Surgical management of the thoracic outlet compression syndrome

Thoracic Outlet Syndrome Part II: Consensus on the Management of Neurogenic Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery

BACKGROUND

In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons.

OBJECTIVE

To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community.

METHODS

The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method.

RESULTS

Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%.

CONCLUSION

Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center.

Unique Case of Neurogenic Thoracic Outlet Syndrome with Arterial Compression in Patient with Bilateral Cervical Ribs and Osteochondroma of the Ribs

Background: Neurogenic thoracic outlet syndrome typically presents with paresthesia, pain, and impaired strength in the neck, shoulder, and arm, and is typically a diagnosis of exclusion. This condition is caused by compression of the brachial plexus, typically by a bony or soft tissue anomaly present congenitally and influenced by repetitive motion or significant trauma. Treatment typically involves removal of the first rib and anterior scalene to decompress the thoracic outlet and relieve stress to the brachial plexus if the patient has failed conservative treatment with physical therapy and lifestyle modifications. Case Presentation: We present a case of neurogenic thoracic outlet syndrome with arterial compression treated surgically via a transaxillary first rib and cervical rib resection in a patient with bilateral cervical ribs and osteochondromas of the ribs.

Outcomes of Surgical Management of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Bayesian Perspective

PURPOSE

To provide a summary of the relevant evidence on outcomes of transaxillary first rib excision (TAFRE), supraclavicular first rib excision with scalenectomy (SCFRE), and supraclavicular release leaving the first rib intact (SCR) for patients with neurogenic thoracic outlet syndrome (TOS), and interpret the treatment effects from a Bayesian perspective.

METHODS

A systematic literature search and review were performed. Random-effects meta-analyses were conducted to estimate success rate and complete relief rate of each procedure. The probabilities of specified success rates and complete relief rates were calculated using a Bayesian method. Sensitivity analyses for TOS type, neck trauma, and cervical rib were performed. Complications of each procedure were also reviewed.

RESULTS

Data were extracted from 17 studies of TAFRE, 9 of SCFRE, and 14 of SCR to conduct the meta-analyses. The pooled success rate and complete relief rate were 0.76 (95% confidence interval [95% CI)], 0.65-0.85) and 0.53 (95% CI, 0.38-0.68) for TAFRE, 0.77 (95% CI, 0.68-0.85) and 0.57 (95% CI, 0.41-0.72) for SCFRE, and 0.85 (95% CI, 0.76-0.92) and 0.61 (95% CI, 0.35-0.84) for SCR, respectively. The probabilities of success rate greater than 70% were 90%, 87%, and 99% for TAFRE, SCFRE, and SCR, respectively. If the success rate of 80% or greater was considered, the probabilities were 34%, 31%, and 91%, respectively. The probabilities of complete relief rate of 50% or greater were 67%, 71%, and 69% for TAFRE, SCFRE, and SCR, respectively. Sensitivity analyses showed similar results. The complication rates for TAFRE, SCFRE, and SCR were, respectively, 22.5%, 25.9%, and 12.6%.

CONCLUSIONS

The SCR has a high probability of success rate greater than 80%; both TAFRE and SCFRE have high probabilities of a success rate greater than 70% but only low probabilities of success rate greater than 80%. The TAFRE and SCFRE have more complications than SCR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Cervical Rib Prevalence and its Association with Thoracic Outlet Syndrome: A Meta-Analysis of 141 Studies with Surgical Considerations

BACKGROUND

Cervical ribs (CR) are supernumerary ribs that arise from the seventh cervical vertebra. In the presence of CR, the boundaries of the interscalene triangle can be further constricted and result in neurovascular compression and thoracic outlet syndrome (TOS). The aim of our study was to provide a comprehensive evidence-based assessment of CR prevalence and their association with TOS as well as surgical approach to excision of CR and surgical patients' characteristics.

METHODS

A thorough search of major electronic databases was conducted to identify any relevant studies. Data on the prevalence, laterality, and side of CR were extracted from the eligible studies for both healthy individuals and patients with TOS. Data on the type of TOS and surgical approach to excision of CR were extracted as well.

RESULTS

A total of 141 studies (n = 77,924 participants) were included into the meta-analysis. CR was significantly more prevalent in patients with TOS than in healthy individuals, with pooled prevalence estimates of 29.5% and 1.1%, respectively. More than half of the patients had unilateral CR in both the healthy and the TOS group. The analysis showed that 51.3% of the symptomatic patients with CR had vascular TOS, and 48.7% had neurogenic TOS. Most CR were surgically excised in women using a supraclavicular approach.

CONCLUSIONS

CR ribs are frequent findings in patients with TOS. We recommended counseling asymptomatic patients with incidentally discovered CR on the symptoms of TOS, so that if symptoms develop, the patients can undergo prompt and appropriate workup and treatment.

Imaging of the Patient with Thoracic Outlet Syndrome

Patients with symptoms from compression of the neurovascular bundle in the thoracic outlet are described as having thoracic outlet syndrome (TOS), which is best thought of as three conditions classified according to which structures are involved. The purpose of this article is to review the role of imaging in evaluation of patients with TOS, beginning with diagnosis and extending through postoperative management. While diagnosis of TOS still rests on the patient's presenting history and physical examination, imaging examinations are helpful in supporting the diagnosis, delineating abnormal anatomy, determining which structures are compressed, identifying the site of compression, and excluding other diagnoses. Magnetic resonance imaging is the noninvasive imaging modality of choice in evaluating patients with suspected TOS, but computed tomography also plays an important role, particularly in delineating bone anatomy. Evidence of vascular damage is required to make the diagnosis of TOS at imaging. Dynamic compression of the axillosubclavian vessels at the thoracic outlet can be a finding supportive of the diagnosis of TOS but is not a stand-alone diagnostic criterion, as it can be seen in patients without TOS. As diagnosis and treatment of TOS increase, radiologists will increasingly encounter the TOS patient after decompression surgery. Recognition of the expected postoperative appearance of these patients is critical, as is an understanding of the imaging findings of potential short- and long-term complications. (©)RSNA, 2016.

Cervical ribs with neurological sequelae in children: a case series

INTRODUCTION

Cervical ribs may result in thoracic outlet syndrome. Neurological compromise in children with cervical ribs, however, is rare.

PATIENTS AND METHODS

We report our experience with cervical ribs in a pediatric population and review this specific literature.

RESULTS

In our experience with a pediatric neurosurgical population, symptomatic cervical ribs were often identified in patients with Chiari I malformation. Surgical resection of symptomatic cervical ribs in children appears to have good long-term results.

CONCLUSIONS

Based on our experience, symptomatic cervical ribs should not be considered pathology peculiar to the adult population. Although uncommon, children may present with symptomatic cervical ribs that may necessitate surgical intervention.

Exercise-induced scalenus syndrome

BACKGROUND

Thoracic outlet syndrome is described as a group of distinct disorders producing signs and symptoms attributed to compression of nerves and blood vessels in the thoracic outlet region.

PURPOSE

To describe the exercise-induced scalenus anticus syndrome attributed to the anterior scalenus hypertrophy as a thoracic outlet syndrome underlying mechanism and to give recommendations for a safe and effective surgical treatment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twelve young professional athletes admitted for thoracic outlet syndrome (8 cases of neurologic thoracic outlet syndrome, 4 cases of mixed neurologic and vascular thoracic outlet syndrome) who reported numbness, tingling, early fatigue, muscle weakness, and pain were enrolled in the study. Scalenus hypertrophy was suspected to be the causative factor. Scalenectomy was performed in all cases.

RESULTS

All patients had moderate to severe hypertrophy of the anterior scalenus muscle. Scalenectomy was performed, and there were no intraoperative or postoperative complications. Full activity was quickly achieved, and no recurrence of symptoms was documented.

CONCLUSION

Surgical intervention for scalenus anticus syndrome can allow an athlete to return to full activity and improve quality of life. Surgical intervention seems to be the treatment of choice in terms of restoring quality of life and physical activity.

Surgical management of thoracic outlet syndrome: a 10‐year experience

BACKGROUND

Thoracic Outlet Syndrome (TOS) refers to compression of the neurovascular structures in the region between the scalene muscles and the first rib, or by anatomical abnormalities such as cervical rib, fibrous bands and other variations in the scalene musculature.

METHODS

Our experience with 63 consecutive operations for TOS, over a period of 10 years, has been reviewed. Preoperative symptoms and signs, investigations, surgery done, complications and the outcome of surgery are analysed.

RESULTS

A total of 60 patients underwent 63 operations for decompression of TOS. All the 63 first ribs, were excised by the transaxillary approach. In seven patients (16%), a combined transaxillary and supraclavicular approach was used. There was no operative mortality in this series. The operative complications included pneumothorax in four patients (6.3%), which was treated by insertion of chest drain, and lower brachial plexus neuropraxia in two patients (3%), which improved with conservative management. The mean duration of postoperative hospital stay was 3.6 days. At 12 months following surgery, 56 patients (93%) had complete or partial relief of symptoms and only four patients (6.6%) had no relief of symptoms.

CONCLUSION

The results of the present study confirm that transaxillary excision of the first rib is a surgical procedure associated with very low morbidity and excellent relief of symptoms. It can therefore be offered as an early option for patients with thoracic outlet syndrome. It may be combined with the supraclavicular approach if exposure of the subclavian artery is required for vascular reconstruction.

Neurogenic thoracic outlet syndrome

Current concepts for the diagnosis of neurogenic thoracic outlet syndrome are presented together with the surgical experience and results in series of 51 patients caused by a cervical rib. Surgical treatment is recommended in patients with persistent and disabling symptoms not responding to conservative therapy. In carefully selected patients good to excellent results can be achieved.

Two-surgeon approach to thoracic outlet syndrome: long-term outcome

An orthopaedic surgeon and a vascular surgeon jointly conducted 30 operations for thoracic outlet syndrome in 27 patients, having done the preoperative assessments in conjunction with a neurologist. Anterior scalenectomy was performed by the supraclavicular route except in one case where the infraclavicular route was used. The further surgical procedure was tailored to the abnormalities identified--i.e. resection of cervical rib or band, or medial scalenectomy. The first rib was spared. At median follow-up of 37 months (range 3-228) results were judged excellent or good on 26/30 sides (87%); on the three occasions when scalenectomy alone was performed, the results were only fair or poor. There were no major complications and no patient required reoperation. The long-term outcome in this series suggests that, with multidisciplinary assessment and two-surgeon operative treatment, good results can be obtained by the supraclavicular route without resection of the first rib.

Experience of supraclavicular exploration and decompression for treatment of thoracic outlet syndrome

The purpose of this study was to assess the symptomatic outcome of patients with thoracic outlet syndrome who underwent decompression of the thoracic outlet. In our unit we prefer the supraclavicular approach, performing anterior scalenectomy with excision of fibrous bands or cervical ribs if present. Operative details were gained by theater logbook and case note review. Over a 6-year period, 31 patients (37 limbs) underwent thoracic outlet decompression. Of the 37 affected limbs, the indications for surgery were a combination of both neurological and vascular symptoms in 24 patients (65%), neurological symptoms in 24 (65%), and 4 patients (11%) had vascular symptoms alone. All patients were assessed for postoperative outcome either at out-patient clinics or by personal contact. From the results of this study we concluded that supraclavicular scalenectomy and cervical rib excision with selective first rib excision is a safe and effective procedure for most patients with thoracic outlet syndrome.

Thoracic Outlet Syndrome: Follow-up on 33 Cases with Regard to Vascular Compression

This follow-up study on 33 operations performed for thoracic outlet syndrome (TOS) proves high efficiency in relieving neurological and arterial symptoms, whereas benefit to venous compression is somewhat less. Twenty-six patients (average age was 36 years) were operated on for TOS, seven of them on both sides. There was a higher incidence in females. All patients showed neurological symptoms. In 15, operations on various entrapment syndromes of the upper extremity were performed previously. Six patients presented with an incomplete resection of the first rib. Arterial compression symptoms were evident in 15 cases, symptoms of venous compression in 14 limbs. All patients underwent a resection of the first rib, bilateral in seven cases, using the axillary and supraclavicular approach. In seven patients, a cervical rib and scalenus muscles were resected additionally, in three patients bilaterally. In two cases a neurolysis of the brachial plexus was performed. Using the supraclavicular approach, no complications occurred. In one early patient using the transaxillary approach to a postoperative hemothorax required a revision. Neurological results after surgery showed a total release in 26 limbs (n = 33). In 14 limbs (n = 15) with arterial compression symptoms and in 6 (n = 14) with symptoms of venous compression the operation showed a curative effect.

770 consecutive supraclavicular first rib resections for thoracic outlet syndrome

During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occured and only 12 patients (2%) required operative intervention for recurrent TOS. First rib resection and scalenectomy can be performed by the supraclavicular route with an acceptable outcome, minimal morbidity, and long-lasting results.

[Thoracic outlet syndrome. A study of 45 cases treated between 1975 and 1993]

Since 1970 we have experience of more than 100 cases of the thoracic outlet syndrome. We have rewied 45 patients operated on between 1975 and 1993.The cause, in agreement with the literature, was in 30% a road accident (cervical spine and clavicular disease), in 54% malformations (cervical rib) with a similar frequency of involvement with neurological pathology of the upper limb.We always found a vascular symptomatology, wich increased in shoulder abduction. In 82% of the cases we found an associated neurological deficit. The diagnosis was confirmed with electromyography and arteriography.The treatment was in initially medical and in resistant case, surgery was performed. We have use a supra-clavicular approach with scalenotomy of the scalenus anterior muscle, resection of the distal part of the cervical rib or an anterior fibrous band. We did not do (first operation) a resection of the first rib throught a transaxillary approach, in order to avoid elongation of the brachialplexus roots.We found 80% good results from the opinion of the patients and after clinical examination.We have operated on 6 recurrent cases throught a supra-clavicular approach (fibrous sheath) or by trans axillary approach with resection of the first rib in case of lack of response to scalenotomy.

Arterial complications of the thoracic outlet syndrome

OBJECTIVES

Arterial complications due to compression of the thoracic outlet are uncommon. The objective of this study was to review our fairly extensive experience with this problem with particular reference to its management.

METHODS

Patients entered into the Vascular Clinic database were reviewed over an 11 year period. Twenty six records were found. In 24 patients the vasculopathy was caused by a cervical rib (complete in 15) and in two by an anomaly of the first rib. In all patients the basic arteriopathy was a fibrous structure with a post-stenotic aneurysm in 13. Seventeen presented with a fixed pulse deficit; 13 had a palpable aneurysm and 12 had distal embolisation.

RESULTS

Two patients refused operation. In 22 with cervical rib, the rib was removed via a supraclavicular incision, an anterior scalenectomy was performed and the arterial pathology repaired on its merit, usually by vein graft replacement or bypass. In two with first rib anomalies these were resected by the transaxillary route. Twenty three patients have been followed for between 3 months and 10 years; 20 are cured and three have residual claudication.

CONCLUSIONS

Our results show that simple excision of the cervical rib via the supraclavicular route together with vascular reconstruction is adequate. This is in disagreement with the view of those who advocate routine excision of the first rib in addition to cervical rib excision.

Continuing experience with transaxillary excision of the first rib for thoracic outlet syndrome

The results of transaxillary excision of the first rib for thoracic outlet syndrome are reported. During a 3-year period, 40 transaxillary rib resections were performed on 32 patients. The symptoms in 33 limbs were completely relieved and in a further four symptoms were improved. These results confirm that transaxillary excision of the first rib is the operation of choice in the management of thoracic outlet syndrome.