[The choice of approach in the surgical therapy of the superior thoracic outlet syndrome]

The symptoms of thoracic outlet syndrome (TOS) may be improved or cured either by physiotherapy or by a surgical operation. The choice of patients to be submitted to surgery must be performed on the basis of clinical picture and of non invasive and invasive assessment. Moreover the surgeon must choose the best procedure to relieve symptoms. The Authors on the basis of their experience and of a literature review refer to the various surgical approaches used in the treatment of TOS.

Continuing experience with transaxillary excision of the first rib for thoracic outlet syndrome

The results of transaxillary excision of the first rib for thoracic outlet syndrome are reported. During a 3-year period, 40 transaxillary rib resections were performed on 32 patients. The symptoms in 33 limbs were completely relieved and in a further four symptoms were improved. These results confirm that transaxillary excision of the first rib is the operation of choice in the management of thoracic outlet syndrome.

[The thoracic outlet: true syndromes, disputed syndrome (TOS, thoracic outlet syndrome). Current status 1991]

There are 5 syndromes involving the thoracic outlet. The first four, although not well known, especially the first two, are authentic; they are: 1) arterial, due to a well formed cervical rib or to an incompletely formed first rib; 2) neurological, related to the fibrous band associated with a rudimentary cervical rib or a giant transverse process of C7; 3) venous, namely "effort thrombosis"; 4) late post-traumatic, secondary to a fracture of the clavicle. The study of these four syndromes prepares the reader to that of the controversial fifth syndrome, which is entirely subjective, made only of symptoms. The fifth syndrome, by very far the most frequent in the literature, called "scalenus anticus syndrome" in the past, now called "thoracic outlet syndrome" or "TOS" by North-American authors, has two varieties, one where hypotonic shoulder muscles, mostly in women, respond well to specific and simple exercises, and one where there is an accident in the background, a whiplash type of injury in most cases. Despite the fact that TOS is made only of symptoms, "diagnosing" it has led to scores of operations, scalenotomy in the past, now mostly resection of the first rib, sometimes scalenectomy. Huge surgical statistics, that deal mostly with resection of the first rib, have not proven the authenticity of this second variety of the 5th syndrome. Surgeons report only early surgical results, and the results claimed are invariably impressive. Never is there a statistic about return to work after surgery. First rib resection can be dangerous and it can be complicated by tardy permanent brachial plexopathy. One very recent European study proves the discrepancy between the early appreciation of the results by the surgeon and the late appreciation by independent observers.

Surgical management of the thoracic outlet compression syndrome

There is some disagreement about whether the first rib should be excised in the presence of a cervical rib for the relief of the thoracic outlet compression syndrome (TOCS). Over a 14-year period (1975-1988) 58 patients have undergone surgery for TOCS. Forty-four patients (76 per cent) had vascular symptoms, 28 (48 per cent) with a neurological component; 11 (19 per cent) had only neurological symptoms. Thirty-six patients (62 per cent) had the first rib excised; 19 (33 per cent) had a cervical rib excised; two (3 per cent) had a division of fibrous bands; and one patient had a large transverse process resected. Follow-up details were available on 53 patients (91 per cent). Overall 38 (72 per cent) were cured of their symptoms, 11 (21 per cent) had a significant improvement, and four (8 per cent) showed no improvement. There was no significant difference between the results following excision of a cervical rib or of a first rib in terms of relief of symptoms. In patients with TOCS who have a cervical rib, excision of the cervical rib alone without excision of the first rib would appear to be an appropriate treatment.

Thoracic outlet syndrome. Neurosurgical perspective

Neurosurgeons have for the most part abdicated a role in thoracic outlet surgery and have left the diagnosis and treatment of these patients to thoracic, vascular, and general surgeons. We view this as unfortunate. Neurosurgeons are well-positioned to diagnose these conditions. The major source of confusion with regard to diagnosis is cervical spine disease or peripheral nerve entrapment diseases with which neurosurgeons are quite familiar. Orthopedic consultations with regard to shoulder pathology are encouraged. The supraclavicular approach to treatment is one with which most neurosurgeons will be comfortable. However, the transaxillary approach is also one which neurosurgeons should be able to master readily. Working with long instruments in deep holes is a familiar surgical environment. It should be stressed, however, that part of the reason for the controversy concerning TOS stems from the fact that the morbidity rate from the transaxillary approach is high in some centers. We believe this results from inadequate technique. Neurosurgeons with training that emphasizes a high regard for neural tissue should be able to master both approaches. Thoracic outlet syndrome is a disease that most neurosurgeons will see on a regular basis. Thus, it needs to be recognized, and patients need to be analyzed from a neurologic perspective. The differential diagnosis should be considered thoughtfully. Operative intervention by experienced surgeons in properly selected patients will yield satisfying results.

Thoracic outlet syndrome. Thoracic surgery perspective

We have attempted throughout this review to identify the issues surrounding thoracic outlet syndrome as well as to highlight their origins. It should be clear that many aspects of TOS remain controversial from the definition of the entity through pathogenesis, diagnosis, and treatment. The conflicts surrounding TOS are underlined most poignantly in the many letters to the editor of the New England Journal of Medicine in response to Urschel's 1972 publication. It is incumbent upon those of us who treat patients with TOS to dispel the ignorance surrounding this syndrome with astute, accurate, and reproducible observations. We must clearly define TOS as a clinical entity such that we may analyze the characteristics of the patients we treat. We must continue to search for innovative and specific diagnostic criteria. We must quantitatively and reproducibly measure subjective end points of pain severity and quality of life. The use of these methods will provide yardsticks for therapeutic success and act as determinants for the natural history of TOS. The objectives of treatment will remain the alleviation of symptoms and the restoration of function. We have applied these principles to the formulation of a protocol in which we record, in a prospective manner, both routine and innovative clinical parameters. With quantification of subjective end points, we may be able to correlate clinical presentation with outcome. We also may be able to define with some accuracy this entity we call thoracic outlet syndrome.

[Complete cervical rib. Possible neurovascular implications of the upper limb]

The thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus or subclavian artery or vein in the region of the neck and shoulder girdle. The neurovascular bundle may be compressed at multiple sites: costoclavicular space, interscalene triangle, insertion of the pectoralis minor into the coracoid process. More than 90% of the patients present with neurologic symptoms: pain, paraesthesias or arm and hand weakness and 10% also have vascular problems. The diagnosis of TOS is always difficult and depends on careful clinical study of patients. For the neurological type of TOS, electromyograms, arteriograms and venograms are not helpful. The value of Doppler study and of arteriography is demonstrated in the present case of a woman with a five month history of pain and paraesthesias of the arm and hand, who shoved sudden occlusion of left humeral artery. Roentgenograms showed the presence of a well developed left cervical rib. Doppler study and arteriography showed the compression of subclavian artery with the arm abduction manoeuver. After first rib resection and humeral artery thrombectomy there was a complete return of humeral artery flow and of all neurologic functions. Thus the role of first cervical rib or other bone and muscular structures must be emphasyzed both in the brachial and in the subclavian artery or vein compression. Embolization of the axillary or humeral artery should be corrected as soon as possible when the cervical rib is corrected.

Results of excision of a cervical rib in patients with the thoracic outlet syndrome

Excision of a cervical rib in patients with the thoracic outlet syndrome has been the subject of debate. One surgeon's experience of 23 cervical rib excisions is presented. Ten operations produced a complete cure, eleven improvement, and two no change in the patient's condition. Of 15 cases with neurological symptoms alone, 9 were cured, 5 improved and 1 was not helped; in contrast, of 8 patients with vascular symptoms, 1 was cured, 6 were improved and 1 was not helped. We conclude that cervical rib resection is the correct treatment for patients whose symptoms are predominantly neurological. Rib resection alone may not be sufficient in patients with vascular symptoms. The management of a cervical rib with vascular involvement is discussed.

Lower trunk brachial plexus compression neuropathy due to cervical rib in young athletes

Compression by a cervical rib may result in neurologic and/or vascular symptoms. Two patients are reported with thoracic outlet syndrome (TOS) secondary to cervical rib. Both patients had vague shoulder pain as well as neurologic manifestations due to compression neuropathy of the lower trunk of the brachial plexus. One patient was suspected initially to have carpal tunnel syndrome.

[Thoracic outlet compression syndrome]

In patients suffering from chronic, therapy-resistant shoulder and arm pains, the thoracic outlet compression syndrome (TOS) should be included in the differential diagnosis. It is very important to look out for neurogenic disorders as well as early signs of vascular compression in order to prevent ischaemic injuries. Although the initial complaints appear slight and can in some cases be treated successfully by conservative methods, neurogenic disorders due to TOS as well as arterial and venous manifestations of the syndrome should be treated by resection of the first rib. Only in this way can irreversible neurogenic lesions and arterial or venous complications be prevented.

Anatomical bases of transaxillary resection of the first rib

Anatomical study of the costoclavicular space, with approach via inferolateral axillary route, allowing resection of the first rib. With the patient in the semisupine position, lifting the arm to the zenith allows the costoclavicular space to be opened widely and separation of the plane of the first rib from the neurovascular structures of the lateral wall of the axillary pyramid. In the first part of our work, we study successively the bony frame and its anatomical variations, the muscular frame and its anomalies, the cervical pleura and its associated fibromembranous complex. The second part is a succinct summary of the different stages of transaxillary resection of the first rib, with mention of the operative risks and landmarks in this approach.

Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome. A combined approach

Transaxillary resection of the first rib alone was performed 97 times to relieve symptoms of irritation of the brachial plexus. Persistent or recurrent symptoms occurred in a fifth of the patients (7 and 13 patients, respectively), and necessitated reoperation using the supraclavicular approach. In all patients, at least one anomaly or acquired deformity was found that could not have been identified or safely removed by the original transaxillary approach alone. Subsequently, 94 combined operations, including supraclavicular radical scalenectomy with neurolysis of the brachial plexus and transaxillary resection of the first rib, were performed for irritation of the brachial plexus. The improved results using the combined procedure has led us to recommend it for the majority of symptomatic patients with irritation of the brachial plexus. The combined approach allows precise assessment of the thoracic outlet anatomy, facilitates first and cervical rib resection, and permits removal of any additional congenital or acquired lesions. It is associated with a low failure rate and results in few postoperative complications. However, the transaxillary approach alone may be suited for the patient with localized lower plexus symptomatology, keeping in mind the risk of recurrent symptoms associated with this technique.

Staging of arterial complications of cervical rib: guidelines for surgical management

Subclavian artery compression by a cervical rib is an uncommon but potentially disabling condition. A series of 12 patients with 15 arterial lesions is reviewed and a staging system proposed to provide guidelines for managing patients with this condition. Stage I lesions have only arterial stenosis and minor poststenotic dilatation and are managed by thoracic outlet decompression, usually consisting of cervical rib resection. Stage II lesions have intrinsic arterial damage usually with subclavian aneurysm formation and require rib resection, aneurysmectomy, and arterial reconstruction. Stage III lesions present with distal thromboembolic complications and require thrombectomy or embolectomy in addition to thoracic outlet decompression and arterial reconstruction. The anatomic and pathophysiologic bases of the syndrome are reviewed and clinical and angiographic examples of each stage are presented.

[Thoracic outlet syndrome. Apropos of 112 cases: toward a more refined tactical approach]

A total of 112 operations were performed in 87 patients with a cervicobrachial syndrome, 25 with bilateral lesions, over a period of 8 years. Surgery was reserved for severe or complicated cases. Presenting signs were complex and intricated in 53 p. cent of cases, with neurological lesions predominating. Absence of radial pulse after 90 degrees abduction of the arm, present in 87 p. cent of patients, is not a specific diagnostic test as positive results are obtained in over one-third of a normal population. Electromyography confirmed clinical lesions of the brachial plexus in only one out of 8 cases. A more precise and more sensitive procedure for electromyographic exploration of the plexus was therefore established. Dynamic arteriography of the upper limbs was not conducted routinely (70 p. cent of cases), but was reserved for arterial, neuro-arterial, and arterial and venous forms. The axillary approach was used exclusively (94 times), between 1974 and 1980. However, the frequency of postoperative complications (10 p. cent), and the high level of poor or incomplete results (19.5 p. cent) led to the reestablishment of the supraclavicular route of approach. The latter is used preferentially in neurological forms (57 p. cent of cases in this series) in cases requiring correction of an arterial lesion (aneurysm, ulcerated plaque), or when a cervical rib or apophysomegalia of the 7th cervical vertebra is associated.

[Cervical rib syndrome with aneurysm of the subclavian artery. Clinical case]

Authors refer to a clinical case in which they observed the association of bilateral cervical ribs with aneurism of subclavian artery. They underline the high frequencey of occasional observations of anomalies of the thoracic outlet, and consider the possible pathogenetic mechanisms of the thoracic outlet syndrome and associated vascular damages.