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Patient Reported Long-Term Quality of Life and Symptom Resolution after First Rib Resection
Justin Linden, Lydia Faber, Lillian Sutton, Akalya Villenthi, Matthew Goldman, Kevin Chang, Julie Ann Freischlag, Ashlee Stutsrim
Atrium Health Wake Forest Baptist, Winston-Salem, NC
INTRODUCTION: Thoracic Outlet Syndrome (TOS) involves compression of the neurovascular structures within the thoracic outlet including the brachial plexus (nTOS), subclavian artery (aTOS), and subclavian vein (vTOS). The aim of this study is to evaluate patient reported long-term outcomes of nTOS and vTOS patients undergoing first rib resection and anterior scalenectomy (FRRAS).
METHODS: Retrospective chart review from a single institution from 2015-2025 was completed after obtaining institutional review board approval. Baseline demographic and clinical data were collected for patients who underwent surgery at least one year prior. A 5-question quality of life (QOL) survey was administered via phone call or through the electronic health record querying chronic pain symptoms (frequency and severity), ongoing paresthesias (with activity, rest, or while sleeping), chronic medication use (daily, weekly, or monthly and medication type - opioid, non-steroidal, or neuropathic), ongoing therapy (physical, occupational, or massage and frequency - weekly or monthly) and lastly overall QOL after FRRAS (improved or not). Descriptive statistics including number (%) of categorical factors or median and inner-quartile range [IQR] of continuous factors were reported. Differences between TOS subtypes were assessed using Fisher's exact test (categorical) or rank sum tests (continuous).
RESULTS: Of the 204 patients with nTOS or vTOS who underwent FRRAS, 108 completed our survey - 57 out of 114 nTOS and 47 out of 90 vTOS. nTOS patients had significantly longer preoperative symptom duration (median [IQR] 24 [12, 60] months vs 2 [1, 10] months for vTOS, p < 0.001). There were no other significant differences between groups (see table 1).
In nTOS, most patients (43/57, 75.4%) indicated improved QOL. While most patients did not have recurrent symptoms (32/57, 56.1%), those that did were more likely to be older (median age 39 [35, 46] years vs 27 [17, 39] years, p 0.003). 30/57 (52.6%) patients reported ongoing paresthesias, though 47/57 (82.5%) did not require chronic medications. Patients requiring chronic medication were more likely to have undergone reoperative surgery (30% vs 4.3%, p=0.033).
In vTOS, most patients (41/47, 87.2%) reported improved QOL with younger patients more likely to have improvement (median 31 [22-41] years vs 47 [44, 50] years, p=0.015). Most veins (45/47, 95.7%) were patent at time of follow-up. As in the nTOS group, most patients did not have recurrent symptoms (36/47, 76.6%), though older patients were more likely to have recurrent symptoms (median age 49 [43, 53] years vs 30 [21, 39] years, p<0.001), have paresthesias (median age 42 [31,48] years vs 30 [20,41], p=0.027 and require chronic medications (median age 52 [50, 55] years vs 32 [22, 41] years, p=0.007). Vessel patency did not affect outcomes.
CONCLUSIONS: Patient reported long-term outcomes are favorable for nTOS and vTOS patients undergoing FRRAS. Our study highlights differences in long-term QOL by age with younger patients having longer-term symptom free experiences. While a small proportion of patients have recurrent symptoms, most report improved QOL.
Table 1: Baseline Data| Characteristic | nTOS, n = 571 | vTOS, n = 471 | p-value2 |
| Age at operation, median [IQR] | 35 [23,44] | 35 [23,45] | 0.7 |
| Sex | | | 0.079 |
| Female, n (%) | 44 (77.2) | 28 (59.6) | |
| Male, n (%) | 13 (22.8) | 19 (40.4) | |
| Preoperative symptom duration (months), median [IQR] | 24 [12,60] | 2 [1,10] | <0.001 |
| Reoperative surgery, n (%) | 5 (8.8) | 4 (8.5) | >0.9 |
| History of chronic repetitive motion, n (%) | 37 (72.5) | 31 (83.8) | 0.3 |
| Prior injury, n (%) | 20 (40.0) | 8 (21.6) | 0.07 |
| Length of follow-up (months), median [IQR] | 28 [19,46] | 35 [21,65] | 0.2 |
| 1Mean ± (SD); Median (25%-75); n (%)2Wilcoxon rank sum test; Pearson's Chi-squared test; Fisher's exact test |
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