VESS21. Reoperation for Recurrent Neurogenic Thoracic Outlet Syndrome Is Effective in Achieving Symptomatic and Functional Improvement Following Surgical Decompression

Abstract

In some patients with neurogenic thoracic outlet syndrome, surgical decompression does not invariably lead to symptom resolution. Symptom persistence or recurrence is debilitating and, yet, tends to be managed conservatively. At our center, reoperative decompression is performed in carefully selected patients with persistent or recurrent symptoms. The purpose of this study was to assess the symptomatic and functional outcomes in patients undergoing reoperation. We performed a retrospective review of patients who required reoperation for thoracic outlet syndrome at our center from January 2009 to December 2017. Sixty-three cases were found and 27 exhibited complete clinical and outcomes data for review. We complied descriptive statistics. Continuous variables are presented as mean ± standard deviation, or median (quartile 1, quartile 3), if skewed. Categorical variables are presented as frequency and percentage. Long term functional outcome was assessed by the 11-item version of the Disability of the Arm, Shoulder, and Hand questionnaire. Twenty-seven patients underwent a reoperative procedure. The majority of patients were female (74%) and Caucasian (96%). Twelve individuals (44%) were elite competitive athletes. The most common index procedure (67%) was a combination first rib resection and scalenectomy with brachial plexus neurolysis. Median age at index procedure was 20 (18, 41). True recurrence occurred in 24 patients (89%) and true persistence occurred in 3 (11%) individuals. Median time to reoperation was 344 days (212, 756 days). The most common reoperative procedure was brachial plexus neurolysis and adhesiolysis with pectoralis minor release (56%). Residual rib resection was required in six patients (22%). The most common intraoperative findings were dense adhesions around the lower plexus and residual compressive scalene attachments. After reoperation, 22 of 27 patients (81%) experienced durable improvement of symptoms, 3 (11%) had complete resolution, and 2 (7%) patients experienced recurrent symptoms after a period of symptomatic improvement. At long-term follow-up (>1 year), the median Disability of the Arm, Shoulder, and Hand score for the 27 patients was 33.6. Despite the complicated nature and limited treatment options for recurrent thoracic outlet syndrome, we demonstrate that reoperation is associated with modest to excellent symptomatic and functional improvement in the majority of cases though some impairment related to residual symptoms may persist.