Neurovascular Compression in the Thoracic Outlet

Abstract

Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular decompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurysm or occlusion was treated successfully in 240 patients. Dorsal sympathectomy was performed concomitantly in 71 patients for occlusion or embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained pain syndrome and causalgia that did not improve with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal sympathectomy. The use of hyaluronic acid significantly reduced recurrent scarring.

A Case Report of Thoracic Outlet Syndrome with Vascular Complications due to Cervical Rib

“…It has been found that such dilated segments of the artery returns to normal dimension over time once the proximal stenotic element has been removed. 5,6 However, we do perform surgical repair of the aneurysmal SCA whenever indicated. Aneurysmorrhaphy is our most common strategy although venous or prosthetic interposition grafting is also performed in appropriate cases.…”

Supraclavicular surgical approach for thoracic outlet syndrome: 10 years of experience

“…One disadvantage of transaxillary intervention is that congenital fibromuscular bands are hard to see and arterial reconstruction is difficult, when required (3). One important complication of transaxillary approach surgery is the 20% recurrence rate (23,24). The main complications of transaxillary surgery include superficial and deep infections, pneumothorax, vascular injuries and neural damage.…”

Deep Vein Thrombosis of the Arms

“…by first rib resection (Zimmermann et al, 1981;Becker et al, 1983;Machleder, 1993;Urschel & Razzuk, 1998). Some investigators recommend such an invasive approach routinely e.g in patients with effort related thrombosis (Paget von Schroetter´s syndrome) (Kommareddy et al, 2002).…”