Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection
Abstract
Background
Thoracic outlet syndrome (TOS) refers to a group of complex symptoms in the upper extremity caused by compression of the brachial plexus, subclavian artery and vein. Different surgical approaches were described for the management of TOS. There is, however, no “gold standard” procedure for this complicated and multidisciplinary problem.
Objectives
This study evaluated the effectiveness of a microsurgical neurovascular decompression in the treatment of TOS.
Methods
11 patients suffering from TOS (for 1.3 to 15 years after the beginning of the symptoms) were selected for a treatment of the complex symptoms of pain (diffuse or irradiated to the arm and hand), aching or paresthesia in the neck, shoulder, anterior chest, upper extremity and hand. Four of the 11 patients were suffering from signs of vascular compression. Eight patients showed slow progressive neurological deterioration (distribution of the ulnar nerve) with partial muscle atrophy. Patients underwent a microsurgical treatment using a supraclavicular approach followed by brachial plexus neurolysis, scalenectomy and release of the subclavian artery and vein without rib resection. Postoperative results were classified, using Am. J. Surg. (176: 215–218, 1998) scale (4), as good, fair and poor.
Results
Surgical results were studied, with a follow-up of 24 to 48 months. Prior to surgery, all patients had partial or severe limitation in physical activities. Post-operative follow-up showed that 9 (82%) of the 11 patients returned to normal everyday physical activities with a complete or significant relief of the symptoms (good results). In 2 patients (18%) the pain decreased and the use of medication was reduced (fair results). Eight of the 11 patients returned to full or partial employment. There were no cases of poor results in the study.
Conclusion
Microsurgical neurovascular decompression of TOS without a removal of the cervical or first rib using a supraclavicular approach is an effective treatment method for a relief or complete release from symptoms and allows most patients to return to an active normal life.
Keywords
Thoracic outlet syndrome microsurgery prognosisPreview
Unable to display preview. Download preview PDF.
References
- 1.Davies AH, Walton J, Stuart E, Morris PJ (1992) Surgical management of the thoracic outlet compression syndrome. Br 1 Surg 79: 372–377Google Scholar
- 2.Dellon AL (1993) The results of supraclavicular brachial plexus neurolysis (without first rib resection) in management of posttraumatic “thoracic outlet syndrome”. J Reconstr Microsurg 9: 11–17PubMedCrossRefGoogle Scholar
- 3.Durham JR, Yao JST, Pearce WH et al (1995) Arterial injuries in the thoracic outlet syndrome. 1 Vasc Surg 21: 57–70CrossRefGoogle Scholar
- 4.Goff CD, Parent FN, Sato DT, Robinson KD, Gregory RT, Gayle RG et al (1988) A comparison of surgery for neurogenic thoracic outlet syndrome between laborers and nonlaborers. Am J Surg 176: 215–218CrossRefGoogle Scholar
- 5.Green RM, McNamare J, Ouriel K (1991) Long-term follow-up after thoracic outlet decompression: an analysis of factors determining outcome. J Vasc Surg 14: 739–746PubMedCrossRefGoogle Scholar
- 6.Mingoli A, Feldhaus RJ, Farina C, Cavallar N, Sapienza P, Marzo L, Cavallaro A (1995) Long-term outcome after transaxillary approach for thoracic outlet syndrome. Surgery 118: 840–844PubMedCrossRefGoogle Scholar
- 7.Novak CB (2003) Thoracic outlet syndrome. Clin Plastic Surg 30: 175–188CrossRefGoogle Scholar
- 8.Rochkind S, Alon M (2000) Microsurgical management of old injuries of the peripheral nerve and brachial plexus. J Reconstr Microsurg 16: 541–546PubMedCrossRefGoogle Scholar
- 9.Sanders RJ, Haung C (1991) Review of arterial thoracic outlet syndrome with a report of five new intances. Surg Ginecol Obstet 173: 415–425Google Scholar
- 10.Sanders RJ, Haung CE, Pearce WH (1990) Recurrent thoracic outlet syndrome. J Vasc Surg 12: 390–400PubMedCrossRefGoogle Scholar
- 11.Sanders RJ, Pearce WH (1989) The treatment of thoracic outlet syndrome: a compression of different operations. J Vasc Surg 10: 626–634PubMedCrossRefGoogle Scholar
- 12.Sellke FW, Kelly TR (1998) Thoracic outlet syndrome. Am J Surg 154–156Google Scholar
- 13.Sessions RT (1989) Reoperation for thoracic outlet syndrome. J Cardiovasc Surg 30: 434–444Google Scholar
- 14.Urshel HC Jr, Razzuk MA (1986) The failed operation for outlet syndrome: the difficulty of diagnosis and management. Thorac Surg 42: 523–528CrossRefGoogle Scholar