Thoracic outlet syndrome (TOS) is a complex of signs and symptoms resulting from compression of the nerves and vessels supplying the upper limb. Previous articles described that physicians who do not regularly treat patients with TOS may not have an accurate view of this disorder, its treatment, or the possible success rate of treatment. Roos reported that TOS is underdiagnosed. Difficulty in diagnosis of TOS correctly may cause unexplained various symptoms and less objective diagnostic criteria. Moreover, surgical management for TOS remains more challenging. Transaxillary first rib resection is a well-established surgical treatment for patients with symptomatic TOS. However, it does not allow an adequate exposure of the insertion of the scalene muscle to the first rib. Because surgery for TOS involves many complex and intimately related structures, theoretical complications are numerous and may be severe. There were reported complications including brachial plexus dysfunction and fatal subclavian artery or vein injury. Recent articles showed that with the help of the endoscope, more safety and less invasive surgery has been achieved. The purpose of this study is to access the feasibility of endoscopic assisted transaxially approach for first rib resection in TOS. Forty-eight cases of TOS (21 women and 27 men; mean age, 28.1 years; range, 13-57 years) who underwent endoscopic assisted first rib partial resection were reviewed retrospectively. Conventional transaxially approach described by Roos was underwent before identification of the first rib. A 4.0 mm 30°arthroscope was introduced with an additional small port placed anterior latissimus dorsi. The scope allowed for visual identification and confirmation of the first rib and the contents of the thoracic outlet. Endoscopic classification of neurovascular bundle patterns (NVB), that is, alignment of the nerve, artery, and vein were evaluated intraoperatively. In addition, distance between anterior and middle scalene muscle at the edge of the first clavicle was measured. The first rib was transected anteriorly near the costochondral junction and posteriorly as close to the transverse process as possible in a piece by piece fashion under good visualization with great care to avoid injury to the subclavian vein immediately anterior to the anterior scalene muscles. Roos and Wood score and DASH score was obtained postoperatively. Intraoperative endoscopic findings revealed 3 classifications of NVB patterns based on alignment of scalene muscles, nerve, and artery: parallel type (9 cases) in which the artery and nerve travel parallelly; oblique type (24 cases), in which the nerve was behind the artery; vertical type (15 cases), in which the nerve were totally behind the middle scalene muscle or abnormal band. Abnormal NVB patterns (24 oblique and 15 vertical type) were found in 39 cases (81.3%). In many patients, the interscalene distance was narrow (4.9 mm, range 0-13 mm). Of the congenital abnormal fibrous bands that were identified, 26 of 31 selectively were compressing the lower trunk of the brachial plexus. The insertion of the anterior or middle scalene exceeded the scalene tubercle and extended onto the superior surface of the rib in 13 cases and this was through to narrow the interscalene interval. Postoperative clinical findings showed that excellent or good results by Roos score were obtained in 38 cases (79.2%) and fair to poor results were recorded in 10 cases (20.8%). Pre- and postoperative mean DASH scores were, 35.1 (range 2-77) and 19 (0-72), respectively. No major complication was reported except one pneumothorax. Although transaxillary first rib resection is a well-established surgical treatment for patients with symptomatic TOS, this procedure requires meticulous technique with special attention to fine details to achieve the best results with the least complications. Therefore, many physicians may hesitate to diagnose and treatment TOS.
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Sep 1, 2021
Elroy Patrick Weledji + 1
Open Access
