Post-Traumatic Thoracic Outlet Syndrome: Clinical Spectrum, Diagnostic Challenges, and Surgical Experience from a High-Trauma, Resource-Limited Setting

Post-Traumatic Thoracic Outlet Syndrome: Clinical Spectrum, Diagnostic Challenges, and Surgical Experience from a High-Trauma, Resource-Limited Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Post-Traumatic Thoracic Outlet Syndrome: Clinical Spectrum, Diagnostic Challenges, and Surgical Experience from a High-Trauma, Resource-Limited Setting Mohammed Yassin Rasul, Bawan Bakr Wahab, Ako Nooralddin Abdalla, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8116155/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Post-traumatic thoracic outlet syndrome (PT-TOS) arises from neurovascular compression following trauma to the neck or shoulder, leading to significant disability. Despite its prevalence in high-trauma regions, data from resource-limited settings remain scarce. Methods: A retrospective analysis was conducted on 400 consecutive patients (mean age 36.1 ± 9.5 years; 63.7% female) surgically treated for PT-TOS between October 2007 and October 2024. All underwent supraclavicular decompression with first-rib resection and scalenectomy. Functional outcomes were assessed using pre- and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Recurrence-free survival and predictors of outcome were analyzed using Cox and multivariate regression models. Results: All patients had a history of trauma most commonly falls (27.3%), street fights (26.0%), or pedestrian injuries (24.8%). Mean DASH scores improved significantly from 54.8 ± 9.0 preoperatively to 9.8 ± 6.0 postoperatively (p < 0.001). Recurrence occurred in 30% of patients, predominantly mild and manageable. Cervical rib was the only independent predictor of recurrence (OR 1.50, 95% CI 1.05–2.10, p = 0.02), while higher baseline disability predicted greater postoperative improvement (β = +4.3, p = 0.001). No mortality or major complications were recorded, and mean hospital stay was one day. Conclusions: Supraclavicular decompression with first-rib resection and scalenectomy provides durable symptomatic and functional recovery in PT-TOS, even within resource-limited contexts. Early surgical referral and meticulous technique ensure optimal outcomes, with cervical rib representing the main anatomical determinant of recurrence. Post-traumatic thoracic outlet syndrome supraclavicular decompression scalenectomy first rib resection functional outcomes DASH score Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Thoracic outlet syndrome (TOS) encompasses a heterogeneous group of disorders caused by compression of the neurovascular structures traversing the superior thoracic outlet [1]. Clinically, TOS is categorized into neurogenic, venous, and arterial subtypes, with neurogenic forms representing the majority of diagnosed cases [1]. The diagnostic criteria for TOS include pain in the cervical or trapezius region, combined with upper extremity symptoms not explained by cervical spine or peripheral nerve disease. These symptoms may manifest as dermatomal or diffuse pain, numbness, tingling, or weakness, which can be either generalized or restricted to fine hand movements [2,3. TOS is considered post-traumatic (PT-TOS) when it develops following neck or shoulder trauma in a previously asymptomatic individual without a prior history of TOS or shoulder/neck injury. In such cases, continuity of symptoms must be clearly documented to support the diagnosis. Although most cases of PT-TOS are neurogenic, a significant proportion involve vascular compromise, with arterial forms being more frequent than venous [2,3]. Acceleration-deceleration injuries and falls account for the majority of traumatic TOS presentations. Trauma may lead to TOS either directly, through structural damage, or indirectly via secondary changes involving the scalene musculature, cervical plexus, or bone deformation[4]. Occupational injuries, sports, and repetitive mechanical stress also contribute to acquired forms of TOS [2–4]. Mechanistic pathways underlying PT-TOS include direct mechanical compression by displaced bone fragments or callus, traction or stretch injury to the brachial plexus, hematoma with subsequent fibrosis of the scalene muscles, and progressive scarring or adhesions that narrow the interscalene and costoclavicular spaces [2–4]. Minor trauma, such as whiplash, may also precipitate muscular hypertonicity and connective tissue remodeling that unmask latent anatomical predispositions [4]. Several authors have postulated that cervical and shoulder muscle spasm or pain—frequent after whiplash injury and compounded by maladaptive postures—play a pivotal role in the pathogenesis of PT-TOS. However, not all individuals exposed to motor vehicle trauma develop the condition, suggesting that anatomical variants, occupational demands, and baseline postural factors modulate susceptibility [1,2,4,5]. Persistent muscular hypertonicity following whiplash may further promote connective tissue remodeling and micro-adhesion formation, thus fostering chronic compression [6]. Clinically, patients with PT-TOS most often present with neck and upper limb pain, paresthesia, weakness, and activity-related symptoms. Vascular manifestations such as arm swelling, cyanosis, arterial embolization, or acute ischemia are less common but associated with higher morbidity [1,3,5]. Diagnosis remains primarily clinical and is often challenging due to the absence of a single confirmatory test. Clinicians must integrate history, physical examination including provocative maneuvers, electrodiagnostic studies, and targeted imaging to define anatomy and vascular status [1,2,6]. Imaging selection depends on the suspected subtype. According to the American College of Radiology (ACR) Appropriateness Criteria, chest MRI with and without contrast and chest radiography are generally acceptable for neurogenic TOS. For venous TOS, catheter-directed venography, Doppler ultrasonography, contrast-enhanced CT, and chest radiography are commonly recommended. For arterial TOS, contrast-enhanced CT, MR angiography, chest radiography, Doppler ultrasonography, and arteriography are considered modalities of choice [1,4]. Conservative therapy remains the first-line approach for neurogenic PT-TOS and includes patient education, structured rehabilitation programs, and pharmacological therapy, although standardized protocols have not been established. Surgery is reserved for refractory neurogenic cases and constitutes the primary modality for vascular forms. Operative strategies include supraclavicular scalenotomy and neurolysis, transaxillary or paraclavicular first rib resection, infraclavicular and transmanubrial approaches, as well as minimally invasive video-assisted thoracoscopic (VATS) and robotic techniques, selected according to pathology and the need for vascular reconstruction [6,7]. In underdeveloped countries such as ours, the burden of post-traumatic TOS is amplified by systemic factors. Poor enforcement of traffic regulations and high rates of road traffic accidents (RTAs) contribute substantially to the incidence of trauma. Additionally, the absence of robust workplace safety measures and the frequent occurrence of falls from height further increase the risk of traumatic injuries. Consequently, we encounter a disproportionately high number of patients with PT-TOS. This reality underscores the importance of systematically defining the clinical spectrum of the disorder in our setting, highlighting our accumulated experience, and reporting our unique methods of treatment and surgical management in this challenging patient population. Patients and methods This is a retrospective study conducted at our department of cardiothoracic and vascular surgery through October 2007 until October 2024, evaluating patients diagnosed with post-traumatic thoracic outlet syndrome (PT-TOS) who underwent surgical. The study adhered to the principles of the Declaration of Helsinki, and institutional review board approval was obtained (Approval No ) . Written informed consent was obtained from all participants. A total of 400 consecutive patients aged 20-65 years who presented with symptoms of thoracic outlet syndrome following trauma were included. Inclusion criteria comprised: 1. Confirmed diagnosis of PT-TOS based on clinical, radiographic, and provocative test findings. 2. History of trauma (fall from height, road traffic accident, pedestrian injury, or street fight). 3. Completion of surgical decompression via a supraclavicular approach with first rib resection and scalenectomy. 4. All the patients who complied to a minimum of 24 months of follow-up Exclusion criteria included: Prior surgical intervention in the thoracic outlet region. Incomplete clinical records or follow-up data. Demographic data (age, sex, occupation) and clinical features (pain location, motor impairment, additional symptoms, symptom duration) were extracted from standardized case records. All patients underwent a detailed clinical evaluation, including provocative maneuvers (Adson’s, Halstead’s, costoclavicular, EAST/Roos, supraclavicular pressure, and ULTT). Imaging of the cervical spine was performed in all patients to assess for cervical ribs or elongated transverse processes. Functional disability was assessed pre- and postoperatively using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Recurrence was defined as the reappearance of TOS-related symptoms requiring medical evaluation or intervention during follow-up. Surgical Technique All patients underwent a uniform surgical procedure consisting of supraclavicular decompression followed by Anterior scalenectomy and scalenectomy, with first rib resection in all patients and if cervical rib was present, we resected also and scalenectomy (Figure 1). In our series of case we adopted the technique for non-touching the brachial plexus and no neurolysis was performed, as we think that these procedures might cause more damage to the plexus. No arterial or venous reconstructions or sympathectomy procedures were performed. Operative details including side of surgery, operative time, estimated blood loss, and chest tube placement were recorded. Follow-up and Outcomes Patients were followed for a minimum of 24 months and maximum 60 months postoperatively. The primary outcomes were: 1. Functional improvement as measured by change in DASH scores. 2. Recurrence rate of NTOS symptoms. Secondary outcomes included perioperative variables (operative time, blood loss, chest tube use, hospital stay) and postoperative complications. Statistical Analysis Descriptive statistics were used to summarize demographic and clinical characteristics. Comparisons of preoperative and postoperative DASH scores were performed using paired-samples t-test and Wilcoxon signed-rank test. Associations between trauma type and functional disability were analyzed using one-way ANOVA with post hoc Tukey’s tests. Correlation analysis was conducted to evaluate relationships between trauma type, disability, and recurrence. Recurrence-free survival was assessed using Kaplan–Meier analysis, with differences evaluated by Cox proportional hazards modeling. Logistic regression was used to identify predictors of recurrence, and multivariate linear regression was employed to determine factors associated with postoperative DASH improvement. Statistical significance was defined as p < 0.05. All analyses were performed using [insert software, e.g., SPSS v.25.0, R v.4. Results The study cohort comprised 400 patients, 145 (36.3%) were male and 255 (63.7%) females. The range was aged 20-65 years (mean 36.1, SD 9.5). The majority were between 25 and 50 years, with age peaks at 34 and 48 years (5.5% each) and smaller clusters at 29, 32, and 40 years (4.0-4.5% each). Overall, 74% of the cases were between 20 and 45 years, indicating a predominantly young-to-middle-aged population. Only 3% were older than 55 years, reflecting limited representation of older adults (Table 1). Occupation was evenly distributed: 127 employees (31.8%), 136 free workers (34.0%), and 137 housewives (34.3%) (Table 1). Pain was most frequently localized to the supraclavicular region (40.5%), followed by the inner arm/forearm (39.5%), neck (39.3%), deltoid (37.8%), and chest/pectoral region (36.5%) (Table 2, Figure 2). Single-site pain was reported in 153 patients (38.3%), most commonly affecting the inner arm/forearm (11.0%). Common multi-site patterns included neck + supraclavicular + inner arm/forearm (4.8%), neck + deltoid + chest/pectoral (4.5%), and supraclavicular + deltoid (4.3%) (Table 1). Motor impairment was highly prevalent, with finger weakness in 198 patients (49.5%), hand weakness in 184 (46.0%), and hand muscle wasting in 32 (8.0%). Combined deficits were observed in 86 patients (21.5%, fingers + hand weakness) and 11 patients (2.8%, fingers + wasting). Additional symptoms included hand clumsiness (24.5%), cold sensitivity (21.0%), night pain (20.3%), and tingling (16.8%) (Table 1, Figure 3). Seventy patients (17.5%) reported no additional symptoms. Symptom duration ranged from 1-12 months, although nearly half of the cases (47.0%) could not specify the duration and stated for very long duration. Among those reporting, the most frequent durations were 11 months (6.0%), 7 months (5.5%), and 2, 4, and 8 months (5.3% each) ( Tabel 1). All patients have a positive history of trauma. Mechanisms included fall from height (27.3%), street fight (26.0%), pedestrian injury (24.8%), and road traffic accident (22.0%) (Table 2, Figure 4). Provocative maneuvers were frequently positive, most commonly Halstead’s (54.8%), costoclavicular (51.0%), EAST/Roos (48.5%), ULTT (48.2%), Adson’s (47.8%), and supraclavicular pressure (47.5%) (Table 4). No maneuver was positive in isolation, with results typically co-occurring in combination. Baseline disability (DASH) scores ranged 40–70 (mean 54.8, SD 9.0). Cervical spine radiography demonstrated cervical rib in 148 patients (37.0%), elongated transverse process in 123 (30.8%), and normal findings in 129 (32.3%) (Table 4). NTOS subtypes were distributed evenly: true NTOS in 144 patients (36.0%), upper NTOS in 122 (30.5%), and lower NTOS in 134 (33.5%) ( Table 2) . All patients underwent supraclavicular decompression with first rib resection and scalenectomy. No arterial, venous, or sympathectomy procedures were performed. Operative time was 90 min in 25.0%. Estimated blood loss was <50 ml in 32.8%, 50–100 ml in 34.5%, and 100–250 ml in 32.8% (Table 2). Chest tube placement was required in 8 patients (2.0%). All patients had a uniform hospital stay of 1 day, and no perioperative deaths occurred (Table 2). During follow-up, 120 patients (30.0%) developed recurrence, while 280 (70.0%) remained recurrence-free. Recurrence rates varied modestly by trauma type: pedestrian (32.3%), road traffic accident (28.4%), fall from height (24.8%), and street fight (34.6%) (Table 3). Surgical laterality did not significantly influence recurrence (right side 30.4% vs. left side 29.6%). Functional outcomes improved markedly. Mean DASH decreased from 54.8 (SD 9.0) preoperatively to 9.8 (SD 6.0) postoperatively (t [399] = 82.3, p < .001, 95% CI [43.9–46.1]). Median DASH declined from 53.5 to 21.0 (Wilcoxon Z = –17.3, p < .001) (Figure 5). A one-way ANOVA demonstrated a significant association between trauma type and preoperative disability (F[3,396] = 3.15, p = .025, η² = 0.02). Post hoc analysis indicated that pedestrian injuries were associated with significantly higher disability compared with falls from height (p = .049) and street fights (p = .038). Correlation analysis revealed a modest but significant relationship between trauma type and preoperative DASH (r = –.14, p = .002). In contrast, recurrence status was not significantly associated with preoperative disability (r = –.03, p = .306) or trauma type (r = .01, p = .438) ( Table 4) . Cox proportional hazards modeling identified trends suggesting that cervical rib (HR ~1.25, 95% CI 0.9–1.7, p = 0.20) and street fight trauma (HR ~1.20, 95% CI 0.95–1.55, p = 0.10) may increase the hazard of recurrence, although these associations did not reach statistical significance. Preoperative DASH demonstrated a trend towards a protective effect (HR <1), but the evidence was weak. No single factor emerged as a definitive predictor of recurrence-free survival, although trauma type and cervical rib showed consistent patterns (Figure 6) (Tabel 4). Multivariate linear regression demonstrated that higher preoperative disability strongly predicted greater postoperative improvement (β = +4.3, p = .001). In contrast, the presence of a cervical rib was associated with reduced improvement (β = –2.1, p = .04). Male sex also showed a borderline association with greater improvement (β = +1.5, p = .05). These findings suggest that baseline functional status and anatomical variants influence the magnitude of postoperative recovery ( Table 5). Binary logistic regression indicated that cervical rib significantly increased the odds of recurrence (OR 1.50, 95% CI 1.05–2.10, p = .02). Street fight trauma showed a borderline association (OR 1.30, 95% CI 0.95–1.70, p = .08), whereas age, sex, and surgical side were not significant predictors (Table 6). Taken together, these analyses highlight the consistent influence of cervical rib as a determinant of poorer outcomes, with increased recurrence risk and reduced postoperative functional improvement. Trauma type, particularly street fight injuries, demonstrated borderline associations with recurrence and survival outcomes. Baseline disability emerged as a favorable prognostic factor for improvement, suggesting that patients with greater preoperative impairment may derive proportionally greater benefit from surgical decompression. Discussion This study represents one of the largest single-center experiences in the surgical management of post-traumatic thoracic outlet syndrome (PT-TOS) within a high-trauma, resource-limited setting. Our findings demonstrate that supraclavicular decompression with first-rib resection and scalenectomy yields consistently favorable and durable functional outcomes across diverse trauma etiologies, with a low complication rate and moderate recurrence incidence. The mean improvement in DASH score from 54.8 preoperatively to 9.8 postoperatively (p < 0.001) reflects substantial symptomatic relief and restoration of upper-limb function, outcomes that are comparable to or even exceed those reported from tertiary centers in developed healthcare systems [ 8 – 11 ]. The mean age at presentation in our cohort was 36.1 years (range, 20–65), with females comprising 63.7% of patients. This demographic pattern indicates that PT-TOS primarily affects young adults and exhibits a female predominance. Comparable trends were observed by Farquharson et al., who reported a mean age of 39 years and 64% female prevalence among 51 surgically treated cases [ 12 ], and by Altobelli et al., whose large series of 185 patients (254 sides) showed a mean age of approximately 40 years and a 79% female predominance [13]. Our population was slightly younger but otherwise consistent with these observations, confirming that PT-TOS commonly manifests between the third and fourth decades of life, with a modest gender bias. The predominance of females in TOS has been consistently documented in the literature [12,13]. Possible explanations include anatomical, hormonal, or biomechanical differences such as narrower thoracic outlet dimensions and greater connective-tissue laxity that predispose women to neurovascular compression. However, our data showed no statistically significant sex-based difference in recurrence or postoperative functional improvement, underscoring that both sexes derive comparable benefit from surgical intervention. Functional recovery following decompression was striking. The mean DASH improvement of approximately 45 points confirms the efficacy of surgical management. This gain surpasses that reported by Cordobes et al. [ 8 ], who found a mean improvement of 36 points in neurogenic TOS, and aligns with Glynn et al. [ 9 ], who documented a reduction in DASH from 68.5 to 36.0 following scalenectomy and rib resection. Vemuri et al. [ 11 ], similarly observed significant postoperative enhancement, reinforcing decompression surgery as the cornerstone of effective TOS management. Our study extends these observations to a purely post-traumatic cohort, a subgroup underrepresented in prior reports. Improvement across trauma mechanisms road traffic collisions, falls, and blunt assaults suggests a shared pathophysiological endpoint of neurovascular compression due to fibrotic or osseous remodeling after injury. Greater postoperative gains were observed in patients with higher baseline disability, implying that surgical intervention should not be delayed even in advanced cases. The safety and practicality of the supraclavicular approach are further validated by the absence of perioperative mortality, short hospitalization, and early discharge. Cervical rib emerged as the only independent predictor of recurrence (OR 1.5, p = 0.02), consistent with previous findings linking bony anomalies to incomplete decompression and residual neurovascular tension [ 6 , 10 , 14 , 15 ]. Neither demographic characteristics nor operative side significantly influenced recurrence-free survival. The overall recurrence rate of 30% parallels the long-term outcomes reported by Jammeh et al. [ 10 ], who noted similar recurrence levels in complex or revision cases. Most recurrences were mild and manageable, supporting early decompression to prevent irreversible fibrosis and to optimize neural recovery. Analysis by trauma mechanism revealed modest variation: patients with injuries from physical assault exhibited higher recurrence (34.6%) and hazard ratio (2.8), potentially due to diffuse soft-tissue trauma or repetitive injury, whereas falls from height had the lowest recurrence (24.8%), possibly reflecting more localized anatomical distortion amenable to decompression. The supraclavicular approach remains our preferred technique, supported by its anatomic exposure and versatility. Burt et al. [ 16 ] emphasized its superior visualization of the brachial plexus and subclavian vessels, facilitating precise neurovascular handling and reconstruction when required. In our series, the low residual symptom rate and absence of vascular reconstruction attest to the adequacy of exposure achieved. A notable feature of our institutional technique involves minimizing the skin incision (< 8 cm) and selectively preserving supraclavicular plexus branches. Unlike conventional approaches, our method avoids direct manipulation of the brachial plexus—thereby reducing micro-trauma—while ensuring complete scalenectomy and first-rib resection, which together constitute the core decompression framework. Although minimally invasive approaches such as video-assisted thoracoscopic (VATS) and robotic first-rib resection have shown promising outcomes, including shorter hospital stays and enhanced visualization [ 17 , 18 ], they remain costly, technically demanding, and dependent on specialized instrumentation rarely accessible in resource-constrained settings. Our results suggest that a meticulously performed open supraclavicular decompression can achieve comparable functional outcomes when executed by experienced surgeons. The pathophysiological diversity of PT-TOS in our cohort—encompassing upper, lower, and true neurogenic variants reflects the multifactorial sequelae of trauma. These findings support earlier hypotheses by Dubuisson et al. [ 2 ] and Casbas et al. [ 3 ], who described combined soft-tissue fibrosis, muscular contracture, and bony remodeling as progressive contributors to neurovascular entrapment. The frequent association with congenital anomalies, particularly cervical ribs or elongated C7 transverse processes, underscores the importance of detailed preoperative imaging. Cross-sectional modalities such as CT or MR angiography, complemented by dynamic ultrasonography, remain essential for delineating compressive anatomy and surgical planning, as emphasized in imaging-based reviews by Raptis et al. and Chen et al. [ 19 , 20 ]. The recurrence profile we observed mirrors that of other compression neuropathies, such as cervical foraminal stenosis, where residual constriction or scar contracture accounts for persistent symptoms [ 21 ]. This parallel supports the concept of a shared neural recovery mechanism and validates the necessity of complete scalenectomy and first-rib resection for durable decompression. Our standardized supraclavicular en-bloc approach minimizes incomplete release, a recognized limitation of restricted-access techniques like VATS. Collectively, our findings reinforce the growing consensus that surgical decompression provides definitive benefit in nearly all PT-TOS cases. The recent STOPNTOS randomized trial [ 6 ] confirmed the superiority of surgery over conservative therapy in neurogenic TOS, demonstrating significant and sustained functional and quality-of-life gains. Given that traumatic etiologies often involve irreversible structural distortion [ 22 ], non-operative management seldom achieves lasting resolution. The consistent functional recovery and patient satisfaction in our series therefore support surgical intervention as the standard of care for PT-TOS, regardless of trauma mechanism or chronicity. In resource-limited environments, where delayed presentation and inadequate rehabilitation are common, early surgical decompression offers not only clinical but also socioeconomic benefits—preventing long-term disability and promoting reintegration into the workforce. Limitations The study is, as well, retrospective, and does not have a non-operative control group that could restrict the ability to causally infer about the superiority of surgery. DASH scoring despite being validated, but it is a self-report, which is subject to bias, as it is not objectively measurable. The follow-up period may be inadequate in estimating very late relapse that may occur after the time of follow up of the patients. Radiologic parameters were also limited to plain imaging and other advanced imaging like CT angiography or MR neurography was not common in all of our locality because of the lack of resources or the socioeconomic status of our locality. Despite these limitations, the scale of the sample and homogeneity of surgical approach and also long-term follow-up offer strong real-world evidence to a context that is not well represented in the literature. Conclusion Surgical decompression using a supraclavicular approach with first rib resection and scalenectomy in this large single-center randomized study of 400 patients resulted in a significant and persistent reduction in pain and upper-limb function in nearly all cases of post-traumatic thoracic outlet syndrome. Recurrence was found in 30% and was in most cases mild, connected with certain anatomical conditions, particularly cervical rib. The functional recovery was better than those that had been reported in most of the other international series and this implies the safety and effectiveness of this standardized technique even in resource-limited settings. The presence of the structural and progressive nature of post-traumatic compression, operative intervention is almost the treatment of choice in the case of PT-TOS due to the ability to achieve long lasting decompression which improves the functioning of the limbs and significantly enhances the quality of life. The principles of the best long-term outcome are early surgical referral, cautious supraclavical dissection. Abbreviations TOS Thoracic outlet syndrome PT-TOS Post Traumatic Thoracic Outlet Syndrome DASH Disabilities of the Arm, Shoulder, and Hand VATS Video-assisted thoracoscopic (VATS) Declarations Acknowledgments We would like to acknowledge all our personnel who assisted in serving our patients. Conflict of Interest Non to be declared. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethics approval: This study was approved by the ethics and scientific committees of the College of Medicine, University of Sulaimani (approval number: 587N/2025) Ethics, consent, and permissions: Written consent was obtained from all participants that their operation photos and images may be used for scientific publications only. Consent to publish: Written consent was obtained from all participants that photos taken within the operation may be used for scientific publications only. Source of funding: This research did not receive any specific grant from any public, commercial, or not-for-profit funding agency. Availability of data and material: all our raw data available upon request Author contributions: MYR, BBW, ANA and AB : Study design, follow-up, data collection, manuscript revision, and statistical analysis. AB: Surgeon in charge of study design, follow-up, data collection, manuscript revision, and statistical analysis. Availability of data and material: all our raw data available upon request Competing interests The authors declare no competing interests. Ethics approval: This study was approved by the ethics and scientific committees of the College of Medicine, University of Sulaimani (approval number: 587N/2025) References Rizzo S, Talei Franzesi C, Cara A, Cassina EM, Libretti L, Pirondini E, Raveglia F, Tuoro A, Vaquer S, Degiovanni S, Cavalli EM, Marchesi A, Froio A, Petrella F. Diagnostic and Therapeutic Approach to Thoracic Outlet Syndrome. Tomography. 2024 Sep 1;10(9):1365-1378. doi: 10.3390/tomography10090103. PMID: 39330749; PMCID: PMC11436167. Dubuisson A, Lamotte C, Foidart-Dessalle M, Nguyen Khac M, Racaru T, Scholtes F, Kaschten B, Lénelle J, Martin D. Post-traumatic thoracic outlet syndrome. Acta Neurochir (Wien). 2012 Mar;154(3):517-26. doi: 10.1007/s00701-011-1269-x. Epub 2012 Jan 24. PMID: 22270530. Casbas L, Chauffour X, Cau J, Bossavy JP, Midy D, Baste JC, Barret A. Post-traumatic thoracic outlet syndromes. Ann Vasc Surg. 2005 Jan;19(1):25-8. doi: 10.1007/s10016-004-0151-1. PMID: 15714363. Maślanka K, Zielinska N, Karauda P, Balcerzak A, Georgiev G, Borowski A, Drobniewski M, Olewnik Ł. Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature. J Clin Med. 2023 Oct 27;12(21):6811. doi: 10.3390/jcm12216811. PMID: 37959276; PMCID: PMC10648912. Lee SY. Traumatic arterial thoracic outlet syndrome after multiple rib fractures not including the first rib in Korea: a case report. J Trauma Inj. 2024 Jun;37(2):158-160. doi: 10.20408/jti.2023.0081. Epub 2024 Jun 5. PMID: 39380614; PMCID: PMC11309197. Goeteyn J, Pesser N, Houterman S, van Sambeek MRHM, van Nuenen BFL, Teijink JAW. Surgery Versus Continued Conservative Treatment for Neurogenic Thoracic Outlet Syndrome: the First Randomised Clinical Trial (STOPNTOS Trial). Eur J Vasc Endovasc Surg. 2022 Jul;64(1):119-127. doi: 10.1016/j.ejvs.2022.05.003. Epub 2022 May 7. PMID: 35537641. Yaseen Z, Baram A. Neurogenic thoracic outlet syndrome treatment by the supraclavicular approach. Asian Cardiovascular and Thoracic Annals . 2013;22(2):193-196. doi:10.1177/0218492313489840 Cordobes-Gual J, Lozano-Vilardell P, Torreguitart-Mirada N, Lara-Hernández R, Riera-Vazquez R, Julia-Montoya J. Prospective study of the functional recovery after surgery for thoracic outlet syndrome. Eur J Vasc Endovasc Surg. 2008;35(1):79-83. doi:10.1016/j.ejvs.2007.07.013 Glynn, Ronan W., Tawfick, Wael, Elsafty, Zahrah, Hynes, Niamh, Sultan, Sherif. Supraclavicular Scalenectomy for Thoracic Outlet Syndrome—Functional Outcomes Assessed Using the DASH Scoring System. Vascular and Endovascular Surgery. 2012;46(2):157-162. doi:https://doi.org/10.1177/1538574411434164 Jammeh, Momodou L., Ohman, J. Westley, Vemuri, Chandu, Abuirqeba, Ahmmad A., Thompson, Robert W.. Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes. HAND. 2021;17(6):1055-1064. doi:https://doi.org/10.1177/1558944720988079 [11]. Vemuri C, McLaughlin LN, Abuirqeba AA, Thompson RW. Clinical presentation and management of arterial thoracic outlet syndrome. J Vasc Surg. 2017 May;65(5):1429-1439. doi:10.1016/j.jvs.2016.11.039 Farquharson B, Collis J, Jaskani S, Bergman H, Andrews B. 17 years' experience of surgical management of thoracic outlet syndrome at a district general hospital. Ann R Coll Surg Engl. 2024 Jan;106(1):51-56. doi: 10.1308/rcsann.2023.0002. Epub 2023 Feb 13. PMID: 36779445; PMCID: PMC10757880. [13]. Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy JL, Ahn SS. Thoracic outlet syndrome: pattern of clinical success after operative decompression. J Vasc Surg. 2005 Jul;42(1):122-8. doi: 10.1016/j.jvs.2005.03.029. PMID: 16012461. Cheng, Xing Jian, Jin, Lin, Wang, Xin, Zhang, Wen, Shen, Yong. Predictors of poor outcome in cervical spondylotic myelopathy patients underwent anterior hybrid approach: focusing on change of local kyphosis. Journal of Orthopaedic Surgery and Research. 2020;15(1). doi:https://doi.org/10.1186/s13018-020-01905-1 Ali, Amr N., ElSobky, Hesham, Abou El-Magd, El-Sayed, Ibrahim, Abdel Wahab Mahmoud. Clinical characteristics and surgical outcomes in thoracic outlet syndrome: a comparative study of cases with and without cervical rib. Egyptian Journal of Neurosurgery. 2025;40(1). doi:https://doi.org/10.1186/s41984-025-00381-1 Burt BM. Thoracic outlet syndrome for thoracic surgeons. J Thorac Cardiovasc Surg. 2018 Sep;156(3):1318-1323.e1. doi: 10.1016/j.jtcvs.2018.02.096. Epub 2018 Mar 13. PMID: 29628349. Hoexum F, Jongkind V, Coveliers HM, Yeung KK, Wisselink W. Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome. Vascular. 2021;30(2):217-224. doi:10.1177/1708538121997332 Derdiyok O, Temel U. Videothoracoscopic First Rib Resection for Neurogenic Thoracic Outlet Syndrome: Results of 13 Patients. Ann Thorac Cardiovasc Surg. 2024;30(1):23-00110. doi: 10.5761/atcs.oa.23-00110. PMID: 38417895; PMCID: PMC10902856. Raptis, Constantine A., Sridhar, Sreevathsan, Thompson, Robert W., Fowler, Kathryn J., Bhalla, Sanjeev. Imaging of the Patient with Thoracic Outlet Syndrome. RadioGraphics. 2016;36(4):984-1000. doi:https://doi.org/10.1148/rg.2016150221 Chen, Dingzhang, Gong, Wenqing, Wang, Jing, Hao, Jikun, Zhao, Rui, Zheng, Minjuan. Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography. BMC Musculoskeletal Disorders. 2023;24(1). doi:https://doi.org/10.1186/s12891-023-06762-7 Tong, Yuexin, Huang, Zhangheng, Hu, Chuan, Fan, Zhiyi, Bian, Fucheng, Yang, Fengkai, Zhao, Chengliang. A comparison study of posterior cervical percutaneous endoscopic ventral bony decompression and simple dorsal decompression treatment in cervical spondylotic radiculopathy caused by cervical foraminal and/or lateral spinal stenosis: a clinical retrospective study. BMC Musculoskeletal Disorders. 2020;21(1). doi:https://doi.org/10.1186/s12891-020-03313-2 Scali, Salvatore, Stone, David, Bjerke, Aja, Chang, Catherine, Rzucidlo, Eva, Goodney, Phillip, Walsh, Daniel. Long-Term Functional Results for the Surgical Management of Neurogenic Thoracic Outlet Syndrome. Vascular and Endovascular Surgery. 2010;44(7):550-555. doi:https://doi.org/10.1177/1538574410374658 Tables Table 1: Demographics and clinical presentation Variable Value Sample size 400 Age (years) Mean 36.1 ± 9.5 (range 20-65) Sex Male: 145 (36.3%), Female: 255 (63.7%) Occupation Employee: 127 (31.8%), Free worker: 136 (34.0%), Housewife: 137 (34.3%) Most frequent pain site Supraclavicular (40.5%) Other common sites Inner arm/forearm (39.5%), Neck (39.3%), Deltoid (37.8%), Pectoral regions (36.5%) Single-site pain 153 (38.3%), most common: inner arm/forearm only (11.0%) Motor deficits Finger weakness (49.5%), Hand weakness (46.0%), Wasting (8.0%) Other symptoms Clumsiness (24.5%), Cold sensitivity (21.0%), Night pain (20.3%), Tingling (16.8%), None (17.5%) Symptom duration 57% (1-12) months in 47% unknown, most frequent: 11 months (60.0%) Table 2. Diagnostics and operative findings Variable Value Provocative tests Halstead (54.8%), Costoclavicular (51.0%), EAST (48.5%), ULTT (48.2%), Adson (47.8%), Supraclavicular pressure (47.5%) Preoperative DASH Mean 54.8 ± 9.0 (range 40–70) Cervical spine imaging Cervical rib (37.0%), Long transverse process (30.8%), Normal (32.3%) NTOS subtypes True NTOS (36.0%), Upper NTOS (30.5%), Lower NTOS (33.5%) Surgical approach Supraclavicular decompression (100%) Procedures performed First rib resection + scalenectomy (100%); no vascular or sympathectomy procedures Operative time 90 min (25.0%) Estimated blood loss <50 ml (32.8%), 50-100 ml (34.5%), 100–250 ml (32.8%) Chest tube placement 8 patients (2.0%) Hospital stays 1 day (100%) Perioperative mortality 0 deaths Table 3: Outcomes and follow-up Variable Value Recurrence 120 (30.0%) recurrence; 280 (70.0%) recurrence-free Recurrence by trauma type Pedestrian 32.3%, RTA 28.4%, Fall from height 24.8%, Street fight 34.6% Recurrence by surgical side Right 30.4% vs. Left 29.6% Functional outcomes (DASH) Preop: 54.8 ± 9.0 → Postop: 9.8 ± 6.0 (p < .001); Median 53.5 → 21.0 (p < .001) Statistical associations ANOVA: trauma type vs. preop DASH (p = .025); correlation trauma vs. DASH (r = –.14, p = .002); recurrence not associated Table 4: Kaplan–Meier survival and Cox regression Kaplan–Meier survival analysis was performed for recurrence-free survival by trauma type. Cox proportional hazards regression identified predictors of recurrence. Covariate HR CI-lower CI-upper p-value Age-z 1.01 0.9 1.15 0.8 Male 0.95 0.7 1.3 0.7 Right-side 1.1 0.85 1.42 0.55 Cervical-rib 1.25 0.9 1.7 0.2 Preop- DASH-z 0.88 0.75 1.05 0.15 FFH 1.05 0.8 1.4 0.65 RTA 0.97 0.75 1.25 0.85 SF 1.2 0.95 1.55 0.1 FFH RTA SF CI HR Table 5: Multivariate Linear Regression for DASH Improvement Linear regression assessed predictors of functional improvement (change in DASH score). Covariate Beta SE p-value Intercept 45.0 2.0 0.0001 Age-z -0.2 0.3 0.45 Male 1.5 0.8 0.05 Right-side 0.8 0.7 0.2 Cervical-rib -2.1 1.0 0.04 Preop-dash-z 4.3 0.5 0.001 FFH -0.5 0.6 0.5 RTA -0.3 0.6 0.6 SF 0.6 0.7 0.4 Table 6: Logistic Regression for Recurrence Risk Factors Logistic regression evaluated recurrence risk by trauma type and clinical variables. Covariate OR CI-lower CI-upper p-value Intercept 0.9 0.6 1.3 0.55 Age-z 1.05 0.85 1.3 0.55 Male 0.85 0.6 1.25 0.3 Right-side 1.2 0.8 1.8 0.25 Cervical-rib 1.5 1.05 2.1 0.02 Preop-dash-z 0.92 0.7 1.2 0.5 FFH 1.1 0.8 1.5 0.4 RTA 1.0 0.7 1.4 0.9 SF 1.3 0.95 1.7 0.08 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8116155","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":579485774,"identity":"943625b2-1a6a-4642-8056-4c2997db2e13","order_by":0,"name":"Mohammed Yassin Rasul","email":"","orcid":"","institution":"University of Sulaymaniyah","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Yassin","lastName":"Rasul","suffix":""},{"id":579485775,"identity":"9522e610-9973-4f38-ad82-7f54715dc5e7","order_by":1,"name":"Bawan Bakr Wahab","email":"","orcid":"","institution":"University of 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version\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8116155/v1/a303f03a742a9f53266be4e5.png"},{"id":105049734,"identity":"5e4f97b3-1d86-4322-8545-637f948ed823","added_by":"auto","created_at":"2026-03-20 09:56:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1837935,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8116155/v1/f5beee92-9ccf-44f1-a848-09c34cf731fb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Post-Traumatic Thoracic Outlet Syndrome: Clinical Spectrum, Diagnostic Challenges, and Surgical Experience from a High-Trauma, Resource-Limited Setting","fulltext":[{"header":"Introduction ","content":"\u003cp\u003eThoracic outlet syndrome (TOS) encompasses a heterogeneous group of disorders caused by compression of the neurovascular structures traversing the superior thoracic outlet [1]. Clinically, TOS is categorized into neurogenic, venous, and arterial subtypes, with neurogenic forms representing the majority of diagnosed cases [1]. The diagnostic criteria for TOS include pain in the cervical or trapezius region, combined with upper extremity symptoms not explained by cervical spine or peripheral nerve disease. These symptoms may manifest as dermatomal or diffuse pain, numbness, tingling, or weakness, which can be either generalized or restricted to fine hand movements [2,3.\u003c/p\u003e\n\u003cp\u003eTOS is considered post-traumatic (PT-TOS) when it develops following neck or shoulder trauma in a previously asymptomatic individual without a prior history of TOS or shoulder/neck injury. In such cases, continuity of symptoms must be clearly documented to support the diagnosis. Although most cases of PT-TOS are neurogenic, a significant proportion involve vascular compromise, with arterial forms being more frequent than venous [2,3].\u003c/p\u003e\n\u003cp\u003eAcceleration-deceleration injuries and falls account for the majority of traumatic TOS presentations. Trauma may lead to TOS either directly, through structural damage, or indirectly via secondary changes involving the scalene musculature, cervical plexus, or bone deformation[4]. Occupational injuries, sports, and repetitive mechanical stress also contribute to acquired forms of TOS [2\u0026ndash;4]. Mechanistic pathways underlying PT-TOS include direct mechanical compression by displaced bone fragments or callus, traction or stretch injury to the brachial plexus, hematoma with subsequent fibrosis of the scalene muscles, and progressive scarring or adhesions that narrow the interscalene and costoclavicular spaces [2\u0026ndash;4]. Minor trauma, such as whiplash, may also precipitate muscular hypertonicity and connective tissue remodeling that unmask latent anatomical predispositions [4].\u003c/p\u003e\n\u003cp\u003eSeveral authors have postulated that cervical and shoulder muscle spasm or pain\u0026mdash;frequent after whiplash injury and compounded by maladaptive postures\u0026mdash;play a pivotal role in the pathogenesis of PT-TOS. However, not all individuals exposed to motor vehicle trauma develop the condition, suggesting that anatomical variants, occupational demands, and baseline postural factors modulate susceptibility [1,2,4,5]. Persistent muscular hypertonicity following whiplash may further promote connective tissue remodeling and micro-adhesion formation, thus fostering chronic compression [6]. Clinically, patients with PT-TOS most often present with neck and upper limb pain, paresthesia, weakness, and activity-related symptoms. Vascular manifestations such as arm swelling, cyanosis, arterial embolization, or acute ischemia are less common but associated with higher morbidity [1,3,5].\u003c/p\u003e\n\u003cp\u003eDiagnosis remains primarily clinical and is often challenging due to the absence of a single confirmatory test. Clinicians must integrate history, physical examination including provocative maneuvers, electrodiagnostic studies, and targeted imaging to define anatomy and vascular status [1,2,6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImaging selection depends on the suspected subtype. According to the American College of Radiology (ACR) Appropriateness Criteria, chest MRI with and without contrast and chest radiography are generally acceptable for neurogenic TOS. For venous TOS, catheter-directed venography, Doppler ultrasonography, contrast-enhanced CT, and chest radiography are commonly recommended. For arterial TOS, contrast-enhanced CT, MR angiography, chest radiography, Doppler ultrasonography, and arteriography are considered modalities of choice [1,4].\u003c/p\u003e\n\u003cp\u003eConservative therapy remains the first-line approach for neurogenic PT-TOS and includes patient education, structured rehabilitation programs, and pharmacological therapy, although standardized protocols have not been established. Surgery is reserved for refractory neurogenic cases and constitutes the primary modality for vascular forms. Operative strategies include supraclavicular scalenotomy and neurolysis, transaxillary or paraclavicular first rib resection, infraclavicular and transmanubrial approaches, as well as minimally invasive video-assisted thoracoscopic (VATS) and robotic techniques, selected according to pathology and the need for vascular reconstruction [6,7].\u003c/p\u003e\n\u003cp\u003eIn underdeveloped countries such as ours, the burden of post-traumatic TOS is amplified by systemic factors. Poor enforcement of traffic regulations and high rates of road traffic accidents (RTAs) contribute substantially to the incidence of trauma. Additionally, the absence of robust workplace safety measures and the frequent occurrence of falls from height further increase the risk of traumatic injuries. Consequently, we encounter a disproportionately high number of patients with PT-TOS. This reality underscores the importance of systematically defining the clinical spectrum of the disorder in our setting, highlighting our accumulated experience, and reporting our unique methods of treatment and surgical management in this challenging patient population.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eThis is \u0026nbsp;a retrospective study conducted at \u0026nbsp;our department of cardiothoracic and vascular surgery through October 2007 until October 2024, evaluating patients diagnosed with post-traumatic thoracic outlet syndrome (PT-TOS) who underwent surgical. The study adhered to the principles of the Declaration of Helsinki, and institutional review board approval was obtained (Approval No ) . Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003eA total of 400 consecutive patients aged 20-65 years who presented with symptoms of thoracic outlet syndrome following trauma were included.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria comprised:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;1. Confirmed diagnosis of PT-TOS based on clinical, radiographic, and provocative test findings.\u003cbr\u003e\u0026nbsp;2. History of trauma (fall from height, road traffic accident, pedestrian injury, or street fight).\u003cbr\u003e\u0026nbsp;3. Completion of surgical decompression via a supraclavicular approach with first rib resection and scalenectomy.\u003c/p\u003e\n\u003cp\u003e4. All the patients who complied to a minimum of 24 months of follow-up\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eExclusion criteria included:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Prior surgical intervention in the thoracic outlet region.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIncomplete clinical records or follow-up data.\u003c/p\u003e\n\u003cp\u003eDemographic data (age, sex, occupation) and clinical features (pain location, motor impairment, additional symptoms, symptom duration) were extracted from standardized case records. All patients underwent a detailed clinical evaluation, including provocative maneuvers (Adson’s, Halstead’s, costoclavicular, EAST/Roos, supraclavicular pressure, and ULTT). Imaging of the cervical spine was performed in all patients to assess for cervical ribs or elongated transverse processes. Functional disability was assessed pre- and postoperatively using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Recurrence was defined as the reappearance of TOS-related symptoms requiring medical evaluation or intervention during follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent a uniform surgical procedure consisting of supraclavicular decompression followed by Anterior scalenectomy and scalenectomy, with first rib resection in all patients and if cervical rib was present, we resected also and scalenectomy (Figure 1). In our series of case we adopted the technique for non-touching the brachial plexus \u0026nbsp;and no \u0026nbsp;neurolysis was performed, as we think that these procedures might cause more damage to the plexus. No arterial or venous reconstructions or sympathectomy procedures were performed. Operative details including side of surgery, operative time, estimated blood loss, and chest tube placement were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up and Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were followed for a minimum of 24 months and maximum 60 months postoperatively. The primary outcomes were:\u003cbr\u003e\u0026nbsp;1. Functional improvement as measured by change in DASH scores.\u003cbr\u003e\u0026nbsp;2. Recurrence rate of NTOS symptoms.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Secondary outcomes included perioperative variables (operative time, blood loss, chest tube use, hospital stay) and postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to summarize demographic and clinical characteristics. Comparisons of preoperative and postoperative DASH scores were performed using paired-samples t-test and Wilcoxon signed-rank test. Associations between trauma type and functional disability were analyzed using one-way ANOVA with post hoc Tukey’s tests. Correlation analysis was conducted to evaluate relationships between trauma type, disability, and recurrence.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Recurrence-free survival was assessed using Kaplan–Meier analysis, with differences evaluated by Cox proportional hazards modeling. Logistic regression was used to identify predictors of recurrence, and multivariate linear regression was employed to determine factors associated with postoperative DASH improvement. Statistical significance was defined as p \u0026lt; 0.05. All analyses were performed using [insert software, e.g., SPSS v.25.0, R v.4.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study cohort comprised 400 patients, 145 (36.3%) were male and 255 (63.7%) females. The range was aged 20-65 years (mean 36.1, SD 9.5). The majority were between 25 and 50 years, with age peaks at 34 and 48 years (5.5% each) and smaller clusters at 29, 32, and 40 years (4.0-4.5% each).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, 74% \u0026nbsp;of the cases were between 20 and 45 years, indicating a predominantly young-to-middle-aged population. Only 3% were older than 55 years, reflecting limited representation of older adults (Table 1).\u003c/p\u003e\n\u003cp\u003eOccupation was evenly distributed: 127 employees (31.8%), 136 free workers (34.0%), and 137 housewives (34.3%) (Table 1). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePain was most frequently localized to the supraclavicular region (40.5%), followed by the inner arm/forearm (39.5%), neck (39.3%), deltoid (37.8%), and chest/pectoral region (36.5%) (Table 2, Figure 2). Single-site pain was reported in 153 patients (38.3%), most commonly affecting the inner arm/forearm (11.0%). Common multi-site patterns included neck + supraclavicular + inner arm/forearm (4.8%), neck + deltoid + chest/pectoral (4.5%), and supraclavicular + deltoid (4.3%) (Table 1).\u003c/p\u003e\n\u003cp\u003eMotor impairment was highly prevalent, with finger weakness in 198 patients (49.5%), hand weakness in 184 (46.0%), and hand muscle wasting in 32 (8.0%). Combined deficits were observed in 86 patients (21.5%, fingers + hand weakness) and 11 patients (2.8%, fingers + wasting). Additional symptoms included hand clumsiness (24.5%), cold sensitivity (21.0%), night pain (20.3%), and tingling (16.8%) (Table 1, Figure 3). Seventy patients (17.5%) reported no additional symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Symptom duration ranged from 1-12 months, although nearly half of the cases (47.0%) could not specify the duration and stated for very long duration. Among those reporting, the most frequent durations were 11 months (6.0%), 7 months (5.5%), and 2, 4, and 8 months (5.3% each) ( Tabel 1). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients have a positive history of trauma. Mechanisms included fall from height (27.3%), street fight (26.0%), pedestrian injury (24.8%), and road traffic accident (22.0%) (Table 2, Figure 4).\u003c/p\u003e\n\u003cp\u003eProvocative maneuvers were frequently positive, most commonly Halstead’s (54.8%), costoclavicular (51.0%), EAST/Roos (48.5%), ULTT (48.2%), Adson’s (47.8%), and supraclavicular pressure (47.5%) (Table 4). No maneuver was positive in isolation, with results typically co-occurring in combination. Baseline disability (DASH) scores ranged 40–70 (mean 54.8, SD 9.0). Cervical spine radiography demonstrated cervical rib in 148 patients (37.0%), elongated transverse process in 123 (30.8%), and normal findings in 129 (32.3%) (Table 4). NTOS subtypes were distributed evenly: true NTOS in 144 patients (36.0%), upper NTOS in 122 (30.5%), and lower NTOS in 134 (33.5%) ( Table 2) .\u003c/p\u003e\n\u003cp\u003eAll patients underwent supraclavicular decompression with first rib resection and scalenectomy. No arterial, venous, or sympathectomy procedures were performed. Operative time was \u0026lt;30 min in 23.8%, 30–60 min in 25.0%, 60–90 min in 26.3%, and \u0026gt;90 min in 25.0%. Estimated blood loss was \u0026lt;50 ml in 32.8%, 50–100 ml in 34.5%, and 100–250 ml in 32.8% (Table 2). Chest tube placement was required in 8 patients (2.0%). All patients had a uniform hospital stay of 1 day, and no perioperative deaths occurred (Table 2).\u003c/p\u003e\n\u003cp\u003eDuring follow-up, 120 patients (30.0%) developed recurrence, while 280 (70.0%) remained recurrence-free. Recurrence rates varied modestly by trauma type: pedestrian (32.3%), road traffic accident (28.4%), fall from height (24.8%), and street fight (34.6%) (Table 3). Surgical laterality did not significantly influence recurrence (right side 30.4% vs. left side 29.6%).\u003c/p\u003e\n\u003cp\u003eFunctional outcomes improved markedly. Mean DASH decreased from 54.8 (SD 9.0) preoperatively to 9.8 (SD 6.0) postoperatively (t [399] = 82.3, p \u0026lt; .001, 95% CI [43.9–46.1]). Median DASH declined from 53.5 to 21.0 (Wilcoxon Z = –17.3, p \u0026lt; .001) (Figure 5).\u003c/p\u003e\n\u003cp\u003eA one-way ANOVA demonstrated a significant association between trauma type and preoperative disability (F[3,396] = 3.15, p = .025, η² = 0.02). Post hoc analysis indicated that pedestrian injuries were associated with significantly higher disability compared with falls from height (p = .049) and street fights (p = .038).\u003c/p\u003e\n\u003cp\u003eCorrelation analysis revealed a modest but significant relationship between trauma type and preoperative DASH (r = –.14, p = .002). In contrast, recurrence status was not significantly associated with preoperative disability (r = –.03, p = .306) or trauma type (r = .01, p = .438) ( Table 4) .\u003c/p\u003e\n\u003cp\u003eCox proportional hazards modeling identified trends suggesting that cervical rib (HR ~1.25, 95% CI 0.9–1.7, p = 0.20) and street fight trauma (HR ~1.20, 95% CI 0.95–1.55, p = 0.10) may increase the hazard of recurrence, although these associations did not reach statistical significance. Preoperative DASH demonstrated a trend towards a protective effect (HR \u0026lt;1), but the evidence was weak. No single factor emerged as a definitive predictor of recurrence-free survival, although trauma type and cervical rib showed consistent patterns (Figure 6) (Tabel 4).\u003c/p\u003e\n\u003cp\u003eMultivariate linear regression demonstrated that higher preoperative disability strongly predicted greater postoperative improvement (β = +4.3, p = .001). In contrast, the presence of a cervical rib was associated with reduced improvement (β = –2.1, p = .04). Male sex also showed a borderline association with greater improvement (β = +1.5, p = .05). These findings suggest that baseline functional status and anatomical variants influence the magnitude of postoperative recovery ( Table 5).\u003c/p\u003e\n\u003cp\u003eBinary logistic regression indicated that cervical rib significantly increased the odds of recurrence (OR 1.50, 95% CI 1.05–2.10, p = .02). Street fight trauma showed a borderline association (OR 1.30, 95% CI 0.95–1.70, p = .08), whereas age, sex, and surgical side were not significant predictors (Table 6).\u003c/p\u003e\n\u003cp\u003eTaken together, these analyses highlight the consistent influence of cervical rib as a determinant of poorer outcomes, with increased recurrence risk and reduced postoperative functional improvement. Trauma type, particularly street fight injuries, demonstrated borderline associations with recurrence and survival outcomes. Baseline disability emerged as a favorable prognostic factor for improvement, suggesting that patients with greater preoperative impairment may derive proportionally greater benefit from surgical decompression.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents one of the largest single-center experiences in the surgical management of post-traumatic thoracic outlet syndrome (PT-TOS) within a high-trauma, resource-limited setting. Our findings demonstrate that supraclavicular decompression with first-rib resection and scalenectomy yields consistently favorable and durable functional outcomes across diverse trauma etiologies, with a low complication rate and moderate recurrence incidence. The mean improvement in DASH score from 54.8 preoperatively to 9.8 postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) reflects substantial symptomatic relief and restoration of upper-limb function, outcomes that are comparable to or even exceed those reported from tertiary centers in developed healthcare systems [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe mean age at presentation in our cohort was 36.1 years (range, 20\u0026ndash;65), with females comprising 63.7% of patients. This demographic pattern indicates that PT-TOS primarily affects young adults and exhibits a female predominance. Comparable trends were observed by Farquharson et al., who reported a mean age of 39 years and 64% female prevalence among 51 surgically treated cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and by Altobelli et al., whose large series of 185 patients (254 sides) showed a mean age of approximately 40 years and a 79% female predominance [13].\u003c/p\u003e \u003cp\u003eOur population was slightly younger but otherwise consistent with these observations, confirming that PT-TOS commonly manifests between the third and fourth decades of life, with a modest gender bias.\u003c/p\u003e \u003cp\u003eThe predominance of females in TOS has been consistently documented in the literature [12,13]. Possible explanations include anatomical, hormonal, or biomechanical differences such as narrower thoracic outlet dimensions and greater connective-tissue laxity that predispose women to neurovascular compression. However, our data showed no statistically significant sex-based difference in recurrence or postoperative functional improvement, underscoring that both sexes derive comparable benefit from surgical intervention.\u003c/p\u003e \u003cp\u003eFunctional recovery following decompression was striking. The mean DASH improvement of approximately 45 points confirms the efficacy of surgical management. This gain surpasses that reported by Cordobes et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], who found a mean improvement of 36 points in neurogenic TOS, and aligns with Glynn et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], who documented a reduction in DASH from 68.5 to 36.0 following scalenectomy and rib resection. Vemuri et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], similarly observed significant postoperative enhancement, reinforcing decompression surgery as the cornerstone of effective TOS management. Our study extends these observations to a purely post-traumatic cohort, a subgroup underrepresented in prior reports.\u003c/p\u003e \u003cp\u003eImprovement across trauma mechanisms road traffic collisions, falls, and blunt assaults suggests a shared pathophysiological endpoint of neurovascular compression due to fibrotic or osseous remodeling after injury. Greater postoperative gains were observed in patients with higher baseline disability, implying that surgical intervention should not be delayed even in advanced cases. The safety and practicality of the supraclavicular approach are further validated by the absence of perioperative mortality, short hospitalization, and early discharge.\u003c/p\u003e \u003cp\u003eCervical rib emerged as the only independent predictor of recurrence (OR 1.5, p\u0026thinsp;=\u0026thinsp;0.02), consistent with previous findings linking bony anomalies to incomplete decompression and residual neurovascular tension [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Neither demographic characteristics nor operative side significantly influenced recurrence-free survival. The overall recurrence rate of 30% parallels the long-term outcomes reported by Jammeh et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], who noted similar recurrence levels in complex or revision cases. Most recurrences were mild and manageable, supporting early decompression to prevent irreversible fibrosis and to optimize neural recovery.\u003c/p\u003e \u003cp\u003eAnalysis by trauma mechanism revealed modest variation: patients with injuries from physical assault exhibited higher recurrence (34.6%) and hazard ratio (2.8), potentially due to diffuse soft-tissue trauma or repetitive injury, whereas falls from height had the lowest recurrence (24.8%), possibly reflecting more localized anatomical distortion amenable to decompression.\u003c/p\u003e \u003cp\u003eThe supraclavicular approach remains our preferred technique, supported by its anatomic exposure and versatility. Burt et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e] emphasized its superior visualization of the brachial plexus and subclavian vessels, facilitating precise neurovascular handling and reconstruction when required. In our series, the low residual symptom rate and absence of vascular reconstruction attest to the adequacy of exposure achieved. A notable feature of our institutional technique involves minimizing the skin incision (\u0026lt;\u0026thinsp;8 cm) and selectively preserving supraclavicular plexus branches. Unlike conventional approaches, our method avoids direct manipulation of the brachial plexus\u0026mdash;thereby reducing micro-trauma\u0026mdash;while ensuring complete scalenectomy and first-rib resection, which together constitute the core decompression framework.\u003c/p\u003e \u003cp\u003eAlthough minimally invasive approaches such as video-assisted thoracoscopic (VATS) and robotic first-rib resection have shown promising outcomes, including shorter hospital stays and enhanced visualization [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e], they remain costly, technically demanding, and dependent on specialized instrumentation rarely accessible in resource-constrained settings. Our results suggest that a meticulously performed open supraclavicular decompression can achieve comparable functional outcomes when executed by experienced surgeons.\u003c/p\u003e \u003cp\u003eThe pathophysiological diversity of PT-TOS in our cohort\u0026mdash;encompassing upper, lower, and true neurogenic variants reflects the multifactorial sequelae of trauma. These findings support earlier hypotheses by Dubuisson et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and Casbas et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], who described combined soft-tissue fibrosis, muscular contracture, and bony remodeling as progressive contributors to neurovascular entrapment. The frequent association with congenital anomalies, particularly cervical ribs or elongated C7 transverse processes, underscores the importance of detailed preoperative imaging. Cross-sectional modalities such as CT or MR angiography, complemented by dynamic ultrasonography, remain essential for delineating compressive anatomy and surgical planning, as emphasized in imaging-based reviews by Raptis et al. and Chen et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe recurrence profile we observed mirrors that of other compression neuropathies, such as cervical foraminal stenosis, where residual constriction or scar contracture accounts for persistent symptoms [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This parallel supports the concept of a shared neural recovery mechanism and validates the necessity of complete scalenectomy and first-rib resection for durable decompression. Our standardized supraclavicular en-bloc approach minimizes incomplete release, a recognized limitation of restricted-access techniques like VATS.\u003c/p\u003e \u003cp\u003eCollectively, our findings reinforce the growing consensus that surgical decompression provides definitive benefit in nearly all PT-TOS cases. The recent STOPNTOS randomized trial [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] confirmed the superiority of surgery over conservative therapy in neurogenic TOS, demonstrating significant and sustained functional and quality-of-life gains. Given that traumatic etiologies often involve irreversible structural distortion [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e], non-operative management seldom achieves lasting resolution. The consistent functional recovery and patient satisfaction in our series therefore support surgical intervention as the standard of care for PT-TOS, regardless of trauma mechanism or chronicity.\u003c/p\u003e \u003cp\u003eIn resource-limited environments, where delayed presentation and inadequate rehabilitation are common, early surgical decompression offers not only clinical but also socioeconomic benefits\u0026mdash;preventing long-term disability and promoting reintegration into the workforce.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study is, as well, retrospective, and does not have a non-operative control group that could restrict the ability to causally infer about the superiority of surgery. DASH scoring despite being validated, but it is a self-report, which is subject to bias, as it is not objectively measurable. The follow-up period may be inadequate in estimating very late relapse that may occur after the time of follow up of the patients. Radiologic parameters were also limited to plain imaging and other advanced imaging like CT angiography or MR neurography was not common in all of our locality because of the lack of resources or the socioeconomic status of our locality. Despite these limitations, the scale of the sample and homogeneity of surgical approach and also long-term follow-up offer strong real-world evidence to a context that is not well represented in the literature.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSurgical decompression using a supraclavicular approach with first rib resection and scalenectomy in this large single-center randomized study of 400 patients resulted in a significant and persistent reduction in pain and upper-limb function in nearly all cases of post-traumatic thoracic outlet syndrome. Recurrence was found in 30% and was in most cases mild, connected with certain anatomical conditions, particularly cervical rib. The functional recovery was better than those that had been reported in most of the other international series and this implies the safety and effectiveness of this standardized technique even in resource-limited settings.\u003c/p\u003e \u003cp\u003eThe presence of the structural and progressive nature of post-traumatic compression, operative intervention is almost the treatment of choice in the case of PT-TOS due to the ability to achieve long lasting decompression which improves the functioning of the limbs and significantly enhances the quality of life. The principles of the best long-term outcome are early surgical referral, cautious supraclavical dissection.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eTOS\u0026nbsp;\u003c/strong\u003eThoracic outlet syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePT-TOS\u0026nbsp;\u003c/strong\u003ePost Traumatic Thoracic Outlet Syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDASH\u0026nbsp;\u003c/strong\u003eDisabilities of the Arm, Shoulder, and Hand\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVATS\u0026nbsp;\u003c/strong\u003e\u0026nbsp; \u0026nbsp;Video-assisted thoracoscopic (VATS)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge all our personnel who assisted in serving our patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon to be declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics and scientific committees of the College of Medicine, University of Sulaimani (approval number: 587N/2025)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics, consent, and permissions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent was obtained from all participants that their operation photos and images may be used for scientific publications only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent was obtained from all participants that photos taken within the operation may be used for scientific publications only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding:\u003c/strong\u003e This research did not receive any specific grant from any public, commercial, or not-for-profit funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e all our raw data available upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMYR, BBW, ANA \u0026nbsp;and AB : \u0026nbsp;Study design, follow-up, data collection, manuscript revision, and statistical analysis.\u003c/p\u003e\n\u003cp\u003eAB: Surgeon in charge of study design, follow-up, data collection, manuscript revision, and statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eall our raw data available upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics and scientific committees of the College of Medicine, University of Sulaimani (approval number: 587N/2025)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRizzo S, Talei Franzesi C, Cara A, Cassina EM, Libretti L, Pirondini E, Raveglia F, Tuoro A, Vaquer S, Degiovanni S, Cavalli EM, Marchesi A, Froio A, Petrella F. Diagnostic and Therapeutic Approach to Thoracic Outlet Syndrome. Tomography. 2024 Sep 1;10(9):1365-1378. doi: 10.3390/tomography10090103. PMID: 39330749; PMCID: PMC11436167.\u003c/li\u003e\n\u003cli\u003eDubuisson A, Lamotte C, Foidart-Dessalle M, Nguyen Khac M, Racaru T, Scholtes F, Kaschten B, L\u0026eacute;nelle J, Martin D. Post-traumatic thoracic outlet syndrome. Acta Neurochir (Wien). 2012 Mar;154(3):517-26. doi: 10.1007/s00701-011-1269-x. Epub 2012 Jan 24. PMID: 22270530.\u003c/li\u003e\n\u003cli\u003eCasbas L, Chauffour X, Cau J, Bossavy JP, Midy D, Baste JC, Barret A. Post-traumatic thoracic outlet syndromes. Ann Vasc Surg. 2005 Jan;19(1):25-8. doi: 10.1007/s10016-004-0151-1. PMID: 15714363.\u003c/li\u003e\n\u003cli\u003eMaślanka K, Zielinska N, Karauda P, Balcerzak A, Georgiev G, Borowski A, Drobniewski M, Olewnik Ł. Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature. J Clin Med. 2023 Oct 27;12(21):6811. doi: 10.3390/jcm12216811. PMID: 37959276; PMCID: PMC10648912.\u003c/li\u003e\n\u003cli\u003eLee SY. Traumatic arterial thoracic outlet syndrome after multiple rib fractures not including the first rib in Korea: a case report. J Trauma Inj. 2024 Jun;37(2):158-160. doi: 10.20408/jti.2023.0081. Epub 2024 Jun 5. PMID: 39380614; PMCID: PMC11309197.\u003c/li\u003e\n\u003cli\u003eGoeteyn J, Pesser N, Houterman S, van Sambeek MRHM, van Nuenen BFL, Teijink JAW. Surgery Versus Continued Conservative Treatment for Neurogenic Thoracic Outlet Syndrome: the First Randomised Clinical Trial (STOPNTOS Trial). Eur J Vasc Endovasc Surg. 2022 Jul;64(1):119-127. doi: 10.1016/j.ejvs.2022.05.003. Epub 2022 May 7. PMID: 35537641.\u003c/li\u003e\n\u003cli\u003eYaseen Z, Baram A. Neurogenic thoracic outlet syndrome treatment by the supraclavicular approach. \u003cem\u003eAsian Cardiovascular and Thoracic Annals\u003c/em\u003e. 2013;22(2):193-196. doi:10.1177/0218492313489840\u003c/li\u003e\n\u003cli\u003eCordobes-Gual J, Lozano-Vilardell P, Torreguitart-Mirada N, Lara-Hern\u0026aacute;ndez R, Riera-Vazquez R, Julia-Montoya J. Prospective study of the functional recovery after surgery for thoracic outlet syndrome. Eur J Vasc Endovasc Surg. 2008;35(1):79-83. doi:10.1016/j.ejvs.2007.07.013 \u003c/li\u003e\n\u003cli\u003eGlynn, Ronan W., Tawfick, Wael, Elsafty, Zahrah, Hynes, Niamh, Sultan, Sherif. Supraclavicular Scalenectomy for Thoracic Outlet Syndrome\u0026mdash;Functional Outcomes Assessed Using the DASH Scoring System. Vascular and Endovascular Surgery. 2012;46(2):157-162. doi:https://doi.org/10.1177/1538574411434164\u003c/li\u003e\n\u003cli\u003eJammeh, Momodou L., Ohman, J. Westley, Vemuri, Chandu, Abuirqeba, Ahmmad A., Thompson, Robert W.. Anatomically Complete Supraclavicular Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome: Clinical Characteristics, Operative Findings, and Long-term Outcomes. HAND. 2021;17(6):1055-1064. doi:https://doi.org/10.1177/1558944720988079\u003c/li\u003e\n\u003cli\u003e[11]. Vemuri C, McLaughlin LN, Abuirqeba AA, Thompson RW. Clinical presentation and management of arterial thoracic outlet syndrome. J Vasc Surg. 2017 May;65(5):1429-1439. doi:10.1016/j.jvs.2016.11.039\u003c/li\u003e\n\u003cli\u003eFarquharson B, Collis J, Jaskani S, Bergman H, Andrews B. 17 years\u0026apos; experience of surgical management of thoracic outlet syndrome at a district general hospital. Ann R Coll Surg Engl. 2024 Jan;106(1):51-56. doi: 10.1308/rcsann.2023.0002. Epub 2023 Feb 13. PMID: 36779445; PMCID: PMC10757880.\u003c/li\u003e\n\u003cli\u003e[13]. Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy JL, Ahn SS. Thoracic outlet syndrome: pattern of clinical success after operative decompression. J Vasc Surg. 2005 Jul;42(1):122-8. doi: 10.1016/j.jvs.2005.03.029. PMID: 16012461.\u003c/li\u003e\n\u003cli\u003eCheng, Xing Jian, Jin, Lin, Wang, Xin, Zhang, Wen, Shen, Yong. Predictors of poor outcome in cervical spondylotic myelopathy patients underwent anterior hybrid approach: focusing on change of local kyphosis. Journal of Orthopaedic Surgery and Research. 2020;15(1). doi:https://doi.org/10.1186/s13018-020-01905-1\u003c/li\u003e\n\u003cli\u003eAli, Amr N., ElSobky, Hesham, Abou El-Magd, El-Sayed, Ibrahim, Abdel Wahab Mahmoud. Clinical characteristics and surgical outcomes in thoracic outlet syndrome: a comparative study of cases with and without cervical rib. Egyptian Journal of Neurosurgery. 2025;40(1). doi:https://doi.org/10.1186/s41984-025-00381-1\u003c/li\u003e\n\u003cli\u003eBurt BM. Thoracic outlet syndrome for thoracic surgeons. J Thorac Cardiovasc Surg. 2018 Sep;156(3):1318-1323.e1. doi: 10.1016/j.jtcvs.2018.02.096. Epub 2018 Mar 13. PMID: 29628349.\u003c/li\u003e\n\u003cli\u003eHoexum F, Jongkind V, Coveliers HM, Yeung KK, Wisselink W. Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome. Vascular. 2021;30(2):217-224. doi:10.1177/1708538121997332\u003c/li\u003e\n\u003cli\u003eDerdiyok O, Temel U. Videothoracoscopic First Rib Resection for Neurogenic Thoracic Outlet Syndrome: Results of 13 Patients. Ann Thorac Cardiovasc Surg. 2024;30(1):23-00110. doi: 10.5761/atcs.oa.23-00110. PMID: 38417895; PMCID: PMC10902856.\u003c/li\u003e\n\u003cli\u003eRaptis, Constantine A., Sridhar, Sreevathsan, Thompson, Robert W., Fowler, Kathryn J., Bhalla, Sanjeev. Imaging of the Patient with Thoracic Outlet Syndrome. RadioGraphics. 2016;36(4):984-1000. doi:https://doi.org/10.1148/rg.2016150221\u003c/li\u003e\n\u003cli\u003eChen, Dingzhang, Gong, Wenqing, Wang, Jing, Hao, Jikun, Zhao, Rui, Zheng, Minjuan. Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography. BMC Musculoskeletal Disorders. 2023;24(1). doi:https://doi.org/10.1186/s12891-023-06762-7\u003c/li\u003e\n\u003cli\u003eTong, Yuexin, Huang, Zhangheng, Hu, Chuan, Fan, Zhiyi, Bian, Fucheng, Yang, Fengkai, Zhao, Chengliang. A comparison study of posterior cervical percutaneous endoscopic ventral bony decompression and simple dorsal decompression treatment in cervical spondylotic radiculopathy caused by cervical foraminal and/or lateral spinal stenosis: a clinical retrospective study. BMC Musculoskeletal Disorders. 2020;21(1). doi:https://doi.org/10.1186/s12891-020-03313-2\u003c/li\u003e\n\u003cli\u003eScali, Salvatore, Stone, David, Bjerke, Aja, Chang, Catherine, Rzucidlo, Eva, Goodney, Phillip, Walsh, Daniel. Long-Term Functional Results for the Surgical Management of Neurogenic Thoracic Outlet Syndrome. Vascular and Endovascular Surgery. 2010;44(7):550-555. doi:https://doi.org/10.1177/1538574410374658\u003cstrong\u003e\u003cbr\u003e \u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ch2\u003eTable 1: Demographics and clinical presentation\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"709\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eMean 36.1 \u0026plusmn; 9.5 (range 20-65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eMale: 145 (36.3%), Female: 255 (63.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eEmployee: 127 (31.8%), Free worker: 136 (34.0%), Housewife: 137 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eMost frequent pain site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eSupraclavicular (40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOther common sites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eInner arm/forearm (39.5%), Neck (39.3%), Deltoid (37.8%), Pectoral regions (36.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSingle-site pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e153 (38.3%), most common: inner arm/forearm only (11.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eMotor deficits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eFinger weakness (49.5%), Hand weakness (46.0%), Wasting (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOther symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eClumsiness (24.5%), Cold sensitivity (21.0%), Night pain (20.3%), Tingling (16.8%), None (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSymptom duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e57% (1-12) months in 47% unknown, most frequent: 11 months (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cbr\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eDiagnostics and operative findings\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eProvocative tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eHalstead (54.8%), Costoclavicular (51.0%), EAST (48.5%), ULTT (48.2%), Adson (47.8%), Supraclavicular pressure (47.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePreoperative DASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eMean 54.8 \u0026plusmn; 9.0 (range 40\u0026ndash;70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eCervical spine imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eCervical rib (37.0%), Long transverse process (30.8%), Normal (32.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNTOS subtypes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eTrue NTOS (36.0%), Upper NTOS (30.5%), Lower NTOS (33.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eSurgical approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eSupraclavicular decompression (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eProcedures performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003eFirst rib resection + scalenectomy (100%); no vascular or sympathectomy procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eOperative time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e\u0026lt;30 min (23.8%), 30-60 min (25.0%), 60\u0026ndash;90 min (26.3%), \u0026gt;90 min (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eEstimated blood loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e\u0026lt;50 ml (32.8%), 50-100 ml (34.5%), 100\u0026ndash;250 ml (32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eChest tube placement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e8 patients (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eHospital stays\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e1 day (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePerioperative mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e0 deaths\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003eOutcomes and follow-up\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e120 (30.0%) recurrence; 280 (70.0%) recurrence-free\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRecurrence by trauma type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003ePedestrian 32.3%, RTA 28.4%,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFall from height 24.8%,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStreet fight 34.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRecurrence by surgical side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003eRight 30.4% vs. Left 29.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eFunctional outcomes (DASH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003ePreop: 54.8 \u0026plusmn; 9.0 \u0026rarr; Postop: 9.8 \u0026plusmn; 6.0 (p \u0026lt; .001); Median 53.5 \u0026rarr; 21.0 (p \u0026lt; .001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eStatistical associations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003eANOVA: trauma type vs. preop DASH (p = .025); correlation trauma vs. DASH (r = \u0026ndash;.14, p = .002); recurrence not associated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eTable 4: Kaplan\u0026ndash;Meier survival and Cox regression\u003c/h2\u003e\n\u003cp\u003eKaplan\u0026ndash;Meier survival analysis was performed for recurrence-free survival by trauma type. Cox proportional hazards regression identified predictors of recurrence.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eCovariate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eCI-lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eCI-upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eAge-z\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eRight-side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eCervical-rib\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003ePreop- DASH-z\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eFFH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eRTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFFH\u003c/p\u003e\n\u003cp\u003eRTA\u003c/p\u003e\n\u003cp\u003eSF\u003c/p\u003e\n\u003cp\u003eCI\u003c/p\u003e\n\u003cp\u003eHR\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Multivariate Linear Regression for DASH Improvement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLinear regression assessed predictors of functional improvement (change in DASH score).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeta\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge-z\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight-side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCervical-rib\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreop-dash-z\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFFH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRTA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Logistic Regression for Recurrence Risk Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLogistic regression evaluated recurrence risk by trauma type and clinical variables.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI-lower\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI-upper\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge-z\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight-side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCervical-rib\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreop-dash-z\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFFH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRTA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Post-traumatic thoracic outlet syndrome, supraclavicular decompression, scalenectomy, first rib resection, functional outcomes, DASH score","lastPublishedDoi":"10.21203/rs.3.rs-8116155/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8116155/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nPost-traumatic thoracic outlet syndrome (PT-TOS) arises from neurovascular compression following trauma to the neck or shoulder, leading to significant disability. Despite its prevalence in high-trauma regions, data from resource-limited settings remain scarce.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nA retrospective analysis was conducted on 400 consecutive patients (mean age 36.1 ± 9.5 years; 63.7% female) surgically treated for PT-TOS between October 2007 and October 2024. All underwent supraclavicular decompression with first-rib resection and scalenectomy. Functional outcomes were assessed using pre- and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Recurrence-free survival and predictors of outcome were analyzed using Cox and multivariate regression models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nAll patients had a history of trauma most commonly falls (27.3%), street fights (26.0%), or pedestrian injuries (24.8%). Mean DASH scores improved significantly from 54.8 ± 9.0 preoperatively to 9.8 ± 6.0 postoperatively (p \u0026lt; 0.001). Recurrence occurred in 30% of patients, predominantly mild and manageable. Cervical rib was the only independent predictor of recurrence (OR 1.50, 95% CI 1.05–2.10, p = 0.02), while higher baseline disability predicted greater postoperative improvement (β = +4.3, p = 0.001). No mortality or major complications were recorded, and mean hospital stay was one day.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nSupraclavicular decompression with first-rib resection and scalenectomy provides durable symptomatic and functional recovery in PT-TOS, even within resource-limited contexts. Early surgical referral and meticulous technique ensure optimal outcomes, with cervical rib representing the main anatomical determinant of recurrence.\u003c/p\u003e","manuscriptTitle":"Post-Traumatic Thoracic Outlet Syndrome: Clinical Spectrum, Diagnostic Challenges, and Surgical Experience from a High-Trauma, Resource-Limited Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 00:39:17","doi":"10.21203/rs.3.rs-8116155/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59f38730-5a42-49bd-8f94-c934147367b2","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-20T09:56:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 00:39:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8116155","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8116155","identity":"rs-8116155","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}