Surgical Treatment

Abstract

In the second half of the nineteenth century, the combined symptoms of numbness, pain, or complete paralysis of the arm were noted. This combination was known in the German literature as “Schlafdrucklähmung” (sleep pressure paralysis) of the arm and was also known as angiospastic neuralgia [1, 2]. In 1903, Bramwell [3] clearly expressed his opinion that compression of the brachial plexus was the cause of this problem occurring between the anterior, the middle scalene muscles, and the first rib [4–7]. This space in the thoracic outlet was clearly described and named by Puussep (or Poussep) as “trigonum costo-interscalenicum” which he identified as definitely the site of the compression of the brachial plexus. He also suggested that all symptoms could be exacerbated if the muscles were hypertrophic [2]. We have to keep in mind that the X-rays were not available until 1895; and all prior years these assumptions were based on cadaveric dissections and the clinical impression that brachial plexus compression was the cause of these symptoms. Murphy [8] in England was the first surgeon who removed a normal first rib to treat this syndrome. The patient experienced full relief of the compressive symptoms. Some [9, 10] believed that the compression was occurring between the first rib and the clavicle, causing the numbness and paralysis of the arm (narkoselähmungen). Following the publication of Bramwell’s description many investigators expressed agreement with this concept [11–15]. All concurring on the need to resect the first rib to relieve compression. New thinking [14, 16] promoted the concept that sinking of the shoulder girdle caused stretching of the scalene muscles which would narrow the triangle producing compressing of the brachial plexus. In 1913 [17] it was proposed that the compression occurred at the narrow slit between the anterior and the middle scalene muscles through which the plexus passes. Many surgeons routinely resected the first rib to relieve the compression on the strength of these conclusions. Brickner [18, 19], for example, reported that he had resected the first rib in five patients with typical symptoms; optimal results were obtained in four. The operative technique used by these surgeons invariably involved a supraclavicular approach to give access to the anterior and medial scalene muscles and also to the brachial plexus. Although the most anterior portion of the rib could not be removed, this was not a relevant consideration because the compression of the brachial plexus was in the posterior portion of the thoracic outlet (Fig. 4.1).