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Management of Unresolved, Recurrent, and/or Contralateral Neurogenic Symptoms in Patients Following First Rib Resection and Scalenectomy
Danielle H Rochlin, Kendall Likes, Marta M Gilson, Julie A Freischlag
Johns Hopkins Medical Institutions, Baltimore, MD

BACKGROUND:
Surgical intervention for patients with neurogenic thoracic outlet syndrome (NTOS) does not always yield successful outcomes. While several studies have presented the benefits of first rib resection and scalenectomy (FRRS), few have analyzed patients with unresolved, recurrent, and/or contralateral neurogenic symptoms following surgical treatment. The purpose of this study was to describe the demographic and clinical features of these patients, and to determine treatment protocols for improving their outcomes.
METHODS:
Data on 161 NTOS patients (182 FRRS procedures) was prospectively collected from 2003-11, and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, pre- and postoperative interventions, and outcomes were compared between these patients and those with an initial successful result.
RESULTS:
Group 1: Unresolved Symptoms (n=24; 13%)
23 patients (24 FRRS) presented with unresolved symptoms at a mean of 16.1 +/- 4.7 postoperative months. Compared to successes, these patients were older (45 vs. 38; p=0.002), active smokers (33% vs. 13%; p=0.031) with higher rates of chronic pain syndromes (67% vs. 14%; p<0.001) and neck and/or shoulder comorbidities (58% vs. 22%; p<0.001). At initial assessment, they reported a longer duration of symptoms (90 vs. 48 months; p=0.005). Etiology favored trauma (58%) compared to repetitive injury (42%) and preoperative interventions more often included other surgery (50% vs. 28%). Patients at high risk for failure had greater narcotic use (67% vs. 31%; p=0.001) and more CT-guided Botox injections (46% vs. 20%; p=0.009) with fewer cases of relief of symptoms (18% vs. 64%; p=0.014). The main postoperative treatments were physical therapy (100%) and local anesthetic and/or steroid injections (38%). Only 6 (26%) patients achieved freedom from narcotics at the end of the follow-up period.
Group 2: Recurrent Symptoms (n=16; 9%)
16 patients presented with recurrent symptoms at a mean of 12.1 +/- 9.7 postoperative months. These patients had higher rates of chronic pain syndromes (38%; p=0.028) and neck and/or shoulder comorbidities (50%; p=0.027). Recurrence was secondary to scar tissue (69%; p<0.001) and re-injury (31%; p=0.002). The main treatment modalities were physical therapy (94%) and CT-guided Botox injections (38%), where nearly all (94%) patients reported benefit. 13 (81%) patients achieved freedom from narcotics at the end of the follow-up period.
Group 3: Contralateral Symptoms (n=21; 13%)
21 patients presented with contralateral symptoms and underwent secondary FRRS at a mean of 15.0 (range 7-30) months following primary FRRS. The first surgery was successful in nearly all (86%) cases. Etiology was more commonly repetitive injury (67%) compared to trauma (33%).
CONCLUSIONS:
1. Patients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer period of symptoms. These patients face a more difficult recovery.
2. Patients with recurrent symptoms are well managed with physical therapy and CT-guided Botox injections.
3. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS.
4. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.


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