Combined Surgical Treatment of Thoracic Outlet Syndrome: Transaxillary First Rib Resection and Transcervical Scalenectomy

Safety of robotic first rib resection for thoracic outlet syndrome

OBJECTIVES

Robotic first rib resection (R-FRR) is an emerging approach in the field of thoracic outlet syndrome (TOS) that has technical advantages over traditional open approaches, including superior exposure of the first rib and freedom from retracting neurovascular structures. We set out to define the safety of R-FRR and compare it with that of the conventional supraclavicular approach (SC-FRR).

METHODS

We queried a prospectively maintained, single-surgeon, single-institution database for all FRR operations performed for neurogenic TOS and venous TOS. Preoperative, intraoperative, and complications were compared between approaches.

RESULTS

Seventy-two R-FRRs and 51 SC-FRRs were performed in 66 and 50 patients, respectively. These groups were not significantly different in age, body mass index, sex, type of TOS, or preoperative use of opioids. Length of procedure and hospital stay were not different between groups. Postoperative inpatient self-reported pain (visual analog scale score 4.7 vs 5.2; P = .049) and administered morphine milligram equivalents (37.5 vs 81.1 MME, P < .001) were significantly lower in R-FRR than SC-FRR. Brachial plexus palsy was less frequent after R-FRR than SC-FRR (1% vs 18%, P = .002) and resolved by 4 months in call cases. All cases were sensory palsies with the exception of 2 motor palsies, which were both in the SC-FRR group. In multivariable analyses, R-FRR was independently associated with less frequent total complications than SC-FRR (P = .002; odds ratio, 0.08; 95% confidence interval, 0.02-0.39).

CONCLUSIONS

R-FRR provides outstanding exposure of the first rib and eliminates retraction of the brachial plexus and its consequences.

Thirty-Day Outcomes Following Surgical Decompression of Thoracic Outlet Syndrome

BACKGROUND

Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013.

RESULTS

There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays ( P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9).

CONCLUSIONS

Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.

All-Endoscopic Brachial Plexus Complete Neurolysis for Idiopathic Neurogenic Thoracic Outlet Syndrome: A Prospective Case Series

PURPOSE

To describe an all-endoscopic technique for infra- and supraclavicular brachial plexus (BP) neurolysis and to assess its functional outcomes for patients suffering from nonspecific neurogenic thoracic outlet syndrome (NTOS).

METHODS

Between January 2010 and January 2013, 36 patients presenting an idiopathic nonspecific NTOS benefited from an endoscopic decompression in our institution. The inclusion criteria were a typical clinical NTOS and failure of a 6-month well-conducted nonsurgical treatment. Preoperative findings about other shoulder conditions and complementary procedures were exclusion criteria. Interscalene, costoclavicular, and retropectoralis minor spaces were released endoscopically. The primary endpoint was the Disability of the Arm, Shoulder and Hand (DASH) score improvement 6 months after the surgery. Postoperative criteria such as pain relief, paresthesia, upper limb weakness, and provocative tests were also assessed.

RESULTS

Of 36 patients, 10 were excluded and 5 were lost during follow-up. The data of the 21 remaining patients were analyzed after 6 months. Pre- and postoperative mean DASH scores were, respectively, 70 (range 36-98) and 34 (range 2-91). The average improvement was 36 (range -20 to 80), with P = .0002. Pain and paresthesia were relieved in 80% to 90% of the cases. No complication was reported.

CONCLUSIONS

Although requiring arthroscopic skills and expert knowledge of the anatomy, our technique seems to be safe and reproducible, and it provides significant functional improvements in the selected patients with nonspecific NTOS, with an average postoperative DASH score improvement of 36%.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A hand surgeon's further experience with thoracic outlet compression syndrome

Because hand surgeons frequently see patients with arm and hand pain, numbness, and tingling, it is important for them to recognize the possibility of the presence of thoracic outlet compression syndrome (TOCS). Approximately 40% to 50% of patients with this condition have associated peripheral nerve compression symptoms. Only about 10% of patients with suspected TOCS might show some objective evidence during physical examination and other examination modalities. For this reason, TOCS is one of the most overlooked, misdiagnosed, and underrated conditions. During the past 20 years (1989-2009) our surgical experience with combined-approach surgery for TOCS, involving transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy, has been gratifying. During this period, more than 750 patients had this combined procedure. Between the end of 1989 and 2002 (13 years), 532 patients (many of whom were from out of state) had this kind of intervention. At the end of 2002, we surveyed our patients for the outcome of their surgery. Unfortunately, we were able to locate only 358 patients, and only 102 patients returned a mailed questionnaire. About 95 patients reported improvement of their symptoms. Since the beginning of 2003, more than 230 patients have had the same procedure. It is our impression that the outcome of the surgery in this last group of patients is at least as good as (if not better than) the earlier reported outcome in the first group of patients. The combined surgical approach to TOCS with transaxillary first rib resection and transcervical scalenectomy is the most complete procedure for total decompression of the thoracic outlet, with a much better rate of improvement of symptoms and a lower rate of recurrences. The surgical techniques of these two procedures are described.

Long-term Outcome Analysis of the Supraclavicular Surgical Release for the Treatment of Thoracic Outlet Syndrome

OBJECTIVE

This is a long-term outcome analysis of patients who underwent surgical treatment with a supraclavicular release for thoracic outlet syndrome (TOS).

METHODS

All patients undergoing supraclavicular release between January 1, 1987, and December 31, 2000, at University Hospital, Inselspital, Bern, Switzerland, were included in this study. Of 29 treated patients, 22 patients (24 TOS) underwent both long-term clinical follow-up (median 12.5 years, standard deviation 3.5 years, range 5–18 years) and short-term clinical follow-up (median 6.6 months, standard deviation 4.5 years, range 3–12 months).

RESULTS

Eleven patients (12 TOS operations) were classified as having a neurogenic cause of TOS, whereas the other 11 (12 TOS operations) were classified as having disputed TOS. Patient data, including various outcome parameters, such as pain and disabilities of arm, shoulder, and hand scores, were evaluated pre- and postoperatively and at long-term follow-up by an independent examiner. The surgical supraclavicular technique is described in detail. In 21 of 24 surgical release procedures, the first rib was resected. There was a marked permanent long-term postoperative reduction of symptoms in both neurogenic and disputed TOS groups. The pain and disabilities of arm, shoulder, and hand scores improved significantly after surgery, regardless of the etiology, in the short- and long-term postoperative observation periods. There were no patients with workers' compensation or litigation issues.

CONCLUSION

This study demonstrates the successful, constant long-term relief of symptoms in carefully selected patients with neurogenic and disputed TOS using the described surgical supraclavicular release technique.

First rib resection in thoracic outlet syndrome

Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement.

TOS-surgery via a single supraclavicular incision

BACKGROUND

We report about our experiences using a single supraclavicular incision at the base of the neck for Thoracic Outlet Syndrome (TOS) surgery.

METHODS

10 patients aged between 12 and 59 years (mean 31 years) underwent 12 times a TOS procedure. Patients suffered from compression of their brachial plexus with main affection of the ulnar nerve (9 out of 12 cases). Electroneurography was positive for TOS 4 times in 3 patients, in other 3 patients additionally a distal nerve compression syndrome was evident. In 7 cases (5 patients) a cervical rib was present on X-ray. In 10 cases (8 patients) the subclavian artery showed a stenosis behind the clavicle on MRI-angiography. In all cases the brachial plexus was prepared and a complete scalenotomy was performed. Whenever present the cervical rib was resected and in 2 cases the first rib (1 with/1 without cervical rib) was taken out.

RESULTS

The surgical procedures did not cause relevant complications. All patients were without discomfort within 6 months, including the nerve regeneration disturbances. One patient suffered from TOS recurrence 10 months after surgery (scalenotomy without resection of the 1st rib).

CONCLUSION

The single supraclavicular incision provided sufficient access to the structures of the brachial plexus, the subclavian artery and the cervical and 1st rib in all cases. The procedure produced not only sufficient pain relief and normalized extremity function but also a cosmetically acceptable, nearly invisible scar.