By Barkhordarian, Siamak
Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement. (J Hand Surg 2007;32A:565-570. Copyright 2007 by the American Society for Surgery of the Hand.)
The first reported excision of a cervical rib was performed by Coote at St. Bartholomew’s Hospital, London, in 1861. With the description of a simpler technique of first rib resection in 1966 using an axillary approach, surgical relief of this common syndrome became technically easier and more acceptable to both patient and physician.1
Thoracic outlet syndrome (TOS) is a well-described entity affecting younger individuals. It frequently involves the brachial plexus and less frequently the subclavian vein or artery. Most patients who present with TOS have well-developed muscles in their upper chest and upper extremities. These individuals are more susceptible to thoracic outlet compressions by the hypertrophie subclavius tendon or scalene muscle. Repetitious injury to these nerves or vessels can result in neuropraxia or symptomatic vascular compromise of the upper extremity.
In this article, different etiologies of TOS are described, and essential surgical maneuvers are further discussed.
Pathophysiology of TOS
Thoracic outlet syndrome results from impending thoracic outlet pressure on the neurovascular bundle exiting the thoracic cavity and entering the upper extremity. The pressure is created by several factors. These include the first rib and accessory or cervical ribs. Associated surrounding hypertrophic muscles, namely the scalene and the subclavius with their corresponding tendons, will also contribute to this local pressure syndrome. Detailed understanding of the local anatomy is critical in both diagnosing the etiology of TOS and offering an effective surgical intervention. The first thoracic rib forms the floor of the compression compartment, trapping or scissoring the brachial plexus and subclavian vessels between the first rib and other local structures. These surrounding structures include the clavicle, a cervical rib, an anomalous cervical band from an elongated C7 transverse process, the subclavius muscle, and bony callous or exostosis.
By removing the first rib, the floor of the compression compartment or the lower blade of the scissor is removed, thereby releasing the entrapment of the brachial plexus and subclavian vessels allowing them to drop away from the clavicle.1
The individuals that are commonly affected are athletes, climbers, and those who use their upper extremities repeatedly (eg, pigeon shooters, pilots, builders, and painters).
Neurogenic TOS compromises the majority of these symptomatic individuals presenting with brachial plexus and Tl nerve palsy. Neck trauma is also the most common cause of neurogenic TOS in patients with abnormal ribs. Cervical and anomalous first ribs are the predisposing factors rather than the cause.2 During evaluation of these patients, one must rule out a prior traumatic insult to the surrounding neck, shoulder, and arm areas.
Unilateral arm swelling without thrombosis, when not caused by lymphatic obstruction, may be due to subclavian vein compression at the costoclavicular ligament because of compression either by that ligament or the subclavius tendon most often because of congenital close proximity of the vein to the ligament. Arm symptoms of neurogenic TOS, pain, and paresthesia often accompany venous TOS, whereas neck pain and headache, other common symptoms of neurogenic TOS, are infrequent.3
Paget-Schroetter syndrome is a condition where the patients present with upper extremity venous congestion secondary to subclavian venous thrombosis. The most common cause for this outflow venous obstruction is an underlying obstructing thoracic outlet. They often present with asymmetrical upper extremity edema with congestive bluish skin discoloration. Venous thrombolysis and first rib resection are mandatory steps in relief of this venous outlet obstruction.
Upper extremity arterial compromise due to this compacted thoracic outlet may also occur with a resulting limb ischemia. Patients often present with a painful upper extremity after exercise albeit limb claudication symptoms. Discolored, pale, underperfused arms with absent or decreased arterial pulse is a common finding in these individuals with an arterial form of TOS.
Figure 1. This right arm angiograph reveals a widely patent right subclavian artery with right arm adducted and in the resting position.
Figure 2. This angiogram of a patient with TOS with right arm abducted and raised above the head depicts complete right subclavian arterial occlusion.
A detailed history and examination is usually sufficient to suspect and even diagnose TOS. Arm claudication, exercise-induced paresthesia, color discoloration after exercise or after erect postures are highly suspicious of TOS. Absent radial pulse with contracterai head rotations (Adson maneuver) is helpful but not always present in patients with TOS. Some normal individuals also tend to have a positive Adson test. Additional investigations are helpful but not mandatory in the diagnostic process. Postural venography, arteriography (Figs. 1, 2) or even magnetic resonance angiography (Figs. 3, 4) may also be helpful.
Figure 3. Magnetic resonance angiography of a patient in the resting position with adducted arms.
Figure 4. Magnetic resonance angiography of a patient with TOS with both arms above the head.
Signs and symptoms helpful in making the diagnosis of neurologic TOS are supraclavicular tenderness on palpation and exacerbation of symptoms with the arms in the abducted external rotated position.4
Thoracic outlet syndrome may also follow trauma and may be seen as a result of postural abnormalities of the shoulder girdle. Cervical ribs and other anatomic variations are not prerequisites for the diagnosis, although they may be more common in patients with TOS. There is no reliable laboratory diagnostic test to confirm or exclude the diagnosis. Proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases.5
Diagnosing and treating TOS can be challenging and frustrating. It must be emphasized that the diagnosis of TOS is a clinical one based on a detailed history and physical examination. This takes time and effort and is often confounded by the patient’s research on the Internet and emotional problems usually resulting from the symptoms and lack of appropriate treatment. Some have had symptoms so long that there may be permanent neurologic damage. Each patient presents his or her own diagnostic challenge. Solving the problem and providing effective therapy can be rewarding for doctor and patient.6,7 There are some congenital anomalies that are superimposed on some form of neck or arm trauma. There are some promising technologies that offer hope of early anatomic diagnosis. Sophisticated imaging of the brachial plexus as advocated by Collins offers hope. High-resolution multidetector computed tomography scanning seems even more promising.6,7
Physical therapy with special dedicated postural exercises should be routinely used as the initial treatment for TOS. However, patients with severe symptomatic TOS will often not benefit from physical therapy.1
The decompression of the neurovascular bundle in vascular TOS should include the first rib resection in each case.8 This is an essential step in therapy of all 3 types of TOS (neurogenic, venous, and arterial).
Cases of the venous form of TOS who present with Paget- Schroetter syndrome (PSS) are best treated with venogram, subclavian vein thrombolysis, as well as first rib resection on the same hospital admission. These patients should be kept on anticoagulation therapy after their lytic interventions while waiting for their first rib resection. Immediate thrombolytic therapy followed by early surgical decompression has been shown to be safe and effective while significantly decreasing the duration of disability suffered by patients with this form of TOS. Therefore, a unified approach to acute axillosubclavian venous thrombosis in a single hospital admission should be considered an alternative standard of care for treatment of PSS.9 Untreated symptomatic patients with PSS can sustain chronic disability from venous obstruction, with arm swelling, pain, and early exercise fatigue.10
Diagnosis of venous TOS is made by dynamic venography. First rib resection, which includes the anterior portion of rib and cartilage plus division of the costoclavicular ligament and subclavius tendon, proves to be an effective treatment.3 Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous TOS. Combination trea\tment with surgical thoracic outlet decompression and intraoperative percutaneous transluminal angioplasty is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative percutaneous transluminal angioplasty may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for future venous stent placement or open venous repair.11 Intravenous stents are however contraindicated in patients with thrombosis of the axillary-subclavian vein (PSS). In one such study, all 22 patients with intravenous stents reoccluded their axillary-subclavian veins from 1 day to 6 weeks after insertion.12
First rib resection can be performed via 2 common surgical routes: a supraclavicular approach and a transaxillary approach. Each has its benefits with minimal limitations, and both remain very effective in TOS management and relief of symptoms.
First Rib Resection: Supraclavicular Approach
Results after supraclavicular decompression are satisfactory, and the complication rates are low.13 The Supraclavicular approach has been a successful route for thoracic outlet decompression. It permits some more options than the transaxillary route. Anterior and middle scalenectomy, together with brachial plexus neurolysis, can be performed with excellent exposure. The same incision can be used to perform cervical or first rib resection. In one large series, the 5-year success rate using life-table methods was approximately 70%.14
In another series, 770 Supraclavicular first rib re sections and scalenectomies were performed for TOS. After Supraclavicular scalenectomy and rib resection, an excellent response was achieved in 455 (59%) cases and a good result was achieved in another 206 (27%) cases. A fair outcome was present in 95 (13%) cases, and a poor result was found in only 13 (1%) cases. There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in 2 cases. No vascular or permanent phrenic nerve injuries occurred, and only 12 (2%) patients required operative intervention for recurrent TOS. First rib resection and scalenectomy can be performed by the supraclavicular route with an acceptable outcome, minimal morbidity, and long-lasting results.15 Decompression for thoracic outlet compression syndrome through a Supraclavicular approach encompassing first rib resection leads to good long-term results with few complications.16
First Rib Resection: Transaxillary Approach
The transaxillary approach to first rib resection is well tolerated, and serious complications should be unusual when the procedure is performed by an experienced surgeon. Postoperative attention to shoulder girdle mechanics is important in the prevention of recurrence of symptoms.5
The relative length of the posterior rib stump is correlated with the outcome after transaxillary first rib resection in patients with TOS. First rib resection in patients with proven vascular compression should be as close as possible to the articulation with the transverse process without injuring the brachial plexus.17 Partial removal of the first rib is usually performed via the Supraclavicular approach and is often inadequate because a long rib stump may entrap the plexus or vessels by periosteal scar tissue leading to severe brachial neuritis, ischemia, or venous congestion. The posterior stump of the first rib should be left so short that it lies posterior to the Tl cervical root clearly seen at the operation and should not extend more than 1 cm anterolaterally when seen by chest x-ray.1 This can be seen in Figure 5 where the right first rib was removed via a right transaxillary approach for PSS.
Figure 5. Postoperative chest x-ray of a TOS patient. The arrow points to the absent right first rib, which was removed via a right axillary approach.
In most series, transaxillary first rib resection provides better relief of symptoms than supraclavicular neuroplasty of the brachial plexus. 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. All patients should be encouraged toward several months of physical exercise starting from the early postoperative period.19
Newer techniques are also available for nerve release. Endoscopie computerized instrumentation in transaxillary first rib resection has been performed, and this decreases the risk of neurovascular injury, promotes complete decompression, and can provide a safe alternative to standard first rib resections.20
Transaxillary rib resection is a safe and effective procedure, allowing almost two thirds of patients a return to normal activity.21
Some prefer a combination of approaches to treat TOS. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. Some prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.22
One study followed 300 operations for TOS for at least 1 year. The first group was treated with either supraclavicular or transaxillary approach and with scalenotomy combined with the resection of the first rib or without rib resection. The second group was operated via the supraclavicular approach without exception and always with the resection of the first rib. The results of the second group were significantly better.23 Others recommend that starting with the first rib resection and following immediately with a transcervical anterior and middle scalenectomy accomplishes total decompression of the thoracic outlet area with much better improvement of symptoms and much lower recurrence rate.24
Surgical intervention is indicated for vascular and true neurogenic TOS and for some patients with the common or nonspecific type of TOS in whom nonoperative therapies fail. With careful patient selection, operative intervention usually yields satisfactory results.25
In one large series of 155 patients after TOS surgery, predictive factors of negative outcomes were acute ischemia (p
Postoperative complications are rare but include hemothorax and/ or pneumothorax, infraclavicular anesthesia, causalgia, lymphocele, wound infection or incisional separation, rib regeneration, and recurrence. Rarely, bleeding and venous injury is encountered during the rib resection. Damage to intercostobrachial sensory nerve should be avoidable. This nerve usually runs across the axillary cavity. The nerve injury occurs with axillary exposure and instrumentation while removing the first rib. This can result in incisional and anterior chest paresthesia.
In another study of 409 adults, 78% (319) of the patients with neurologic TOS in this group improved postoperatively: 21% (86) had complete relief, 32% (131) had good relief, and 25% (102) had fair relief. Twenty-two percent showed no improvement. The surgical procedures are safe. Patients with TOS refractory to conservative management can benefit from TOS.4
Thoracic outlet syndrome should be suspected in individuals with upper extremity vascular compromise and paresthesia. First rib resection remains an important and essential step in management of the TOS. This procedure can be performed with minimal morbidity and with excellent outcomes. Both the supraclavicular route and the transaxillary route of the first rib resection remain effective surgical techniques and should be considered in patients with refractory symptoms.
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Siamak Barkhordarian, MD
From Brown Medical School, Providence, RI.
Received for publication November 28, 2006; accepted January 22, 2007.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Corresponding author: Siamak Barkhordarian, MD, 10445 Wilshire Blvd. Los Angeles, CA 90024; e-mail: [email protected]
Copyright 2007 by the American Society for Surgery of the Hand
Copyright Churchill Livingstone Inc., Medical Publishers Apr 2007
(c) 2007 Journal of Hand Surgery, The. Provided by ProQuest Information and Learning. All rights Reserved.