Does age really matter? Evaluating Outcomes in Pediatric and Adult Patients Following First Rib Resection and Anterior Scalenectomy for Thoracic Outlet Syndrome
Lydia L Faber, Rasikh Hamid, Caroline Minnick, Randolph L. Geary, Kevin Z Chang, Matthew P Goldman, Julie A Freischlag, Gabriela Velazquez
Atrium Health Wake Forest Baptist, Winston Salem, NC
INTRODUCTION: Thoracic outlet syndrome (TOS) results from compression of the brachial plexus (nTOS), subclavian vein (vTOS) or subclavian artery (aTOS). Historically, pediatric patients have been excluded from studies and few reports describe management and outcomes for these patients. This retrospective review examines the presentation and outcomes of pediatric patients and adults over the age of 40 following first rib resection and anterior scalenectomy (FRRAS) for TOS. METHODS: Electronic medical records were retrospectively reviewed for patients with TOS between 2016-2023 at a single institution. Demographics, history of symptoms and duration, operative technique and complications, and post-operative outcomes (length of stay (LOS), post-operative symptoms, and time to symptom resolution were analyzed. Outcomes were compared between patients 18 years and younger (pediatric) versus patients 40 years and older (adult). Patients aged 19-39 were excluded. RESULTS: Of the 148 patients who underwent FRRAS, 23 were in the pediatric group and 36 patients were in the adult group.Of the 36 adult patients, there were 38 operations as 2 patients had bilateral nTOS. Of the remaining 34 patients, 19 had nTOS, 13 had vTOS, and 2 had aTOS. The average age was 48.6 years (40-66 years). Chronic repetitive motion (CRM) was reported by 87% of patients and 49% reported antecedent trauma. Average symptom duration prior to diagnosis was 43.7 months (0-252 months). 8% of patients had a boney abnormality. 34 patients underwent the transaxillary approach (2 supraclavicular, 2 infraclavicular). Six patients developed a pneumothorax intraoperatively. Average LOS was 1.13 days (1-2 days). At the first post-operative follow-up, 14 reported neurogenic symptoms, 7 had post-operative pain and discomfort, 3 had both neurogenic and post-operative pain, and 12 reported no symptoms. At an average of 5.8 months (0.2 - 33.1 months) post-operative, 33 patients had resolved or improved symptoms. Two patients were lost to follow-up and 1 did not have symptom improvement. Mean follow-up was 11.9 months (0.2 - 65.5 months).Within the pediatric group, 14 had nTOS and 9 had vTOS. The average age was 15.9 years (13-18 years). CRM was reported in 91% of patients and antecedent trauma in 30% of patients. Average symptom duration prior to diagnosis was 8.1 months (0-48 months). 35% of patients had boney abnormalities. 20 patients underwent transaxillary approach. (1 supraclavicular, 2 infraclavicular). Six patients developed intraoperative pneumothorax. Average LOS was 1.5 days (1-2 days). At the first post-operative visit, 7 reported neurogenic symptoms, 2 had post-operative pain, 1 had neurogenic and post-operative pain, and 12 were symptom-free. Two patients were lost to follow-up. At an average of 2.0 months (0.2 - 6.3 months) post-operative, 21 patients had resolved or improved symptoms. Mean follow-up was 15.8 months (0.7 - 66.0 months).There were no mortalities or major morbidity in either group. All patients completed physical therapy and resumed daily activities. CONCLUSIONS: Patients over 40 are more likely to have ongoing symptoms at initial follow-up and have longer recovery time to achieve symptom improvement or resolution. Despite longer recovery, symptom resolution was still achieved in a majority of the patients regardless of age group.
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