Five Hundred Rib-Sparing Scalenectomies for the Treatment of Neurogenic Thoracic Outlet Syndrome

Abstract

Neurogenic thoracic outlet syndrome (TOS) is no longer either controversial or disputed, but its optimal surgical management remains unclear. Most thoracic outlet decompression procedures are carried out by first rib resection, usually through a transaxillary route. A retrospective review was conducted of a prospectively maintained TOS database. Patients with neurogenic TOS associated with a cervical rib were excluded from analysis, as were patients with recurrent neurogenic TOS. All study patients satisfied a 5-point clinical diagnostic protocol and experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis by a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All patients completed a shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) preoperatively and at 1 month, 3 months, and 6 months postoperatively; operative success was defined as 50% improvement of 6-month postoperative vs preoperative QuickDASH scores. Between 2011 and 2019, there were 500 consecutive thoracic outlet decompression procedures carried out in 448 patients. Average operative time was 1.15 hours, and hospital length of stay was 1.05 days. Major complications (serious bleeding, permanent nerve injury, infection) occurred in seven patients (1.3%). All but two (99.6%) patients improved symptomatically; using the more rigorous definition of operative success noted before, 452 (90.9%) rib-sparing neurogenic TOS operations were successful. These results suggest that adherence to a rigorous preoperative diagnostic regimen, including scalene block, ensures, at the least, that operation for neurogenic TOS can successfully be restricted to patients actually suffering from the condition; fibrotic, contracted scalene muscles are the cause of neurogenic TOS; the first rib need not be removed for successful surgical treatment of neurogenic TOS; and >90% of patients so treated can expect significant medium-term symptomatic and functional improvement.