of TOS for more than three months and alternative diagnoses have been explored and tests are negative.

ii. Neurophysiologic-may have normal EMG/NCV studies.

2. Surgical Indications

a. Early surgical intervention should be performed if there is:

i. documented EMG/NCV evidence of nerve compression with sensory loss, and weakness (with or without muscle atrophy); or

ii. acute subclavian vein thrombosis or arterial thrombosis; or

iii. subclavian artery aneurysm or stenosis secondary to a cervical or anomalous rib (Note: this condition is almost never work related.).

b. After failed conservative therapy, the following criteria must be fulfilled:

i. true neurogenic or non-specific TOS: see criteria in the preceding subsection; and

ii. a positive upper limb tension test; and

iii. failed three months of active participation in non-operative therapy including worksite changes; and

iv. disabling symptoms interfering with work, recreation, normal daily activities, sleep; and

v. pre-surgical psychiatric or psychological clearance has been obtained, demonstrating motivation and long-term commitment without major issues of secondary gain or other psychological contraindications for surgery, and with an expectation that surgical relief of pain probably would improve the patient's functioning.

c. Even if return to their prior job is unlikely, an individual may need surgical intervention to both increase activities-of-daily living and/or return-to-work in a different job.

d. It is critically important that all other pathology, especially shoulder disorders, be treated prior to surgical intervention for TOS.

e. Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and provided with appropriate counseling.

f. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise requirements. The patient should understand the amount of post operative therapy required and the length of partial and full disability expected post operatively.

3. Surgical Procedures

a. Since the success rates for the various surgical procedures are similar, the OWCA suggests that the surgeon performing the procedure use the technique with which the surgeon has the most experience and is most appropriate for the patient.

b. No controlled quality literature on surgical outcome for non-specific neurogenic TOS have been published. Uncontrolled case series suggest some improvement in symptoms in the majority of patients. In one study of workers' compensation patients operated on for TOS, work disability was reported to be 60 percent at one year. Other pathologies were commonly diagnosed in this population. Comorbid conditions of the shoulder, cervical spine, and carpal tunnel should be treated or ruled out before surgery is considered. Reported repeat surgery rates vary between approximately 10 percent and 30 percent. Some literature contends that patients with non-specific TOS treated conservatively have similar long-term outcomes as those treated with surgery. Complications and/or unsatisfactory outcomes are reportedly in the range of 15 to 20 percent. Acknowledged complications depend on the procedure and include complex regional pain syndrome; Horner's syndrome; permanent brachial plexus damage; phrenic, intercostal brachial cutaneous, or long thoracic nerve damage; and pneumothorax.

c. Vascular TOS procedures include resection of the abnormal rib and repair of the involved vessel. Anticoagulation is required for thrombotic cases.

i. first rib resection;

ii. anterior and middle scalenectomy;

iii. anterior scalenectomy;

iv. combined first rib resection and scalenectomy;

v. pectoralis minor tenotomy. This procedure is done under local anesthesia, normally in an out-patient setting for patients meeting the criteria for pectoralis minor syndrome.

4. Post-Operative Treatment

a. Individualized rehabilitation programs based upon communication between the surgeon and the therapist.

b. Generally, progressive resistive exercise no earlier than two months post-operatively with gradual return to full-activity at four to six months.

c. Return-to-work and restrictions after surgery may be made by an experienced primary occupational medicine physician in consultation with the surgeon or by the surgeon. Depending upon the patient's functional response and their job requirements, return-to-work with job modifications may be considered as early as one week post operatively. The employer must be able to fully accommodate restrictions of overhead activities or heavy lifting. Work restrictions should be evaluated every four to six weeks during post-operative recovery and rehabilitation, with appropriate written communications to both the patient and the employer.

d. Should progress plateau, the provider should re-evaluate the patient's condition and make appropriate adjustments to the treatment plan.

e. Post-operative therapy will frequently require a repeat of the therapy provided pre-operatively. Refer to Therapeutic Procedures, Non-operative, and consider the first post-operative visit as visit number one for the time frame parameters provided.

f. Refer to the following areas in the non-operative therapeutic section for post-operative time parameters:

i. activities of daily living;

ii. functional activities;

iii. nerve gliding;

iv. neuromuscular re-education;

v. therapeutic exercise;

vi. proper work techniques. Refer to jobsite evaluation, and return-to-work, of these guidelines;

vii. limited passive therapies may be appropriate in some cases.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.

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