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770 Consecutive Supraclavicular First Rib Resections for Thoracic Outlet Syndrome
770 Consecutive Supraclavicular First Rib Resections for Thoracic Outlet Syndrome G. Ken Hempel, MD, William P. Shutze, MD, John F. Anderson, MD, and Hassan I. Bukhari, MD, Dallas, Texas
During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occurred and only 12 patients (2%) 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. (Ann Vasc Surg 1996;10:456-463.)
Thoracic outlet syndrome (TOS) is often confusing and always controversial. ~ There are m a n y who deny the existence of such an entity or attempt to limit its scope. ~ For those involved in the care of patients with TOS, the inadequacies of the "diagnostic" tests are all too real. Additionally, there is little agreement as to the best treatment for these patients let alone the most appropriate surgical approach. Currently the most frequently used method for decompression of the thoracic outlet is the transaxillary approach 3 and m a n y authors have espoused its use. 4s However, numerous other operations have been described. These include the suFrom the Division of Vascular Surgery, Department of General Surgery, Baylor University Medical Center, Dallas, Tex. Reprint requests: G. Ken Hempel, MD, Surgical Associates of Dallas, 4001 Worth St., Worth-Hill Medical Building, Dallas, TX 75246.
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praclavicular method, 9 claviculectomy,'° posterior paraspinous rib resection," subclavicular rib resection, '2~4 transthoracic rib removal, ~5 and the combined transaxillary and supraclavicular technique. ~6 There have been no randomized trials comparing these techniques in terms of results and perioperative morbidity. Therefore we must rely on a comparison of individual reports on each TOS surgical technique to draw conclusions regarding safety, efficacy, and durability. We report herein the results of a very large experience with supraclavicular rib resection. This operation is evaluated with regard to the preceding parameters so that a suitable reference will exist for supraclavicular first rib resection for TOS.
MATERIAL AND METHODS The records of patients undergoing surgery for TOS between 1964 and 1992 by members of our
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Fig. 1. Arteriogram of a 30-year-old w o m a n with a pulseless and ischemic right hand and clinical evidence of digital emboli. The right subclavian artery is occluded in the thoracic outlet at the origin of the internal mammary artery (arrow) and a unilateral cervical rib is present (curved arrow). This patient was treated with supraclavicutar rib resection, scalenectomy, and a subclavian artery interposition graft.
surgical group were reviewed. Demographic data and all other pertinent information were obtained and analyzed. Some of these patients had been the subject of a previous report. 9 Most patients were seen for evaluation of the nonvascular symptoms of TOS and had undergone a similar preoperative diagnostic evaluation. At the initial interview, the patient's symptoms were detailed and a complete examination of the neck, shoulder, and upper arm was performed. Patients were examined for tenderness over the brachial plexus and first rib. Cervical muscle spasm was noted w h e n present. Each patient underwent numerous positional tests including hyperabduction, costoclavicular, and Adson's tests. Evidence of cervical disk disease, shoulder abnormalities, ulnar entrapment, and carpal tunnel syndrome (non-TOS conditions) was sought during this initial evaluation. X-ray films of the neck, chest, and shoulder were obtained, with additional imaging tests ordered as necessary to confirm or rule out the presence of non-TOS conditions. The presence of cervical ribs was noted. Electromyography and nerve conduction velocity studies were employed to assess the ulnar nerve for a slowing of conduction to less than 70 m/sec across the thoracic outlet. Electromyography and nerve conduction velocity studies were also used to test for radic-
ulopathy, distal median nerve abnormalities, or distal ulnar nerve entrapment. Orthopedic surgeons, neurologists, and neurosurgeons were consulted w h e n required to completely rule out non-TOS conditions. Once the diagnosis of TOS was established with reasonable certainty, patients with neurologic symptoms were begun on a program of physical therapy, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and narcotics as needed. Patients were seen m o n t h l y after the initiation of this therapeutic regimen. If there was no improvement or worsening of the symptoms at this point, then supraclavicular rib resection and scalenectomy was performed as previously described. ~7 Conversely, if there was any improvement after 1 m o n t h of nonsurgical treatment, this regimen was continued until symptoms were relieved or maximal medical improvement was achieved. In those patients who remained suboptimally improved but had reached their maximal improvement level, a supraclavicular rib resection and scalenectomy was recommended to further minimize or relieve symptoms. In patients with arterial and venous complications of TOS, such an extensive evaluation was usually unnecessary. In patients with arterial complications of TOS, such as subclavian artery aneurysm (Fig. 1 ) or thrombosis or upper extrem-
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Fig. 2. Venogram showing an occluded right axillosubcla~ian vein and small venous collaterai vessels (curved arrow). This patient, a 42-year-old woman, developed right arm swelling and pain after an international excursion during which she carried a hea~"~, suitcase for prolonged periods with her right hand.
Fig. 3. Venogram of the patient in Fig, 2 after thrombolytic therapy. The axillosubclavian vein is now patent but is severely stenosed (large arrow) at the level of the first rib (small arrows),
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Fig. 4. Postoperative chest x-ray film of the patient in Figs. 2 and 3 after supraclavicular first rib resection and scalenectomy.
ity thromboembolization, the diagnosis is based on clinical examination followed by arteriography. Ischemic symptoms are treated with intravenous heparin. After the arterial a n a t o m y has been defined, supradavicular rib resection and scalenectomy are performed in combination with the indicated arterial reconstruction. Usually the subclavian artery is replaced with a prosthetic bypass via the supraclavicular incision. Distal embolectomy is performed if needed during this operation. Patients with axillosubclavian vein thrombosis (effort thrombosis or Paget-Schroetter syndrome) presented with acute onset of unilateral arm swelling. Prominent chest wall collateral vessels were usually seen and there was commonly a history of lifting activity. Venographic confirmation was obtained in these patients (Fig. 2). Before 1985 these patients were treated with a 5to 7-day course of heparin and converted to warfarin sodium maintenance therapy. Surgery was performed 2 to 3 weeks later. Since 1985 these patients have been initially treated with local thrombolytic therapy (Fig. 3) and heparin. After maximal clot lysis is achieved, these patients are converted to a regimen of warfarin sodium maintenance therapy; and supradavicular rib resection and scalenectomy is performed within 1 to 2 weeks (Fig. 4). Venous reconstruction is generally not done for the persistent intraluminal or extraluminal defects that
are seen on preoperative venograms. Postoperative venography has not been required in these patients. Patients with neurologic symptoms of TOS and mild chronic h a n d or arm edema with no visible chest wall collateral vessels are not subjected to venography and are treated according to the neurologic TOS protocol. All patients were followed by us in our office following surgery. After surgery, patients were continued on a regimen of NSAIDs, muscle relaxants, and narcotics. They were instructed not to elevate or abduct their arms above the shoulder and to refrain from lifting for 2 weeks. After 2 weeks, they were begun on a program of graduated range of motion exercises for the next 4 to 6 weeks. They then gradually increased their arm use to full capacity over the next 1 to 2 months. Patients who could not follow this postoperative regimen or were unable to return to work at the completion of the postoperative rehabilitation program underwent supervised physical therapy and a "work hardening" program if needed. Postoperative results were graded as excellent, good, fair, or poor according to the following criteria: excellent = complete relief of symptoms and return to employment; good = symptoms were significantly improved and the patient was able to work with minimal restrictions; f a i r - significant residual symptoms; and poor = no postoperative improvement or the patient was unable to return to work.
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1 J
200
J
1
150
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t
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I
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I
I 2029
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Fig. 5. Age distribution for the 770 cases of TOS in this series. There was only one patient over the age of 70 years.
RESULTS During this 28-year period 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for TOS. Three fourths of the patients were w o m e n and the age distribution of these patients is detailed in Fig. 5. The neurologic form of TOS predominated in 705 cases (92%). The vascular form was found in the other 65 cases (8%) of which 47 (6%) had venous complications and 18 (2%) had arterial sequelae of TOS. There was a history of trauma in 216 cases (28%). In those with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). These symptoms were aggravated by lifting in 253 (36%) and during sleep in 82 (12%). Physical therapy was of no benefit at all in 289 cases (40%) and it was of limited value in the remainder. The results of the various clinical tests for TOS are detailed in Table I. It is noteworthy that in 395 patients (62%) these findings were abnormal on the contralateral side. Almost one third (133 patients) of those with bilaterally positive outlet maneuvers had bilateral TOS, whereas the remainder (262 patients) had positive outlet maneuvers in an asymptomatic limb. In only 37 patients (5%) were none of the outlet maneuvers positive. Two patients (0.3%) had a neck mass, five (0.6%) had absent arm pulses, and 20 (2.6%) had venous congestion with edema or cyanosis. Associated cervical muscle spasm was present in 61 patients (8%). One hundred twenty-two anatomic abnormalities were identified. There were 45 cervical ribs, 12 cases with a prominent C7 transverse process, and eight anomalous first ribs. Five patients had
T a b l e I. Provocative thoracic outlet tests Maneuver Hyperabduction Costoclavicular Adson Supraclavicular tenderness
Positive 509 423 301 219
(66%) (55%) (39%) (28%)
healed clavicular fractures. Arteriographic abnormalities were found in the subclavian artery in 12 cases and in the subclavian vein in 40. Nerve conduction velocity studies were done in 714 cases (93%). The ulnar nerve velocity was less t h a n 50 m/sec in 72 cases (10%), 50 to 59 rn/sec in 499 (70%), and 60 to 70 m/sec in 143 (20%). The operative location was fairly evenly distributed in this series. The right side was operated on in 240 cases and the left side in 264 cases. Bilateral operations were performed in 266 cases (133 patients). A concomitant lower cervical and upper thoracic sympathectomy was performed in 60 cases, and subclavian arterial replacement or bypass was required in 10 cases. One patient underwent excision of a subclavian venous web. There were few operative complications. Although the pleural space was entered in 20% of cases, no postoperative pneumothorax was encountered since we routinely test for this at the time of surgery and leave a suction drain in place until any defect is sealed. A single lymphatic leak occurred but resolved spontaneously. No brachial plexus injuries were encountered, although postoperative causalgia did develop in two cases and required subsequent sympathectomy, which was curative. No permanent symptomatic phrenic
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nerve injuries were identified in this series. One patient died unexpectedly, and for no apparent reason, 48 hours postoperatively for a mortality rate of 0.1%. Overall, acceptable results were achieved in 86% of cases. An excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). Outcome was fair in 13% (95 cases), and a poor result was noted in only 1% (13 cases). To achieve these results, postoperative supervised physical therapy with or without "work hardening" was necessary in 231 patients. Only 12 patients had recurrent TOS requiring operative reintervention for a recurrence rate of less than 2%. The group of patients with vascular TOS did much better than the group with the neurologic type of TOS. All of the vascular TOS patients had an excellent result after surgery compared to only 55% of the neurologic TOS patients. All patients with venous occlusion and arm edema had complete or near-complete relief of edema, and postoperative venography was not needed in our experience. On follow-up of patients with arterial complications of TOS, there have been no recurrences of arterial symptoms. Analysis of subsets of patients with poor outcomes and those who had recurrent TOS failed to yield any preoperative characteristics or operative findings that could predict such a result. Patients with worker's compensation claims were more likely to have failure or a recurrence after surgery but this attribute was of no reliable predictive value. The ulnar nerve velocities were analyzed relative to the likelihood of failure or recurrence and although those with slower ulnar nerve conduction were more likely to show improvement after supraclavicular first rib resection and scalenectomy, this finding also was of poor predictive value.
DISCUSSION As is the case for m a n y diseases, the key to a successful outcome is proper diagnosis followed by precise treatment. It has been repeatedly emphasized that the best results in TOS surgery are obtained with proper patient selection. 3"5"13'x8 However, there is no specific clinical, laboratory, or imaging test available that can be used to make a diagnosis of TOS. Therefore we must use our best clinical judgment in advising patients to undergo TOS surgery and then subsequently provide this unfortunate population with an operation that is as free of risk as possible while still
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achieving the necessary goal of complete thoracic outlet decompression. As mentioned previously, there are numerous operative approaches to choose from w h e n contemplating decompression of the thoracic outlet. The transaxillary route is probably the most popular. We are not proposing to compare the supraclavicular approach with the transaxillary route since this would require a direct comparison for validity. On the contrary, we believe that either method is probably satisfactory depending on the level of expertise of the surgeon performing that particular operation. However, the reported experience with transaxillary rib resection has greatly exceeded that of supraclavicular TOS surgery. We believe this deficiency in the literature has contributed to the perception that the supraclavicular technique provides "very poor exposure" and poses a risk of injury to the neurovascular structures, s Until now the majority of the supraclavicular rib resection series have consisted of less than 130 cases, ls23 There are two exceptions: one is our previously reported series of 433 operations 9 and the other is the series of Sanders and Pearce, 24 who reported 278 supraclavicular rib resections. Our updated series provides a substantial number of cases that support the safety, efficacy; and durability of this technique. It has been noted that the morbidity that occurs following rib resection can be quite frequent and significant. 25 Complications such as brachial plexus injury, causatgia, phrenic nerve injury, and vascular injuries have all been reported to occur following thoracic outlet decompression, ~s'24-26 and Dale's report 2s appropriately quelled the enthusiasm for indiscriminate rib resection. With the use of a supraclavicular exposure we have encountered no permanent symptomatic phrenic nerve palsies and no brachial plexus injuries after first rib resection. The two cases of causalgia that we encountered were not disabling, in contrast to w h a t others have reported following transaxillary rib resection, 26 and both patients responded well to cervicothoracic sympathectomy. Other t h a n brachial plexus injury, the vascular complications of TOS surgery are the most serious. The supraclavicular approach provides good visualization of the vascular structures in the thoracic outlet, and we encountered no vascular misadventures w h e n we used this method of rib resection. The composition and results of this series are comparable to w h a t has been reported in other large series. 3'7'16'24 The most common type of TOS
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in these reports is the neurologic form. As others have noted, anatomic abnormalities are not commonly identified in these patients, but they should be searched for and addressed w h e n found. Good to excellent results have ranged from 80% to 99% for TOS surgery, 5''625 and it is well accepted that until there is a better diagnostic selection process the overall results will always be less than we would hope, Several authors have mentioned that recurrences may be encountered m a n y years after s u r g e r y . 2729 B u t this issue is not clear, inasmuch as others have stated that recurrences are usually observed early after TOS surgery. 3"25 We have noted very few relapses after successful supraclavicular rib resection and scalenectomy. We attribute our good results to careful preoperative evaluation and the unhurried trial of physical therapy, which gives us time to assess each patient for integrity, discipline, and character. Even with this selection process, there are bound to be some failures. Because of our low complication rate, we are willing to offer TOS surgery to even those patients who do not seem to be very motivated to recover or who have not been very compliant, as long as they understand that their chances of achieving a curative result are limited. In some instances a suboptimal postoperative result can be predicted prior to surgery. Because of difficulties with patient selection and the nature of m a n y of the patients seeking assistance with TOS-type problems, the operation must be performed with an absolute m i n i m u m of complications. Our technique has been previously described but a few comments are worth restating. This technique allows all members of the operating team a good view of the operative field. The surgeon achieves excellent exposure of the important structures (i.e., the brachial plexus, the subclavian vessels the phrenic nerve, and the long thoracic nerve). No traction is placed on the plexus at any time. Cautery is used on a very limited basis, and the arm is never held in an abducted position stretching the plexus. The supraclavicular approach avoids intercostobrachial nerve injury because this nerve is not encountered in the dissection.
CONCLUSION We have shown with this extensive experience that TOS surgery can be performed by the supraclavicular route with acceptable results and minimal morbidity. Eighty-six percent of the cases showed significant improvement after surgery
and overall 99% showed some improvement. This was accomplished without injury to the brachial plexus, the subclavian vessels, or the phrenic nerve and with a recurrence rate of less than 2%. Achieving these results in the treatment of this challenging illness requires careful preoperative assessment and surgical precision. In light of the numerous problems ascribed to TOS surgery and the limited instruction that is provided in surgical training programs, this surgery should probably be performed only by those whose results meet the standards that have been reported.
REFERENCES 1. Roos DB. The thoracic outlet syndrome is underrated, Arch Neurol 1990;47:327-328. 2. Wilborn AJ. The thoracic outlet syndrome is over diagnosed. Arch Neurol 1990;47:328-329. 3. Lord JW. Critical reappraisal of diagnostic and therapeutic modalities for thoracic outlet syndromes. Surg Gynecol Obstet 1989;168:337-340. 4. Roos DB. Thoracic outlet syndromes: Update 1987. Am d Surg 1987; 154:568-573. 5. Wood VE, Twito R, Verska JM. Thoracic outlet syndrome. The results of first rib resection in 100 patients. Orthop Clin North Am 1988;19:131-146. 6. Catty NJ, Carpenter R, Webster JHH. Continuing experience with transaxillary excision of the first rib for thoracic outlet syndrome. Br d Surg 1992;79:761-762. 7. Selke FW, Kelly TR. Thoracic outlet syndrome. Am J Surg 1988;156:54-57. 8. S/illstr6m d. Gj6res JE. Surgical treatment of the thoracic outlet syndrome. Acta Chit Scand 1983;149:555-560. 9. Hempel GK, Rusher HA Jr, Wheeler CG, et al. Supraclavicular resection of the first rib for the thoracic outlet syndrome. Am J Surg 1987;141:213-215. 10. Lord JW, Wright IS. Total clavicutectomy for neurovascular compression in the thoracic outlet. Surg Gynecol Obstet 1993;176:609-612. 11. Dubuisson AS, Kline DG, Weinshell SS. Posterior subscapular approach to the brachial plexus. Report of 102 patients. J Neurosurg 1993;79:319-330. 12. Nelson RIM, Dava RW. Thoracic outlet compression syndrome. Ann Thorac Surg 1969;8:432-437. 13. Murphy TO, Piper CA, Kanar EA, et al. Subclavicular approach to first rib resection. Am J Surg 1980;139:634-636. 14. Nelson RM, Jenson CB. Anterior approach for excision of the first rib. Ann Thorac Surg 1970;9:30-35. 15. Pr6tre R, Spiliopoulos A, M6gevand R. Transthoracic approach in the thoracic outlet syndrome: An alternate operative route for removal of the first rib. Surgery 1989; 106:856860. 16. Qvarfordt PG, Ehrenfield WK, Stoney RJ. Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome. A combined approach. Am d Surg 1984;148:111-116. 17. Sendzischew H, HempeI GK. Anterior approach for resection of the first rib and total scalenotomy. Surg Gynecol Obstet 1985;160:275-276. 18. Thomas GL Jones TW, Stavney LS, et al. Thoracic outlet syndrome. Am Surg 1978;44:483-495.
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19~ Brown SCW, Charlesworth D. Results of excision of a cervical rib in patients with the thoracic outlet syndrome. Br J Surg 1988;75:431-433. 20. Davies AH, Walton J, Stuart E, et al. Surgical m a n a g e m e n t of the thoracic outlet compression syndrome. Br J Surg 1991; 78:1193-1195. 21. Scher LA, Veith FJ, Haimovici H, et al. Staging of arterial complications of cervical rib: Guidelines for surgical management. Surgery 1984;95:644-649. 22. Thompson JB, Hernandez A, The thoracic outlet syndrome: A second look. Am J Surg 1979;138:251-253. 23. Thomas GI, Jones TW, Stavney LS, et al. The middle scalene muscle and its contribution to the thoracic outlet syndrome, Am J Surg 1983;145:589-592. 24. Sanders RJ, Pearce WIt. The treatment of thoracic outlet syndrome: A comparison of different operations. J Vasc Surg 1989;10:626-634.
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25. Dale WA. Thoracic outlet compression syndrome. Critique in 1982. Arch Surg 1982;117:1437-t445. 26. Horowitz SH. Brachial plexus injuries with causalgia resulting from transaxillary rib resection. Arch Surg 1985;120: 1189-1191. 27. Lep~intolo M, Lfindgren K-A, Leino E, et al. Long-term outcome after resection of the first rib for thoracic outlet syndrome. Br J Surg 1989;76:1255-1256. 28. Green RM, McNamara J, Ouriel K. Long-term follow-up after thoracic outlet decompression: An analysis of factors determining outcome. J Vasc Surg 1991;14:739-746, 29. Lindgren KA, Leino E, Lepantalo M, et al. Recurrent thoracic outlet syndrome after first rib resection. Arch Phys Med Rehabil 1991;72:208-210.
Commentary The authors have nicely demonstrated that a supraclavicular incision for first rib resection is a safe, effective approach for treating neurogenic TOS. We have been using this approach for more than 20 years and prefer it to the transaxfllary approach for the following reasons: it provides better exposure; serious nerve complications are less likely to occur; and the second intercostal brachial cutaneous nerve is avoided. The supraclavicular incision also permits performance of complete anterior and middle scalenectomy and excision of scalene minimus muscles and bands without first rib resection. Our results comparing scalenectomy with vs. without first rib resection are the same. The supraclavicular approach is not appropriate for venous TOS. The underlying cause of subclavian vein thrombosis is usually narrowing of the vein at the costoclavicular ligament. Proper treatment of venous TOS requires resection of the entire anterior end of the rib, and often some of its costal cartilage and portions of the sternum, in order to totally free the vein as far as the innomi-
nate junction. This area cannot be accessed from above the clavicle. Supraclavicular first rib resection permits easy removal of the neck of the rib to the transverse process, but the anterior 1 to 2 cm of the rib cannot be seen and removed from above; it can only be reached via the transaxillary or inffaclavicular route. Since the authors did not obtain postoperative venograms, they could not confirm whether the supraclavicular rib resection had corrected the anatomic venous defect. We suggest that it did not. The authors' good to excellent success rate of 86% is commendable and comparable to the results of transaxillary first rib resection achieved by other surgeons. However, their length of follow-up is not stated but should be. In our experience the success rate in the first 3 months postoperatively is 90%. However, this falls to 70% at 2 years according to life-table analysis. This failure rate is the same for anterior and middle scalenectomy with or without first rib resection, as well as for transaxillary first rib resection. Richard J. Sanders, MD Denver, CO
During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occurred and only 12 patients (2%) 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. (Ann Vasc Surg 1996;10:456-463.)
Thoracic outlet syndrome (TOS) is often confusing and always controversial. ~ There are m a n y who deny the existence of such an entity or attempt to limit its scope. ~ For those involved in the care of patients with TOS, the inadequacies of the "diagnostic" tests are all too real. Additionally, there is little agreement as to the best treatment for these patients let alone the most appropriate surgical approach. Currently the most frequently used method for decompression of the thoracic outlet is the transaxillary approach 3 and m a n y authors have espoused its use. 4s However, numerous other operations have been described. These include the suFrom the Division of Vascular Surgery, Department of General Surgery, Baylor University Medical Center, Dallas, Tex. Reprint requests: G. Ken Hempel, MD, Surgical Associates of Dallas, 4001 Worth St., Worth-Hill Medical Building, Dallas, TX 75246.
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praclavicular method, 9 claviculectomy,'° posterior paraspinous rib resection," subclavicular rib resection, '2~4 transthoracic rib removal, ~5 and the combined transaxillary and supraclavicular technique. ~6 There have been no randomized trials comparing these techniques in terms of results and perioperative morbidity. Therefore we must rely on a comparison of individual reports on each TOS surgical technique to draw conclusions regarding safety, efficacy, and durability. We report herein the results of a very large experience with supraclavicular rib resection. This operation is evaluated with regard to the preceding parameters so that a suitable reference will exist for supraclavicular first rib resection for TOS.
MATERIAL AND METHODS The records of patients undergoing surgery for TOS between 1964 and 1992 by members of our
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Fig. 1. Arteriogram of a 30-year-old w o m a n with a pulseless and ischemic right hand and clinical evidence of digital emboli. The right subclavian artery is occluded in the thoracic outlet at the origin of the internal mammary artery (arrow) and a unilateral cervical rib is present (curved arrow). This patient was treated with supraclavicutar rib resection, scalenectomy, and a subclavian artery interposition graft.
surgical group were reviewed. Demographic data and all other pertinent information were obtained and analyzed. Some of these patients had been the subject of a previous report. 9 Most patients were seen for evaluation of the nonvascular symptoms of TOS and had undergone a similar preoperative diagnostic evaluation. At the initial interview, the patient's symptoms were detailed and a complete examination of the neck, shoulder, and upper arm was performed. Patients were examined for tenderness over the brachial plexus and first rib. Cervical muscle spasm was noted w h e n present. Each patient underwent numerous positional tests including hyperabduction, costoclavicular, and Adson's tests. Evidence of cervical disk disease, shoulder abnormalities, ulnar entrapment, and carpal tunnel syndrome (non-TOS conditions) was sought during this initial evaluation. X-ray films of the neck, chest, and shoulder were obtained, with additional imaging tests ordered as necessary to confirm or rule out the presence of non-TOS conditions. The presence of cervical ribs was noted. Electromyography and nerve conduction velocity studies were employed to assess the ulnar nerve for a slowing of conduction to less than 70 m/sec across the thoracic outlet. Electromyography and nerve conduction velocity studies were also used to test for radic-
ulopathy, distal median nerve abnormalities, or distal ulnar nerve entrapment. Orthopedic surgeons, neurologists, and neurosurgeons were consulted w h e n required to completely rule out non-TOS conditions. Once the diagnosis of TOS was established with reasonable certainty, patients with neurologic symptoms were begun on a program of physical therapy, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and narcotics as needed. Patients were seen m o n t h l y after the initiation of this therapeutic regimen. If there was no improvement or worsening of the symptoms at this point, then supraclavicular rib resection and scalenectomy was performed as previously described. ~7 Conversely, if there was any improvement after 1 m o n t h of nonsurgical treatment, this regimen was continued until symptoms were relieved or maximal medical improvement was achieved. In those patients who remained suboptimally improved but had reached their maximal improvement level, a supraclavicular rib resection and scalenectomy was recommended to further minimize or relieve symptoms. In patients with arterial and venous complications of TOS, such an extensive evaluation was usually unnecessary. In patients with arterial complications of TOS, such as subclavian artery aneurysm (Fig. 1 ) or thrombosis or upper extrem-
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Fig. 2. Venogram showing an occluded right axillosubcla~ian vein and small venous collaterai vessels (curved arrow). This patient, a 42-year-old woman, developed right arm swelling and pain after an international excursion during which she carried a hea~"~, suitcase for prolonged periods with her right hand.
Fig. 3. Venogram of the patient in Fig, 2 after thrombolytic therapy. The axillosubclavian vein is now patent but is severely stenosed (large arrow) at the level of the first rib (small arrows),
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Fig. 4. Postoperative chest x-ray film of the patient in Figs. 2 and 3 after supraclavicular first rib resection and scalenectomy.
ity thromboembolization, the diagnosis is based on clinical examination followed by arteriography. Ischemic symptoms are treated with intravenous heparin. After the arterial a n a t o m y has been defined, supradavicular rib resection and scalenectomy are performed in combination with the indicated arterial reconstruction. Usually the subclavian artery is replaced with a prosthetic bypass via the supraclavicular incision. Distal embolectomy is performed if needed during this operation. Patients with axillosubclavian vein thrombosis (effort thrombosis or Paget-Schroetter syndrome) presented with acute onset of unilateral arm swelling. Prominent chest wall collateral vessels were usually seen and there was commonly a history of lifting activity. Venographic confirmation was obtained in these patients (Fig. 2). Before 1985 these patients were treated with a 5to 7-day course of heparin and converted to warfarin sodium maintenance therapy. Surgery was performed 2 to 3 weeks later. Since 1985 these patients have been initially treated with local thrombolytic therapy (Fig. 3) and heparin. After maximal clot lysis is achieved, these patients are converted to a regimen of warfarin sodium maintenance therapy; and supradavicular rib resection and scalenectomy is performed within 1 to 2 weeks (Fig. 4). Venous reconstruction is generally not done for the persistent intraluminal or extraluminal defects that
are seen on preoperative venograms. Postoperative venography has not been required in these patients. Patients with neurologic symptoms of TOS and mild chronic h a n d or arm edema with no visible chest wall collateral vessels are not subjected to venography and are treated according to the neurologic TOS protocol. All patients were followed by us in our office following surgery. After surgery, patients were continued on a regimen of NSAIDs, muscle relaxants, and narcotics. They were instructed not to elevate or abduct their arms above the shoulder and to refrain from lifting for 2 weeks. After 2 weeks, they were begun on a program of graduated range of motion exercises for the next 4 to 6 weeks. They then gradually increased their arm use to full capacity over the next 1 to 2 months. Patients who could not follow this postoperative regimen or were unable to return to work at the completion of the postoperative rehabilitation program underwent supervised physical therapy and a "work hardening" program if needed. Postoperative results were graded as excellent, good, fair, or poor according to the following criteria: excellent = complete relief of symptoms and return to employment; good = symptoms were significantly improved and the patient was able to work with minimal restrictions; f a i r - significant residual symptoms; and poor = no postoperative improvement or the patient was unable to return to work.
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250 '
1 J
200
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1
150
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t
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I
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I 2029
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Fig. 5. Age distribution for the 770 cases of TOS in this series. There was only one patient over the age of 70 years.
RESULTS During this 28-year period 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for TOS. Three fourths of the patients were w o m e n and the age distribution of these patients is detailed in Fig. 5. The neurologic form of TOS predominated in 705 cases (92%). The vascular form was found in the other 65 cases (8%) of which 47 (6%) had venous complications and 18 (2%) had arterial sequelae of TOS. There was a history of trauma in 216 cases (28%). In those with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). These symptoms were aggravated by lifting in 253 (36%) and during sleep in 82 (12%). Physical therapy was of no benefit at all in 289 cases (40%) and it was of limited value in the remainder. The results of the various clinical tests for TOS are detailed in Table I. It is noteworthy that in 395 patients (62%) these findings were abnormal on the contralateral side. Almost one third (133 patients) of those with bilaterally positive outlet maneuvers had bilateral TOS, whereas the remainder (262 patients) had positive outlet maneuvers in an asymptomatic limb. In only 37 patients (5%) were none of the outlet maneuvers positive. Two patients (0.3%) had a neck mass, five (0.6%) had absent arm pulses, and 20 (2.6%) had venous congestion with edema or cyanosis. Associated cervical muscle spasm was present in 61 patients (8%). One hundred twenty-two anatomic abnormalities were identified. There were 45 cervical ribs, 12 cases with a prominent C7 transverse process, and eight anomalous first ribs. Five patients had
T a b l e I. Provocative thoracic outlet tests Maneuver Hyperabduction Costoclavicular Adson Supraclavicular tenderness
Positive 509 423 301 219
(66%) (55%) (39%) (28%)
healed clavicular fractures. Arteriographic abnormalities were found in the subclavian artery in 12 cases and in the subclavian vein in 40. Nerve conduction velocity studies were done in 714 cases (93%). The ulnar nerve velocity was less t h a n 50 m/sec in 72 cases (10%), 50 to 59 rn/sec in 499 (70%), and 60 to 70 m/sec in 143 (20%). The operative location was fairly evenly distributed in this series. The right side was operated on in 240 cases and the left side in 264 cases. Bilateral operations were performed in 266 cases (133 patients). A concomitant lower cervical and upper thoracic sympathectomy was performed in 60 cases, and subclavian arterial replacement or bypass was required in 10 cases. One patient underwent excision of a subclavian venous web. There were few operative complications. Although the pleural space was entered in 20% of cases, no postoperative pneumothorax was encountered since we routinely test for this at the time of surgery and leave a suction drain in place until any defect is sealed. A single lymphatic leak occurred but resolved spontaneously. No brachial plexus injuries were encountered, although postoperative causalgia did develop in two cases and required subsequent sympathectomy, which was curative. No permanent symptomatic phrenic
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nerve injuries were identified in this series. One patient died unexpectedly, and for no apparent reason, 48 hours postoperatively for a mortality rate of 0.1%. Overall, acceptable results were achieved in 86% of cases. An excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). Outcome was fair in 13% (95 cases), and a poor result was noted in only 1% (13 cases). To achieve these results, postoperative supervised physical therapy with or without "work hardening" was necessary in 231 patients. Only 12 patients had recurrent TOS requiring operative reintervention for a recurrence rate of less than 2%. The group of patients with vascular TOS did much better than the group with the neurologic type of TOS. All of the vascular TOS patients had an excellent result after surgery compared to only 55% of the neurologic TOS patients. All patients with venous occlusion and arm edema had complete or near-complete relief of edema, and postoperative venography was not needed in our experience. On follow-up of patients with arterial complications of TOS, there have been no recurrences of arterial symptoms. Analysis of subsets of patients with poor outcomes and those who had recurrent TOS failed to yield any preoperative characteristics or operative findings that could predict such a result. Patients with worker's compensation claims were more likely to have failure or a recurrence after surgery but this attribute was of no reliable predictive value. The ulnar nerve velocities were analyzed relative to the likelihood of failure or recurrence and although those with slower ulnar nerve conduction were more likely to show improvement after supraclavicular first rib resection and scalenectomy, this finding also was of poor predictive value.
DISCUSSION As is the case for m a n y diseases, the key to a successful outcome is proper diagnosis followed by precise treatment. It has been repeatedly emphasized that the best results in TOS surgery are obtained with proper patient selection. 3"5"13'x8 However, there is no specific clinical, laboratory, or imaging test available that can be used to make a diagnosis of TOS. Therefore we must use our best clinical judgment in advising patients to undergo TOS surgery and then subsequently provide this unfortunate population with an operation that is as free of risk as possible while still
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achieving the necessary goal of complete thoracic outlet decompression. As mentioned previously, there are numerous operative approaches to choose from w h e n contemplating decompression of the thoracic outlet. The transaxillary route is probably the most popular. We are not proposing to compare the supraclavicular approach with the transaxillary route since this would require a direct comparison for validity. On the contrary, we believe that either method is probably satisfactory depending on the level of expertise of the surgeon performing that particular operation. However, the reported experience with transaxillary rib resection has greatly exceeded that of supraclavicular TOS surgery. We believe this deficiency in the literature has contributed to the perception that the supraclavicular technique provides "very poor exposure" and poses a risk of injury to the neurovascular structures, s Until now the majority of the supraclavicular rib resection series have consisted of less than 130 cases, ls23 There are two exceptions: one is our previously reported series of 433 operations 9 and the other is the series of Sanders and Pearce, 24 who reported 278 supraclavicular rib resections. Our updated series provides a substantial number of cases that support the safety, efficacy; and durability of this technique. It has been noted that the morbidity that occurs following rib resection can be quite frequent and significant. 25 Complications such as brachial plexus injury, causatgia, phrenic nerve injury, and vascular injuries have all been reported to occur following thoracic outlet decompression, ~s'24-26 and Dale's report 2s appropriately quelled the enthusiasm for indiscriminate rib resection. With the use of a supraclavicular exposure we have encountered no permanent symptomatic phrenic nerve palsies and no brachial plexus injuries after first rib resection. The two cases of causalgia that we encountered were not disabling, in contrast to w h a t others have reported following transaxillary rib resection, 26 and both patients responded well to cervicothoracic sympathectomy. Other t h a n brachial plexus injury, the vascular complications of TOS surgery are the most serious. The supraclavicular approach provides good visualization of the vascular structures in the thoracic outlet, and we encountered no vascular misadventures w h e n we used this method of rib resection. The composition and results of this series are comparable to w h a t has been reported in other large series. 3'7'16'24 The most common type of TOS
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in these reports is the neurologic form. As others have noted, anatomic abnormalities are not commonly identified in these patients, but they should be searched for and addressed w h e n found. Good to excellent results have ranged from 80% to 99% for TOS surgery, 5''625 and it is well accepted that until there is a better diagnostic selection process the overall results will always be less than we would hope, Several authors have mentioned that recurrences may be encountered m a n y years after s u r g e r y . 2729 B u t this issue is not clear, inasmuch as others have stated that recurrences are usually observed early after TOS surgery. 3"25 We have noted very few relapses after successful supraclavicular rib resection and scalenectomy. We attribute our good results to careful preoperative evaluation and the unhurried trial of physical therapy, which gives us time to assess each patient for integrity, discipline, and character. Even with this selection process, there are bound to be some failures. Because of our low complication rate, we are willing to offer TOS surgery to even those patients who do not seem to be very motivated to recover or who have not been very compliant, as long as they understand that their chances of achieving a curative result are limited. In some instances a suboptimal postoperative result can be predicted prior to surgery. Because of difficulties with patient selection and the nature of m a n y of the patients seeking assistance with TOS-type problems, the operation must be performed with an absolute m i n i m u m of complications. Our technique has been previously described but a few comments are worth restating. This technique allows all members of the operating team a good view of the operative field. The surgeon achieves excellent exposure of the important structures (i.e., the brachial plexus, the subclavian vessels the phrenic nerve, and the long thoracic nerve). No traction is placed on the plexus at any time. Cautery is used on a very limited basis, and the arm is never held in an abducted position stretching the plexus. The supraclavicular approach avoids intercostobrachial nerve injury because this nerve is not encountered in the dissection.
CONCLUSION We have shown with this extensive experience that TOS surgery can be performed by the supraclavicular route with acceptable results and minimal morbidity. Eighty-six percent of the cases showed significant improvement after surgery
and overall 99% showed some improvement. This was accomplished without injury to the brachial plexus, the subclavian vessels, or the phrenic nerve and with a recurrence rate of less than 2%. Achieving these results in the treatment of this challenging illness requires careful preoperative assessment and surgical precision. In light of the numerous problems ascribed to TOS surgery and the limited instruction that is provided in surgical training programs, this surgery should probably be performed only by those whose results meet the standards that have been reported.
REFERENCES 1. Roos DB. The thoracic outlet syndrome is underrated, Arch Neurol 1990;47:327-328. 2. Wilborn AJ. The thoracic outlet syndrome is over diagnosed. Arch Neurol 1990;47:328-329. 3. Lord JW. Critical reappraisal of diagnostic and therapeutic modalities for thoracic outlet syndromes. Surg Gynecol Obstet 1989;168:337-340. 4. Roos DB. Thoracic outlet syndromes: Update 1987. Am d Surg 1987; 154:568-573. 5. Wood VE, Twito R, Verska JM. Thoracic outlet syndrome. The results of first rib resection in 100 patients. Orthop Clin North Am 1988;19:131-146. 6. Catty NJ, Carpenter R, Webster JHH. Continuing experience with transaxillary excision of the first rib for thoracic outlet syndrome. Br d Surg 1992;79:761-762. 7. Selke FW, Kelly TR. Thoracic outlet syndrome. Am J Surg 1988;156:54-57. 8. S/illstr6m d. Gj6res JE. Surgical treatment of the thoracic outlet syndrome. Acta Chit Scand 1983;149:555-560. 9. Hempel GK, Rusher HA Jr, Wheeler CG, et al. Supraclavicular resection of the first rib for the thoracic outlet syndrome. Am J Surg 1987;141:213-215. 10. Lord JW, Wright IS. Total clavicutectomy for neurovascular compression in the thoracic outlet. Surg Gynecol Obstet 1993;176:609-612. 11. Dubuisson AS, Kline DG, Weinshell SS. Posterior subscapular approach to the brachial plexus. Report of 102 patients. J Neurosurg 1993;79:319-330. 12. Nelson RIM, Dava RW. Thoracic outlet compression syndrome. Ann Thorac Surg 1969;8:432-437. 13. Murphy TO, Piper CA, Kanar EA, et al. Subclavicular approach to first rib resection. Am J Surg 1980;139:634-636. 14. Nelson RM, Jenson CB. Anterior approach for excision of the first rib. Ann Thorac Surg 1970;9:30-35. 15. Pr6tre R, Spiliopoulos A, M6gevand R. Transthoracic approach in the thoracic outlet syndrome: An alternate operative route for removal of the first rib. Surgery 1989; 106:856860. 16. Qvarfordt PG, Ehrenfield WK, Stoney RJ. Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome. A combined approach. Am d Surg 1984;148:111-116. 17. Sendzischew H, HempeI GK. Anterior approach for resection of the first rib and total scalenotomy. Surg Gynecol Obstet 1985;160:275-276. 18. Thomas GL Jones TW, Stavney LS, et al. Thoracic outlet syndrome. Am Surg 1978;44:483-495.
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19~ Brown SCW, Charlesworth D. Results of excision of a cervical rib in patients with the thoracic outlet syndrome. Br J Surg 1988;75:431-433. 20. Davies AH, Walton J, Stuart E, et al. Surgical m a n a g e m e n t of the thoracic outlet compression syndrome. Br J Surg 1991; 78:1193-1195. 21. Scher LA, Veith FJ, Haimovici H, et al. Staging of arterial complications of cervical rib: Guidelines for surgical management. Surgery 1984;95:644-649. 22. Thompson JB, Hernandez A, The thoracic outlet syndrome: A second look. Am J Surg 1979;138:251-253. 23. Thomas GI, Jones TW, Stavney LS, et al. The middle scalene muscle and its contribution to the thoracic outlet syndrome, Am J Surg 1983;145:589-592. 24. Sanders RJ, Pearce WIt. The treatment of thoracic outlet syndrome: A comparison of different operations. J Vasc Surg 1989;10:626-634.
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25. Dale WA. Thoracic outlet compression syndrome. Critique in 1982. Arch Surg 1982;117:1437-t445. 26. Horowitz SH. Brachial plexus injuries with causalgia resulting from transaxillary rib resection. Arch Surg 1985;120: 1189-1191. 27. Lep~intolo M, Lfindgren K-A, Leino E, et al. Long-term outcome after resection of the first rib for thoracic outlet syndrome. Br J Surg 1989;76:1255-1256. 28. Green RM, McNamara J, Ouriel K. Long-term follow-up after thoracic outlet decompression: An analysis of factors determining outcome. J Vasc Surg 1991;14:739-746, 29. Lindgren KA, Leino E, Lepantalo M, et al. Recurrent thoracic outlet syndrome after first rib resection. Arch Phys Med Rehabil 1991;72:208-210.
Commentary The authors have nicely demonstrated that a supraclavicular incision for first rib resection is a safe, effective approach for treating neurogenic TOS. We have been using this approach for more than 20 years and prefer it to the transaxfllary approach for the following reasons: it provides better exposure; serious nerve complications are less likely to occur; and the second intercostal brachial cutaneous nerve is avoided. The supraclavicular incision also permits performance of complete anterior and middle scalenectomy and excision of scalene minimus muscles and bands without first rib resection. Our results comparing scalenectomy with vs. without first rib resection are the same. The supraclavicular approach is not appropriate for venous TOS. The underlying cause of subclavian vein thrombosis is usually narrowing of the vein at the costoclavicular ligament. Proper treatment of venous TOS requires resection of the entire anterior end of the rib, and often some of its costal cartilage and portions of the sternum, in order to totally free the vein as far as the innomi-
nate junction. This area cannot be accessed from above the clavicle. Supraclavicular first rib resection permits easy removal of the neck of the rib to the transverse process, but the anterior 1 to 2 cm of the rib cannot be seen and removed from above; it can only be reached via the transaxillary or inffaclavicular route. Since the authors did not obtain postoperative venograms, they could not confirm whether the supraclavicular rib resection had corrected the anatomic venous defect. We suggest that it did not. The authors' good to excellent success rate of 86% is commendable and comparable to the results of transaxillary first rib resection achieved by other surgeons. However, their length of follow-up is not stated but should be. In our experience the success rate in the first 3 months postoperatively is 90%. However, this falls to 70% at 2 years according to life-table analysis. This failure rate is the same for anterior and middle scalenectomy with or without first rib resection, as well as for transaxillary first rib resection. Richard J. Sanders, MD Denver, CO