Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> Various surgical approaches have been proposed for the treatment of thoracic outlet syndrome (TOS). The authors of this study focused on the differences in outcome after supraclavicular neuroplasty of brachial plexus (SNBP [no rib resection]) and transaxillary first rib resection (TFRR) in patients in whom the dominant clinical problem was pain.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Fifty-five patients were randomized to undergo TFRR or SNBP. Patients with an anomalous cervical rib, intrinsic weakness, and primarily vascular findings were excluded from the study. Preoperatively, the following findings were typically observed: provocation of symptoms by certain postures (the so-called spear-throwing position as well as downward tugging of the shoulder) and marked tenderness in the supraclavicular fossa.</jats:p> <jats:p content-type="fine-print">The intergroup severity of the symptoms was comparable. Eight patients were lost to follow up. There were 24 TFRRs (in two cases the procedure was bilateral) and 25 SNBPs. The mean follow-up interval was 37 months. In both groups pain decreased significantly after surgery. By all measures the TFRR operation conferred superior results. Patients reported significantly less pain (39 ± 7 compared with 61 ± 7; score range 0–100 on a visual analog scale), greater percentage of pain relief (52 ± 8% compared with 30 ± 7%), and less pain (3.7 ± 0.4 compared with 5.1 ± 0.5) on an affective scale (all p &lt; 0.05) in the TFRR and SNBP groups, respectively). In the TFRR group, 75% of patients reported good or excellent outcomes compared with 48% in the SNBP group (p &lt; 0.05).</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> Transaxillary first rib resection provided better relief of symptoms than SNBP. The major compressive element in patients with TOS-associated pain appeared to be the first rib.</jats:p>

Magnetic resonance neurography‐surgical correlation of neurologic thoracic outlet syndrome

“…5 Sheth and Campbell reported that the transaxillary approach was superior to the supraclavicular approach in a prospective randomized control trial of 55 patients with painful neurologic TOS. 20 However, a recent Cochrane review concluded that there is insufficient evidence to support any treatment of TOS over another. 21 Our patient demonstrated good short-term improvement following supraclavicular decompression and resection of the cervical rib and pseudoarthrosis.…”

First Rib Resection in Thoracic Outlet Syndrome

“…The major compressive element in patients with TOS-associated pain appeared to be the first rib. 18 Total resection of the first rib with its periosteum should be preferred in all of these cases with accompanying pathologies such as cervical rib, fibrous ligaments, and scalene muscle. The transaxillary approach provides a good exposure for the resection of cervical ribs, the first rib, and excision of fibrous ligaments and scalene muscle with an excellent cosmetic result.…”

Editorial on Totally endoscopic (VATS) first rib resection for thoracic outlet syndrome

“…On the other hand, superiority of the transaxillary approach for better outcomes compared with supraclavicular approach has been documented (19). This varying knowledge confirms that there is still big room to field of surgical treatment of TOS.…”

“…Transaxillary approach has a potential of better cosmetic outcome due to the incision site but pointed for higher risk for brachial plexus injury (1). The surgical outcomes comparing 2 common approaches do not show a significant difference (15,16). Both methods may have operative complications including long thoracic nerve injury during dissection of middle scalenus muscle, brachial plexus injury, phrenic nerve injury (17) and Horner syndrome which has been addressed to occur in supraclavicular approach more (17).…”