Thoracic Outlet Syndrome Patients Research Articles

The Morphology of the Dorsal Part of the First Rib in Neurogenic Thoracic Outlet Syndrome Patients: A Retrospective Clinical Study.

The recurrence or persistence of symptoms after thoracic outlet decompression (TOD) in patients with neurogenic thoracic outlet syndrome (NTOS) is not uncommon. Some authors have shown significantly better clinical outcomes in patients who underwent TOD with exarticulation of the first rib compared to a group who underwent TOD with preservation of the dorsal portion of the first rib. Several other case series have shown significant improvement after redo surgery with removal of the dorsal first rib remnant. This indicates the importance of the dorsal part of the first rib in NTOS. However, radical exarticulation may not always be necessary. In this study, we tried to answer the question of whether there is a morphological difference in the dorsal part of the first rib in NTOS patients that might help in the diagnosis and treatment of NTOS. We used the CT data of 21 NTOS patients who underwent TOD surgery and measured the dorsal part of the first rib, then compared them with a quota sample. We found no difference in the dorsal part of the first rib between NTOS patients and the quota sample in our data. As there was no detectable difference, we were not able to use these data to help decide whether exarticulation is necessary in achieving adequate symptom relief. Therefore, we advocate exarticulation of the first rib when TOD is indicated.

How I do it. Thoracic outlet syndrome and the transaxillary approach

Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach.

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review.

Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome. Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS. In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

Relationships between the Clinical Test Results and Neurophysiological Findings in Patients with Thoracic Outlet Syndrome.

A thoracic outlet syndrome (TOS) is the type of brachial plexus disorder most difficult to objectively assess using a clinical examination and differential diagnosis. Its symptoms can be frequently misdiagnosed, especially among others with cervical disc-root conflicts, plexopathies, and peripheral neuropathies. In this study, we aim to identify the correlations between positive Doppler ultrasonography results indicating pathological changes in the subclavian flow velocity, clinical tests, and chosen clinical neurophysiology recordings as proposed alternative or supplementary diagnostic tools for evaluating TOS patients. Sixty TOS patients with positive Doppler ultrasonography and Roos test results and sixty healthy people as a control group were bilaterally examined, and the results were compared. Pain intensity was assessed using a visual analogue scale (VAS). Sensory perceptions within C4–C8 dermatomes were assessed with Von Frey filament (FvF) tests. The activity of motor units in the proximal and distal muscles of the upper extremities was evaluated using surface electromyography (sEMG) during maximal contractions before and after a provocative raised hands test (RHT). An electroneurography (ENG) was used to evaluate the transmission of nerve impulses peripherally. Motor evoked potential (MEP) recordings, induced by the over-vertebral magnetic stimulation of the C5–C7 neuromeres, were used to examine motor transmissions from the cervical motor centres to the upper extremities muscles. The results revealed a relationship between positive Doppler test scores and pathological changes in the subclavian flow velocity through the results of the following diagnostic tools: a VAS score of 1.9 was detected on average, superficial sensory perception abnormalities were found in the innervation areas of the ulnar nerves detected by FvF tests, a decrease in the amplitudes of sEMG recordings was seen in distal rather than proximal muscles (especially following the RHT), a decrease in the motor and sensory peripheral transmissions of nerve impulses in the median, ulnar and cutaneous anterobrachial median nerves was seen, as well as MEP amplitudes recorded from the abductor pollicis brevis muscle. The provocative RHT combined with sEMG and MEP recordings can be considered accurate and objective clinical neurophysiology tools that could supplement the commonly used clinical tests. Such an approach may result in a more precise neurogenic TOS diagnostic algorithm.

Sleep Problems and Disabilities of the Arm, Shoulder, and Hand in Persons with Thoracic Outlet Syndrome-A Cross-Sectional Study.

Thoracic outlet syndrome (TOS) arises as a result of a specific relationship among the anatomical structures that may cause compression in the muscles, nerves, and/or blood vessels in the neck, thereby compromising the local circulation. The aim of the current study was to establish the presence of sleep disturbance and disability in the shoulder, arm, and hand in individuals affected by TOS, as well as to ascertain if there are any differences in these findings relative to TOS-free individuals. The study sample comprised 82 TOS patients and 81 TOS-free individuals aged 19–66 years. Data were gathered by administering the Disabilities of the Arm, Shoulder, and Hand (DASH) and Pittsburgh Sleep Quality Index (PSQI) instruments. The results showed that both the DASH (t = −13.21, p < 0.001) and PSQI (t = −7.27, p < 0.001) scores obtained by the TOS group were higher relative to the controls and were strongly and positively correlated (ρ = 0.58, p < 0.01). As positive DASH scores may be indicative of TOS, they signal the need for further diagnostic evaluations. In individuals in whom TOS is already diagnosed, high DASH scores imply that further sleep quality assessments are required, as compromised sleep patterns may undermine quality of life.

Thoracic outlet compression neuropathy and decompression surgery at chang gung memorial hospital

Thoracic outlet syndrome (TOS) has many controversies that include nomenclature, etiology, diagnosis, treatment and surgical approach. The aim of this article is to give a comprehensive review of our experience of treatment of TOS for more than 35 years. From 1985 to 2021, a total of 100 TOS patients were treated and 114 surgeries were performed. They all had decompression surgeries for their compression neuropathy in the thoracic outlet with at least one year postoperative follow-up. Fourteen patients were bilateral TOS, undergoing bilateral TOS surgeries. Preoperative evaluation covered “TOS Examination Sheet” and imaging studies MRI and CT. Diagnosis was confirmed by intraoperative findings. All had near-total resection of the anterior scalene muscle and the first rib. Additional structual abnormalities were treated at the same time. The operative time was typically 2–3 h. Major postoperative complications were rare. Nearly all patients (96%) experienced significant symptoms and signs relief after a period of clinical follow-up and rehabilitation. TOS is a real clinical entity. Once the preoperative diagnosis is made, conservative treatment is followed but failed, decompression surgery with extensive resection of anterior scalene muscle and the 1 st rib, and any other structural abnormalities is recommended to resolve the problems. Long-term postoperative follow-up is crucial and important to resolve the residual problems. Our result carries a 96% success rate with a favorable benefit:risk ratio. • A total of 100 thoracic outlet syndrome (TOS) patients were treated and 114 surgeries were performed. • Preoperative evaluation, intraoperative findings and procedure, and postoperative follow-up were included. • Decompression surgery included resection of anterior scalene muscle, the 1st rib, and any other structural abnormalities. • Our result carries a 96% success rate with a favorable benefit:risk ratio.

Innominate Vein Stenosis Is Present in Neurogenic Thoracic Outlet Syndrome Patients

It has been established that subclavian and internal jugular vein stenosis is common in patients with neurogenic thoracic outlet syndrome (nTOS). However, a population of nTOS patients with innominate vein stenosis exists that has not been well researched. We compared the demographics and treatment outcomes of nTOS patients with and without innominate vein stenosis.

Quality Assessment of Online Resources for Thoracic Outlet Syndrome Patients

The internet has become a leading resource for patients, to research information about their medical conditions. Access to inaccurate information can lead to miscommunication, poor patient satisfaction and effect shared decision-making with the provider. This study seeks to evaluate the quality and readability of patient resources that appear in the top search results for Thoracic Outlet Syndrome (TOS). Searches were performed for "TOS" and "Thoracic Outlet Syndrome" on the search engines Google ©, Yahoo ©, and Bing©, and on the meta-search platforms Yippy© and Dogpile©. Websites were screened for exclusion and evaluated by 2 reviewers for accountability, interactivity, structure/organization, and content. Exclusion criteria included duplications, no original content on TOS, resources not intended for patients, foreign language, and inaccessible websites. Reviewers came to a consensus on scoring discrepancies. Four indices were used to evaluate readability. Statistical analysis was performed using the Rstudio with ANOVA. In total, 44 websites met inclusion criteria. There were 25 hospital/healthcare organization websites (57%), 11 open access (25%), 5 government agency (11%), 2 professional medical society (5%), and 1 industry sponsored (2%). Median scores were 5.00 out of 16.00 for Accountability (interquartile range IQR: 1.50-8.75), 1.50 out of 5.00 for Interactivity (IQR:1.50-1.50), 3.00 out of 4.00 for Structure/Organization (IQR: 2.00-3.13), 10.00 out of 25.00 for Content (IQR: 7.90-12.63) and 20.25 out of 50.00 for Total Score (IQR: 16.73-27.75). Websites performed well-describing TOS with 98% of websites providing a definition, 90% providing an etiology, 93% providing description or images of the anatomy, 98% providing symptoms of neurogenic TOS, 93% providing symptoms of venous TOS, and 93% providing symptoms of arterial TOS. Physical therapy was the most discussed treatment option (91%) followed by decompression surgery (86%), thrombolysis (41%), vascular repair (39%), interscalene injections (18%), and embolectomy (11%). There was no significant difference across website types for any category other than accountability where Open Access scored the highest (Table II). Readability was difficult with median Flesch Reading Ease formula score correlating to a college level (IQR: 10th-12th grade-college), median Flesch-Kincaid Grade Level of 10 (IQR: 9th-12th grade), median Standardized Measure of Gobbledygook (SMOG) grade of 10 (IQR: 9th-11th grade), and median Dale-Chall Readability Formula Score correlating to 11th-12th grade (IQR: 11th to 12th-college grade level). There was no significant difference between website types for readability. The top web results for TOS have varying degrees of quality with a clear gap in certain areas of information. While websites performed well-explaining the disease, they lacked discussion of the full scope of treatment that may be offered. In addition, readability was poor across all website types which will not help patients' understanding of their condition. Providers should take into account the variability in websites when entering into shared decision-making discussions with patients.

Convergent Validity of Thoracic Outlet Syndrome Index (TOSI)

No disease-specific evaluation score for thoracic outlet syndrome (TOS) patients was available prior to the presentation of the Thoracic Outlet Syndrome Index (TOSI) score. Our aim was to assess the convergent validity of the TOSI when compared with the short form of Disabilities of the Arm, Shoulder and Hand (QDASH), the Cervical Brachial Symptom Questionnaire (CBSQ), and pain numeric rating scale (painNRS) after supraclavicular rib-sparing decompression for neurogenic TOS. The TOSI takes into account five domains important to TOS patients with 15 questions, whereas QDASH considers only four domains, and CBSQ and painNRS each has only one domain. Our 67 TOS patients, mean age 36.5 years at surgery, were evaluated clinically for a mean 13.2 years after rib-sparing surgery. They completed the QDASH, the CBSQ, the pain NRS, and the TOSI questionnaires. Correlations between TOSI total score and QDASH, CBSQ total scores, and the painNRS were strong: 0.67 for TOSI vs. QDASH; 0.75 for TOSI vs. CBSQ; and 0.65 for TOSI vs. painNRS. The TOSI demonstrated good convergent validity. It may thus become a valuable addition among tools for assessing the quality of life and functioning of those with neurogenic thoracic outlet syndrome as well as for improving comparability of results across varying settings in this field.

Arterial thoracic outlet syndrome - Clinical presentation, surgical management, and outcome: An institutional experience of 10-year period

Objective: The main objective of this study was to review the clinical presentations, surgical management, and outcome of surgical procedures for arterial thoracic outlet syndrome (TOS). Methodology: This is a retrospective analysis of arterial TOS patients admitted in our department (Institute of Vascular Surgery, Madras Medical College, Chennai) from August 2012 to July 2022. Results: This study enrolled 81 patients, with mean age of 41.13 (12-65 years) and 50.61% male (41) and 49.39% female (40), associated with distal arterial lesions - 63 (77.77%), among which 50.61% - occlusion in the brachial artery (33), 24.69% in forearm arteries (15), and 24.69% in the axillary artery (15). About 95.06% of patients had cervical rib (77), 2.46% - first rib abnormality (2), 2.46% - soft-tissue compression (2), 59.25% was SCHER Stage III (48), 33.33% SCHER stage I (27), and 7.40% SCHER stage II (6). All patients had undergone a supraclavicular approach. The most common arterial lesions were subclavian artery (SCA) thrombus in 53.08% (43), occlusion in 17.28% (14), and dilatation in 29.62% (24) cases. The cervical rib excision with anterior scalenectomy in 95.06% (77), and 1st rib excision with anterior scalenectomy 2.46% (2) and soft tissue resection with anterior scalenectomy 2.46% (2) of patients. SCA intervention/reconstruction was done in 88.88% (72) of cases. Two patients had underwent above elbow amputation (2.46%) and no mortality and SCA patency was 100%. Conclusion: Cervical rib excision with anterior scalenectomy with or without thrombectomy is an effective procedure for arterial TOS cases.

Measurement of interscalene space volume in diagnosis of thoracic outlet syndrome: a cadaver study

Background/aimThe aim of this study was to measure the volume of interscalene space in thoracic outlet region on cadavers and radiological images and to analyze the potential value of these measurements in diagnosis and treatment of thoracic outlet syndrome (TOS).Materials and methodsThe dimensions of the anterior interscalene space in 8 formalin-fixed human cadavers were studied by direct measurement and additionally evaluation of the volume of this space were done by using mold and volume calculation formula of square pyramid, due to resembling a pyramid. In the second phase of this study, interscalene space volume was calculated by formula and compared to calculations from computed tomography (CT) sections in 18 TOS and 16 control patients. ResultsThere was a strong correlation between the volume calculated by formula (4.79 ± 2.18 cm3) and by mold (4.84 ± 1.58 cm3), (R = 0.934, p = 0.001) in cadavers. The average volume measured in TOS patients (2.05 ± 0.32 cm3) was significantly smaller than control patients (4.30 ± 1.85 cm3, p < 0.0001). There were excellent or good results in 14 patients whereas in 4 patients who had neurogenic TOS achieved fair results after surgery. In these 4 patients the average volumes of abnormal sides were close to the healthy sides. ConclusionIn our study, volume of interscalene space in TOS patients was statistically smaller than control group. Also, the volume was even smaller in patients with excellent or good results after surgery. In this respect, volumetric measurements from CT sections could be used in diagnosis and treatment selection in TOS patients.

Quality Assessment of Online Resources for Thoracic Outlet Syndrome Patients

Quality Assessment of Online Resources for Thoracic Outlet Syndrome Patients

Efficacy of intensive, hospital-based rehabilitation in cases of thoracic outlet syndrome that failed to respond to private-practice physiotherapy.

Rehabilitation is currently the preferred first-line treatment for thoracic outlet syndrome (TOS). When physiotherapy fails, the next treatment option is usually surgery - a complex procedure with potential complications. We sought to establish whether an intensive, multidisciplinary, day-hospital-based rehabilitation programme could reduce the symptoms of TOS after the failure of private-practice physiotherapy and before surgery was considered. We performed a retrospective, single-centre study of 63 TOS patients admitted to our day hospital for 3 weeks (15 therapy sessions) between 2003 and 2014. The data were extracted from hospital records or gathered in a phone interview. Immediately after discharge, the observed improvements in hand function were related to lifting a load, reaching a high shelf, sweeping the floor, cleaning windows, and combing hair. Three months after the end of the intensive rehabilitation program, 80% of the patients reported a reduction in their symptoms. Forty-one of the 63 patients were subsequently contacted by phone. The mean time interval between the end of the rehabilitation programme and the phone interview was 4.5 years (median: 3.5 years; range: 1-12 years). Twenty-seven patients (66%) reported a worsening in hand function, and 25% had undergone surgery. Twenty-three patients had kept the same job, 7 had changed jobs after retraining, 4 had stopped working before the programme but were able to return to work afterwards (including one patient in a part-time job), 4 had not returned to work, and 3 received disability benefits. An intensive, multidisciplinary, hospital-based rehabilitation programme was associated with improvements in the great majority of patients with TOS - even after private-practice physiotherapy had failed.

Miscarriage is associated with cervical ribs in thoracic outlet syndrome patients

The constancy of the number of cervical vertebrae in mammals is probably the result of selection against associated variations. A survey among patients with and without cervical ribs showed an association between miscarriage and the presence of cervical ribs. This supports the hypothesized selection against variations in cervical vertebral number.

Validity and internal consistency of the thoracic outlet syndrome index for patients with thoracic outlet syndrome

No validated scales exist specifically for measuring quality of life (QoL) and functioning level in patients with thoracic outlet syndrome (TOS). This cross-sectional survey examined whether some items adopted from validated QoL scales could be suitable for patients with TOS. To find an optimal thoracic outlet syndrome index (TOSI), a panel of 14 specialists experienced in treating TOS independently evaluated the relevance of 19 items adopted from scales used in other upper-extremity syndromes. After undergoing surgery for TOS, 52 patients rated the relevance of those items found by experts to be relevant. Content validity was measured by a content validity index, content validity ratio, and modified κ. The internal consistency of 15 retained items was assessed with the Cronbachα, and its construct validity was assessed by an exploratory factor analysis. Of the 19 items, 15 were considered relevant for TOS by the panelists, with an overall test content validity index of 0.93. The internal consistency of these 15 items was excellent. The exploratory factor analysis accompanied by a parallel analysis confirmed the uni-dimensionality of the TOSI. All 15 items that the panelists considered relevant were also items that the patients marked with scores over 7 points on an 11-point scale of relevance. The internally consistent, face- and content-valid TOSI scale is proposed for use in evaluating specifically the QoL in TOS patients, as well as improving future longitudinal studies comparing functioning before and after interventions or spontaneous recovery in TOS patients.

Supraclavicular Approach on Thoracic Outlet Syndrome

Background: Thoracic Outlet Syndrome (TOS) is a clinical syndrome that refers to abnormal compression of the neurovascular in the neck and axilla with signs and symptoms manifesting in the shoulders, neck, arms, hands and sometimes fingers. It may be underdiagnosed because this syndrome is poorly understood. The compression is primarily neurogenic, vascular, or both. As the number of patients undergoing successful treatment increases, TOS is becoming a common diagnosis. In those patients in whom pain is refractory to conservative care, surgery should be considered. The aim of this study is to evaluate the outcome of a supraclavicular approach to treat the thoracic outlet syndrome patients in Dr. Ramelan Navy Hospital Surabaya.Materials and methods: This study is a case series of 16 patients (10 females and 6 males) of 19-50 years old, who underwent neurovascular compression with the supraclavicular approach. Symptoms were evaluated with medical records based on peri-operative anamnesis and physical examination.Results: The follow-up with 16 patients showed excellent results such as decreasing pain, decreasing sensory or motoric symptoms, and complications like pneumothorax hematothorax, and injury of artery, vein or plexus brachialis were not found.Conclusion: Supraclavicular approach is relatively effective and safe for neurovascular decompression of TOS. Excellent outcomes were observed with a small incision, safe and minimal complications.

Supraclavicular Approach on Thoracic Outlet Syndrome

Background: Thoracic Outlet Syndrome (TOS) is a clinical syndrome that refers to abnormal compression of the neurovascular in the neck and axilla with signs and symptoms manifesting in the shoulders, neck, arms, hands and sometimes fingers. It may be underdiagnosed because this syndrome is poorly understood. The compression is primarily neurogenic, vascular, or both. As the number of patients undergoing successful treatment increases, TOS is becoming a common diagnosis. In those patients in whom pain is refractory to conservative care, surgery should be considered. The aim of this study is to evaluate the outcome of a supraclavicular approach to treat the thoracic outlet syndrome patients in Dr. Ramelan Navy Hospital Surabaya.Materials and methods: This study is a case series of 16 patients (10 females and 6 males) of 19-50 years old, who underwent neurovascular compression with the supraclavicular approach. Symptoms were evaluated with medical records based on peri-operative anamnesis and physical examination.Results: The follow-up with 16 patients showed excellent results such as decreasing pain, decreasing sensory or motoric symptoms, and complications like pneumothorax hematothorax, and injury of artery, vein or plexus brachialis were not found.Conclusion: Supraclavicular approach is relatively effective and safe for neurovascular decompression of TOS. Excellent outcomes were observed with a small incision, safe and minimal complications.

IF13. Arterial Thoracic Outlet Syndrome: Outcomes of Direct Repair of Subclavian Artery Aneurysms

Arterial complications of thoracic outlet syndrome (TOS) are rare (<1%). Surgery involves decompression of thoracic outlet, repair of subclavian aneurysm, and often embolectomy. Most published series have reported interposition graft for repair of subclavian aneurysm. The objective of this study was to evaluate the long-term results of decompression and direct repair of subclavian artery aneurysm in arterial TOS. This was a retrospective review of a prospectively maintained database. All patients who underwent surgery for arterial TOS from January 2001 to April 2017 were included. Patients’ demographics, presentation, treatment, and outcomes were reviewed. Direct repair of subclavian artery aneurysm included longitudinal arteriotomy, intimectomy, and tailoring. There were 62 operations performed on 53 patients for arterial TOS. Mean age at presentation was 35.62 years (range, 13-65 years). The female to male ratio was 1.65:1.0. There were 12 patients with bilateral arterial TOS, although all presented with unilateral symptoms. Three patients presented with acute limb ischemia. The remaining patients had delayed presentation (range, 30 days-2 years), including neck pain and swelling (7), upper limb claudication (33), rest pain and digital cyanosis (5), and stroke (1). The cause of arterial TOS was complete cervical rib in 50 (94%) patients (12 bilateral), incomplete first rib in 2 (4%) patients, and compression with scalenus anticus in 1 (2%) patient. All 12 asymptomatic TOS patients showed arterial compression, and 3 patients refused surgery for the asymptomatic limb. Surgery included thoracic outlet decompression by anterior scalenotomy (62), excision of cervical rib (59), and excision of first rib (3). Of the 62 operations (89%), 55 included direct repair of subclavian aneurysm: longitudinal arteriotomy, intimectomy, and aneurysmorrhaphy; 2, resection and end-to-end anastomosis; and 2, interposition grafts. Trans-subclavian embolectomy was done in 47 and transbrachial in 27 patients. Early complications included hemothorax requiring chest drain (one), lymph leak (one), phrenic nerve paresis (one), and brachial neurapraxia (two). Mean follow-up was 2 years (range, 6 months-5 years); 13 patients were lost to follow-up after 6 months. Follow-up is at regular intervals clinically and with duplex ultrasound scan. Residual ischemia (asymptomatic) is present in 12 of 53 patients (23%). One patient has persistent neuralgia. Asymptomatic dilation of directly repaired subclavian artery was identified in one patient at 18 months of follow-up, and he is under surveillance. Direct repair of subclavian artery aneurysm in arterial TOS patients can be performed safely. Recurrent dilation is rare and can be managed conservatively.

First Rib Resection for Thoracic Outlet Syndrome: The Robotic Approach.

First rib resection is a well-recognized treatment option for thoracic outlet syndrome (TOS). In case of a vascular insufficiency that can be provoked and/or progressive neurologic symptoms without response to conservative treatment, surgical decompression of the space between the clavicle and the first rib is indicated. The aim of this paper is to present our experience with a new minimally invasive robotic approach using the da Vinci Surgical System®. Between January 2015 and October 2017, eight consecutive first rib resections in seven patients were performed at our institution. Four patients presented with neurologic (one bilateral), and three patients with vascular (venous) impairment. In all cases, a transthoracic robotic-assisted approach was used. The first rib was removed using a 3-port robotic approach with an additional 2-cm axillary incision in the first six patients. The latest resection was performed through only three thoracic ports. Median operative time was 108min, and the median hospital stay was 2days. Postoperative courses were uneventful in all patients. Clinical follow-up examinations showed relief of symptoms in all nonspecific TOS patients, and duplex ultrasonography confirmed complete vein patency in the remaining patients 3months after surgery. While there are limitations in conventional transaxillary, subclavicular and supraclavicular approaches in the first rib resection, the robotic method is not only less invasive but also allows better exposure and visualization of the first rib. Furthermore, the technique takes advantage of the benefits of the da Vinci Surgical System® in terms of 3D visualization and improved instrument maneuverability. Our early experience clearly demonstrates these advantages, which are also supported by the very good outcomes.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs

ObjectiveThe transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. MethodsWe reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. ResultsBetween 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). ConclusionsThis series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.