Safety and efficacy of the supraclavicular approach to thoracic outlet decompression

BACKGROUND: Thoracic outlet syndrome (TOS) is a clinical diagnosis encountered by both thoracic and vascular surgeons. The goal of surgical therapy involves relieving compression of the neurovascular structures at the superior thoracic aperture. The traditional approach to thoracic outlet decompression has been transaxillary; however more centers are moving toward a more tailored approach through a supraclavicular incision. METHODS: The medical records of 67 patients who underwent surgical decompression between 1993 and 2001 for TOS were retrospectively reviewed. Patient demographics and early outcome were assessed through clinic follow-up. RESULTS: Seventy-two thoracic outlet decompressions were performed on 67 patients with the diagnosis of TOS. Five patients underwent bilateral thoracic outlet decompression. All operations in this time period were safely accomplished through a supraclavicular approach. The syndromes associated with thoracic outlet compression were neurogenic (n = 59), venous (n = 10), and arterial (n = 3). Forty-six of 72 (63.9%) operations resulted in complete resolution of symptoms, 17 cases (23.6%) had partial resolution, and 9 patients (12.5%) had no resolution. There were no deaths and morbidity was minimal with 6 complications (8.3%). CONCLUSIONS: The supraclavicular approach is a safe and effective technique in managing all forms of thoracic outlet compression.     

Supraclavicular approach for thoracic outlet decompression

Supraclavicular decompression of the thoracic outlet was performed in 40 patients with symptoms arising from brachial plexus compression were irritation. Both osseous and soft tissue structures responsible for this nerve compression were identified and removed without significant neurologic morbidity despite a 25% incidence of secondary operative procedures in this series. The cure or improvement rate matched what we previously reported for combined transaxillary and supraclavicular approach. Further follow-up will allow a determination of the durability of this technique, which, if acceptable, will justify a confident recommendation for its adoption in patients having thoracic outlet decompression.     

Surgical decompression for thoracic outlet syndrome

Fifty consecutive surgical decompression operations for thoracic outlet syndrome (TOS) were performed in 43 patients over a 7-year period. Of these, 54% presented with neurological symptoms alone; the others complained of symptoms of vascular or combined origin. Operations for decompression consisted of excisions of 14 cervical ribs, 22 first ribs, and 14 soft tissue or fibrous bands. In six limbs, cervical sympathectomy was also performed for patients who had secondary Raynaud's phenomenon. Surgery resulted in complete relief of symptoms in 37 limbs (74%) and an improvement was achieved in another 10 (20%). In three limbs (6%) surgery gave no benefit. There was no mortality. Thoracic outlet decompression via the supraclavicular approach gave good results in 94% of the patients.     

Transaxillary or supraclavicular decompression for the thoracic outlet syndrome. A comparison of the risks and benefits

The difficult exposure with the transaxillary resection of the first rib (TAR) prompted an analysis of the TAR versus the supraclavicular approach (SCR) for decompressing the thoracic outlet in patients with thoracic outlet syndrome (TOS). Thirty-seven patients underwent 30 TAR and 15 underwent SCR for TOS. The operating time was similar for the two groups. Mean blood loss was 61 cc for the SCR group and 218 cc for the TAR group. There was one complication in the SCR group, a urinary tract infection, whereas the TAR group had 21 complications including pneumothorax (13), laceration of subclavian vessel (3), winged scapula (3), pleural effusion (1), and wound infection (1). Postoperative hospitalization averaged 3 and 5 days, respectively, for the SCR and TAR patients. All SCR patients and all but one TAR patient were improved or asymptomatic immediately postoperatively. Ninety-three per cent and 81 per cent, respectively, of SCR and TAR patients were improved at 2 months, whereas 100 per cent and 83 per cent, respectively, remained improved at a mean follow-up of 3 years. The significantly fewer complications, decreased blood loss and shorter postoperative hospitalization, noted in the SCR patients supports this approach as the preferred form of management for TOS.     

770 Consecutive supraclavicular first rib resections for thoracic outlet syndrome

During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occurred and only 12 patients (2%) required operative intervention for recurrent TOS. First rib resection and scalenectomy can be performed by the supraclavicular route with an acceptable outcome, minimal morbidity, and long-lasting results.     

Long-term follow-up after thoracic outlet decompression: an analysis of factors determining outcome

We reviewed our 12-year experience with transaxillary first rib resection in 136 patients screened by neurologists and thought to have neurologic thoracic outlet syndrome to determine what factors affected outcome. These patients represented 85% of the operative experience in a referral area of 1.2 million people. Patients were recalled every 2 years for surveillance. The mean follow-up was 60 +/- 7 months. There were no brachial plexus or vascular injuries. Secondary operations in the neck were required in 20 patients. The quality of the operative result was determined by whether the patient was able to return to preillness activities and whether the patient would undergo operation again if the same result would be obtained. The most important determinant of result was a history of trauma precipitating the neurologic symptoms, particularly in women. Only 25 of the 53 patients (47%) with a history of trauma returned to preillness activities compared to 65 of the 83 patients (78%) without such a history. Overall patient satisfaction was not affected by trauma. Thirty-eight of the 53 patients with trauma (72%) and 69 of the 83 patients (83%) without trauma were satisfied. When the men and women were analyzed separately men were found to have better results after trauma than did women. Other factors with a negative impact on operative results were the need to return to an activity that required repetitive arm movements, coverage under a worker's compensation insurance policy, and fixed joint abnormalities or neurologic findings in the upper extremity. The presence of an anatomic abnormality had no effect on operative results.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcome after thrombolysis and selective thoracic outlet decompression for primary axillary vein thrombosis

PURPOSE: Treatment for primary subclavian-axillary vein thrombosis (SAVT) at our institution consists of thrombolysis and anticoagulation for 3 months. Thoracic outlet decompression has been performed for a small number of patients. We wanted to review the functional outcomes of patients treated in such a manner. MATERIAL AND METHODS: The records of all patients treated for a first episode of SAVT at our hospital over the past 10 years were reviewed. Demographics, comorbidities, method of diagnosis, and treatment for SAVT were recorded. Long-term follow-up was obtained by chart review and asking patients to complete the DASH (disabilities of the arm, shoulder and hand) questionnaire that was developed by the American Academy of Orthopedic Surgeons. RESULTS: Twenty-eight patients, 20 men and eight women, with a mean age of 36 were treated during the study period. The median time between onset of symptoms and treatment was 5.5 (range, 1-100) days. All patients had confirmation of the diagnosis by venography. Twenty-five patients received thrombolytic treatment with catheter-directed infusions of urokinase; in the other three patients the vein was chronically occluded. Twelve patients had some degree of residual stenosis and were treated with percutaneous transluminal angioplasty after thrombolysis. During the study period two patients underwent decompressive surgery. Twenty-one patients responded to the DASH questionnaire a mean of 2.9 years (range, 2 months to 8 years) after the episode of SAVT. Six (28%) of 21 patients were completely symptom free, 13 patients (62%) had DASH scores consistent with mild symptoms, and two patients had more severe symptoms. Twenty percent (4 of 21) of patients report some difficulty with work. CONCLUSIONS: Thrombolysis, followed by selective thoracic outlet decompression on the basis of the severity of patients' symptoms can be used as a therapeutic approach to SAVT without undue morbidity. The DASH questionnaire is a useful tool to evaluate results after therapy for SAVT.     

Therapy after thoracic outlet release

The authors believe that early motion after thoracic outlet syndrome surgery helps minimize scarring and enhances the healing process. This article describes the authors' protocol of treatment at the various stages of the postoperative period.     

Anterior decompression and fusion for multiple thoracic disc herniation

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% +/- 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results.     

Long-term results of surgical decompression of thoracic outlet compression syndrome

BACKGROUND: Thoracic outlet compression syndrome is characterised by a variety of symptoms relating to compression of the neurovascular bundle. Though no one test is specific for the syndrome, relief of symptoms may be obtained following surgery in up to 99% of cases. PATIENTS AND METHODS: The notes of 118 patients operated on in 126 operations by a single surgeon using a supraclavicular approach were reviewed. Symptoms, pre-operative investigations, and complications were all documented. Outcome at 6 weeks, 6, 12 and 24 months follow-up was also recorded. In addition, 61 patients were contacted by telephone, in order to assess current level of symptoms. RESULTS: Symptoms were predominantly motor, sensory or vasomotor, and were present for a mean of 19.6 months prior to surgery. Complications were rare, but included a pneumothorax requiring a chest drain (n = 1) and infraclavicular anaesthesia (n = 13). The mean duration of hospital stay was 2.1 days. At 6 weeks follow up, 86.5% of patients reported either an improvement, or complete resolution of their symptoms. Sixty-one patients were contactable, a mean of 55 months following decompression. Of these, 44 (72.1%) were either improved or asymptomatic. CONCLUSION: Decompression for thoracic outlet compression syndrome through a supraclavicular approach encompassing first rib resection leads to good long-term results with few complications.     

Neurogenic thoracic outlet decompression: rationale for sparing the first rib

A total of 168 primary supraclavicular decompressions were performed on 146 patients with neurogenic thoracic outlet syndrome. This report compares the results of rib resection (supraclavicular anterior and middle scalenectomy and first rib resection) with rib-sparing (supraclavicular anterior and middle scalenectomy alone) operations. All patients with cervical ribs were excluded. In total, 125 rib resections and 43 rib-sparing procedures were performed between 1983 and 1992 by a single surgeon. The patients were otherwise comparable in symptoms and physical signs. During surgery there was a significantly higher proportion of pleural injury associated with rib resection (59%) than with rib-sparing (40%) procedures. The mean hospital stay was also prolonged by 1 day in patients undergoing rib resection (P = 0.005). There was no significant difference in early success between the two groups (83% for rib resection, 91% for rib sparing) and no difference in those resuming employment (52% and 63% respectively). Life-table analysis showed that the two groups have similar long-term results (69% and 76% at 2 years). The only important factor determining clinical outcome in primary supraclavicular thoracic outlet syndrome decompression was the duration of symptoms before operation. Some 83% of patients with symptoms less than 2 years had a successful result compared with only 68% in those with symptoms longer than 2 years (P < 0.05). Spontaneous or post-traumatic neurogenic symptoms responded to operation identically. The theoretical benefit of first rib resection to relieve mechanical compression of the brachial plexus is not evident from this review. Thorough removal of the scalene musculature and other myofascial anomalies, preferably through the supraclavicular approach, leads to less patient morbidity, shortens hospitalization, and is recommended for patients with neurogenic thoracic outlet syndrome requiring operative intervention.     

侧前方减压治疗腰椎间盘突出症

目的 讨论腰椎间盘突出症的治疗方法。方法 用侧前方减压术对11例胸椎间盘突出进行手术治疗。结果 该手术方法直接、充分显露硬膜囊和神经结构,切除突出的椎间盘和刮除骨赘,减压安全有效,同时对脊柱的稳定性和脊髓的血供影响较小,通过对11例患者观察结构为优7例,良4例。结论 侧前减压术进行胸椎间盘切除减压是治疗胸椎间盘突出症的一种安全有效的方法。     

胸椎间盘突出症减压术后疗效及影响因素分析

[目的]探讨胸椎间盘突出症减压术后的手术疗效,并分析其影响因素。[方法]回顾性分析2006年1月~2013年12月因确诊胸椎间盘突出症于本院接受手术治疗并获得随访的48例患者。男26例,女22例;年龄26~73岁,平均53.6岁。术前JOA脊髓损害评分(11分法)平均(6.26±1.92)分。按JOA评分改善率进行疗效分级,并计算疗效优良率及有效率。在术前MRI矢状位T2相观察脊髓受压节段数、脊髓内有无高信号,MRI轴位T2相上观察椎间盘突出类型(中央型,侧方型),在受压最重节段测量并计算正中矢状径残余率、硬膜囊横截面积残余率。采用多元线性回归检验年龄、性别、术前病程、术前JOA评分、中央/侧方突出、软性/硬性突出、手术节段、T2髓内高信号、手术方式、是否合并其他脊柱疾患、正中矢状径残余率、硬膜囊横截面积残余率对JOA改善率的影响。[结果]随访时间13~109个月,平均48个月。至随访结束时,疗效优良率为81.25%(39/48),改善率平均为62.56%(-20%~100%)。多元线性回归分析显示:术前JOA评分与MRI轴位中矢状径残余率对手术疗效的影响有统计学意义(P0.05),而年龄、性别、术前病程、中央/侧方突出、软性/硬性突出、手术节段、T2髓内高信号、脑脊液漏、手术入路、合并其他脊柱疾患、MRI轴位硬膜囊横截面积残余率对手术疗效的影响无统计学意义(P0.05)。[结论]胸椎间盘突出症减压术后疗效相对满意,MRI轴位正中矢状径残余率与术前JOA评分是胸椎间盘突出症减压术后疗效的影响因素。     

Outcomes after surgery for thoracic outlet syndrome

PURPOSE: This study determined whether there is an association between psychological and socioeconomic characteristics and the long-term outcome of operative treatment for patients with sensory neurogenic thoracic outlet syndrome (N-TOS). METHODS: Clinical records, preoperative psychological testing results, and long-term follow-up questionnaire data were reviewed for consecutive patients who underwent surgery for N-TOS from 1990 to 1999. Multivariate logistic regression models were developed as a means of identifying independent risk factors for postoperative disability. RESULTS: Operative decompression of the brachial plexus via a supraclavicular approach was performed for upper extremity pain and paresthesia with no mortality and minimal morbidity in 170 patients. After an average follow-up period of 47 months, 65% of patients reported improved symptoms, and 64% of patients were satisfied with their operative outcome. However, 35% of patients remained on medication, and 18% of patients were disabled. Preoperative factors associated with persistent disability include major depression (odds ratio [OR], 15.7; P =.02), not being married (OR, 7.9; P =.04), and having less than a high school education (OR, 8.1; P =.09). CONCLUSION: Operative decompression was beneficial for most patients. Psychological and social factors, including depression, marital status, and education, are associated with self-reported disability. The impact of the preoperative treatment of depression on the outcome of TOS decompression should be studied prospectively.     

Lung herniation after a single cough

We present the case of an overweight male patient with a lung hernia caused by a single massive coughing attack. The diagnosis could only be verified by CT-scans. Following a conservative therapeutic approach, surgical intervention was necessary. Lung hernias are easy to detect using radiological diagnostic. Standard X-ray examinations where a subcutaneous air mass can be seen have become, since the inauguration of computed tomography, second line tests. Large traumatic lung hernias should be treated surgically. Spontaneous and especially cervical hernias should be handled conservatively and only must be surgically treated when complications or a progression in size should be observed.     

CT引导经皮穿刺激光减压治疗胸椎间盘突出症

经皮穿刺椎间盘激光减压术（PLDD）是近年来发展起来的一种新的椎间盘微创治疗方法，主要应用于颈、腰椎椎间盘突出症的治疗，应用于胸椎间盘突出治疗的报道较少，现将2004年8月-2005年11月在CT引导下经皮穿刺激光减压治疗的6例胸椎间盘突出症，报告如下。     

Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty

OBJECTIVE: Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. METHODS: Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months. RESULTS: Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis. CONCLUSIONS: Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.     

Safety and efficacy of early surgical decompression of the thoracic outlet for paget-schroetter syndrome

The surgical treatment of Paget-Schroetter syndrome has evolved to include early thrombolytic therapy and an interval period of anticoagulation, followed by late surgical decompression of the thoracic outlet. More recently, we have developed an abbreviated course of therapy in which the thrombolytic therapy is followed by early surgical decompression during the same admission, then a period of anticoagulation. We compared early surgical decompression with the standard management protocol to determine safety and efficacy of the early treatment algorithm. Nine patients were treated with lysis and early operation. These were compared with the preceding nine consecutive patients treated with lysis and staged operation. Demographic data, risk factors, duration of thrombosis, lytic therapy, time to surgery, operative variables, and postoperative complications were analyzed. Our results showed that thrombolysis followed by early operation does not result in increased perioperative morbidity or mortality. Early surgical decompression of the thoracic outlet during the same admission as lysis is as safe and efficacious as the traditional (staged decompression) approach to Paget-Schroetter syndrome. Lysis followed by early surgical decompression should be considered a new standard of care in the management of Paget-Schroetter syndrome. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000.