Reoperations for Recurrence of Neurogenic Symptoms

Abstract

Urschel [1, 2] and collaborators have emphasized the difficulties inherent in treating patients with recurrent symptoms after an initial operation for neurogenic thoracic outlet syndrome. Usually, recurrence is the result of incomplete removal of the first rib during the first operation, a common finding seen on plain X-ray studies. Occasionally it is just a short stump; other times it is a longer segment in which the periosteum of the excised rib has regenerated causing the problem. Incomplete removal of the first rib is a common occurrence in cases operated using the transaxillary approach because of the difficulties encountered in exposing the posterior distal end of the rib. This in turn leads the surgeon to divide the rib at some distance from its origin with the transverse process, resulting in recurrent symptoms. Conversely, if the rib is completely excised during the first operation, recurrent symptoms are unlikely. Accordingly, it is very important during the first operation to achieve complete removal of the rib. The two approaches that have shown to be most effective in this regard are the supraclavicular approach [3, 4] and the combined approach as described by us [5] (i.e., using the transaxillary approach for the anterior portion of the rib and then a limited posterior incision along the trapezius ridge to reach the posterior end of the rib). Removal of residual posterior end of the rib has been also approached using what is called the posterior route, as introduced by Clagget [6] and used by others [1]. As previously noted, this is a very formidable operation requiring division of several muscles. It may also still pose difficulties of visualizing the rib for which Ferguson [7] proposed removal also of the second rib in order to reach the first adequately. This is very tedious and difficult because of the fibrosis that invariably encases the nerve trunks and the subclavian artery. For these reasons, my personal recommendation for removal of the posterior residual stump of the first rib is to use a limited incision parallel to the trapezius ridge which allows the surgeon to approach the top of the residual rib and remove it without risk of injuries to either artery or brachial plexus.