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INTRODUCTION: Surgical intervention for Thoracic Outlet Syndrome (TOS) may not always be successful. Treatment plans can be difficult in patients presenting with recurrent symptoms following anterior scalenectomy and/or brachial plexus lysis or incomplete first rib resection and scalenectomy (FRRS). The purpose of this study was to evaluate outcomes of 12 such patients who underwent operative intervention to remove the remaining or residual first rib.
METHODS: Data on 12 patients who presented with previous scalenectomy, brachial plexus lysis, or FRRS with residual rib present on chest radiograph between 2004 and 2012 were retrospectively reviewed from a prospectively maintained, IRB approved database. Demographic and clinical characteristics along with postoperative outcomes were evaluated.
RESULTS: Different precipitating events re-aggravated symptoms in 9 of these 12 patients. These events included car accidents (n=3), work related repetitive movements (n=3), lifting heavy objects (n=2) and repetitive injury (n=1).
Group 1: Previous scalenectomy (n=3), brachial plexus lysis alone (n=2), or both (n=1)
Six patients (2M/4F; mean age 35(25-53)) presented with neurogenic TOS symptoms due to a remaining first rib at an average of 27 months (range 2-68) following their initial operation. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein or brachial plexus injury. Average follow-up was 19 months (range 1-79) and all patients improved in the postoperative period.
Group 2: Residual rib (n=6)
Six patients (2M/4F; mean age 37(24-58)) presented with a residual first rib at an average of 52 months (range 12-107) following their initial operation. Five patients had undergone prior FRRS via a supraclavicular approach and 1 had undergone previous FRRS via an anterior chest approach. Initial indications were neurogenic TOS in 4 patients and venous thrombosis in 2. Five of the 6 patients presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all 6 patients, as seen by chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and any other scar tissue. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. The patient who had venous thrombosis underwent venography at 2 weeks postoperatively and was maintained on anticoagulation for 5 months. The patient’s vein was patent at 1 year postoperatively, as seen by duplex scan. Average follow-up was 17 months (range 1-64) and all patients improved in the postoperative period.
CONCLUSIONS:
1. Patients who present with recurrent symptoms of thoracic outlet syndrome need to be evaluated for remaining or residual first ribs.
2. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity.
3. Patients undergoing procedures for thoracic outlet syndrome should have the entire first rib removed at the time of the initial operation to prevent recurrence of TOS symptoms.