Costoclavicular true neurogenic thoracic outlet syndrome after revision clavicle surgery with plate screw osteosynthesis and iliac crest bone graft: a case report

Thoracic outlet syndrome (TOS) is a rare and diagnostically challenging condition. Demonstration of objective neurologic deficits and a corresponding structural compressive substrate is essential to establish the diagnosis of true neurogenic TOS and to define appropriate surgical indications. We report the case of a 65-year-old white Belgian male who developed iatrogenic neurogenic thoracic outlet syndrome at the costoclavicular level following revision surgery for a midshaft clavicle fracture with bone grafting. Clinical examination revealed objective neurologic deficits, including weakness and hypoesthesia of the left upper extremity. Electrodiagnostic studies demonstrated a severe, incomplete brachial plexus injury predominantly affecting the C7–T1-innervated musculature. Computed tomographic imaging revealed significant narrowing of the costoclavicular space due to hypertrophic callus formation and a pre-existing intramuscular lipoma. Following failure of conservative management, surgical treatment consisting of removal of the clavicular osteosynthesis material and infraclavicular brachial plexus neurolysis was performed. Brachial plexus pathology at the level of the costoclavicular space should be considered in postoperative settings after revision clavicle surgery with bone grafting, particularly in midshaft fractures. Awareness of this potential complication may facilitate timely diagnosis and appropriate management.