A rare cause of thoracic outlet syndrome

First rib pathology can narrow the thoracic outlet thus producing compression of the brachial plexus and subclavian vessels. There have been only three case reports of neurogenic thoracic outlet syndrome (TOS) caused by a nonunion of the first rib and there have been no reports of a first rib malunion causing TOS. A rare case of TOS caused by a malunion of the first rib is presented. This work has not received financial support and the authors declare no conflict of interest.     

First rib resection in thoracic outlet syndrome

Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement.     

经典与改良斜角肌切断术治疗胸廓出口综合征疗效的长期随访

目的 比较经典及改良的斜角肌切断术治疗胸廓出口综合征（thoracic outlet syndrome，TOS）的远期疗效。方法 对1985—1994年TOS26例29侧行经典斜角肌切断术，1996—2000年TOS28例30侧行改良斜角肌切断术的患者进行长期随访（5～19年）。分别测定手部肌力、手及前臂尺侧感觉、颈肩部不适及患肢血运等情况。结果 经典与改良方法对手内肌萎缩、前臂及手尺侧感觉减退的缓解率分别为80．0％、80．8％、88．5和88．8％、85．2％、92．0％，两组差异无统计学意义；经典与改良方法对患肢发冷、发白以及颈肩部不适的缓解率较低，分别为47．1％、44．4％和80．0％、78．9％．两组相比差异有统计学意义（P〈0．05）。结论 改良的斜角肌切断术能更好地缓解TOS的各种症状，尤其对颈肩部不适及患肢血运情况的改善疗效明显好于经典方法。     

Lung herniation after supraclavicular thoracic outlet decompression

Lung herniation after first rib resection for thoracic outlet syndrome (TOS) has not been reported to our knowledge. We present a unique case of cervical lung herniation causing displacement of the brachial plexus and chronic pain in a patient who had previously undergone supraclavicular thoracic outlet decompression with first rib resection. This was successfully treated with thoracoscopic reduction and resection of the herniated lung and pleural flap closure of the defect.     

Surgical Treatment of Thoracic Outlet Syndrome Secondary to Clavicular Malunion

According to the literature, thoracic outlet syndrome (TOS) secondary to the malunion of displaced fractures of the clavicle is rare. Various surgical methods, including simple neurolysis, resection of the first rib or clavicle and corrective osteotomy, have been reported. We report a case of TOS secondary to malunion of the clavicle that was treated by an anterior and middle scalenectomy without a rib resection.     

Combined endovascular and open surgical approach for the management of subclavian artery occlusion due to thoracic outlet syndrome

A 32-year-old male with arterial thoracic outlet syndrome (TOS) underwent endovascular treatment for the chronic total occlusive lesion from the subclavian to the brachial artery after resection of the first rib and cervical rib. A combined endovascular and surgical treatment represents an attractive alternative to the traditional surgical approach for the treatment of complicated arterial TOS.     

Thoracic outlet syndrome in a patient with SAPHO syndrome – A case report

Introduction and ImportanceThoracic outlet syndrome (TOS) includes disorders caused by compression of the neurovascular structures in the upper thoracic outlet (Roos and Owens, 1996 [1]; Bürger, 2014; Curuk, 2020 [3]). Depending on the compressed structure, it is categorized into neurological, arterial and venous TOS.SAPHO syndrome (synovitis–acne–pustulosis–hyperostosis–osteitis syndrome) is a rare chronic inflammatory disease of unknown etiology. With its typical involvement of sternoclavicular joint and clavicle, complication due to hyperostosis in this region, leading to thrombosis of the subclavian vein have been reported in some cases of SAPHO syndrome.Between 2015 and 2019 488 patients, suffering from neurological, vascular or combined TOS presented at our department. Depending on clinical and diagnostic results surgical therapy was performed in 175 cases via the transaxillary approach, including complete first rib and/or cervical rib resection, neurolysis of plexus brachialis, thoracic sympathectomy and vascular reconstruction if indicated (Curuk, 2020). During this period, only one single patient presented with SAPHO syndrome with thrombosis of the subclavian vein and neurovascular TOS.Case presentationWe present a 50-year-old female patient, in line with the SCARE 2020 criteria (Agha et al., 2020 [12]) suffering from extremely rare combination of neurovascular TOS and SAPHO syndrome with thrombosis of the left subclavian vein due to hyperostosis of the left clavicle.ConclusionProgressive bone changes associated with SAPHO syndrome can lead to narrowing of the thoracic outlet. Pharmacological therapies to avoid the progression of the hyperostosis of the costoclavicular joint and the clavicle do currently not exist. First rib resection is a therapeutic option to widen the space in the upper thoracic region. Surely, it is a rare condition and more long-term follow-up data are required.     

Resection of the first rib, following deep arm vein thrombolysis in patients with thoracic outlet syndrome

In order to evaluate, the prophylactic effect of first rib resection in patients with fibrinolytic recanalised deep arm vein thrombosis, we present our experience with 21 patients. After recanalisation 12 had phlebographic signs of venous compression in the costoclavicular space, with the arm in the normal position. This fulfills the requirements for thoracic outlet syndrome (TOS). In 60 normal persons without symptoms of TOS none had phlebographic signs of venous compression with the arm in normal position. This difference is significant. In the 12 patients TOS was suspected was to be the underlying cause of rethrombosis and first rib resection was performed. Two patients with TOS had rethrombosis before first rib resection could be performed. At follow up 1 to 6 years after the thrombosis no rethrombosis was found. TOS and deep arm vein thrombosis is rare. Controlled studies are not available. We advocate first rib resection in patients with successful fibrinolysis and TOS in order to avoid rethrombosis.     

Computer-assisted instrumentation during endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe alternate approach

The purpose of this article is to discuss the feasibility of using computer-enhanced instrumentation to improve visualization and therefore patient safety during transaxillary first rib resection. From November 1998 to July 2005, 105 patients who had failed conservative treatment underwent 131 procedures for thoracic outlet decompression. Eighty-nine endoscopic transaxillary first rib resections were completed using Aesop/Hermes integrated voice control instrumentation (Computer Motion, Goleta, CA). Since February 2003, dissection in 42 procedures was performed using the daVinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). The surgical findings with cervical bands correlated with the preoperative symptoms. One hundred percent of patients with a combination of neurogenic and arterial thoracic outlet syndrome (TOS) requiring cervical rib resection had Roos type I and/or II bands. Additional surgical findings included the following: combination of neurogenic and arterial TOS without cervical ribs or neurogenic TOS alone had type III, IV, or V bands, and patients with venous compression (100%) had type VII bands. No mortalities or permanent neurovascular injuries occurred. There was a 6.1% postoperative complication rate. Persistent myofibrositis was found in 34% of patients with ongoing symptoms. CONCLUSION: The daVinci three-dimensional optical imaging system enhances visualization, thereby promoting telemanipulation of soft tissue structures in a relatively inaccessible working space. Endoscopic computerized instrumentation in transaxillary first rib resection decreases the risk of neurovascular injury, promotes complete decompression, and therefore provides a safe alternative to standard first rib resections.     

A new surgical approach to the innominate and subclavian vein

A new technique extending the incision used for thoracic outlet decompression with a subclavicular approach to the first rib is presented. After the first rib and scalenotomy are removed, the subclavicular incision is continued into the sternum medially and superiorly to the sternal notch. This gives easy access to the innominate-subclavian-axillary vein segment. Eight patients with extensive chronic fibrotic obstruction of the subclavian-innominate vein segment underwent operation with this technique. It allows placement of either long patches of saphenous vein to reestablish normal caliber or replacement, as is our choice, with a small-sized cryopreserved descending thoracic aortic homograft. The operation is carried out in an extrapleural plane preserving the sternoclavicular joint, avoiding the deformity caused by transclavicular techniques. Repair of the sternotomy creates a stable incision. Follow-up to 14 months shows patency of the venous channel with no complications. This surgical approach is recommended to solve the problem of satisfactory exposure of the subclavian-innominate venous channel after decompression of the thoracic outlet. (J Vasc Surg 1998;27:576-81.)     

切断前中小斜角肌治疗胸廓出口综合征的远期疗效

目的 远期随访切断前中斜角肌治疗胸廓出口综合征（thoracic outlet syndrome，TOS）的疗效。方法对31例32侧胸廓出口综合征患者术后的疗效作远期随访。其中上干型4例，下干型26例27侧，全臂丛型1例。X线片示颈肋1例。第七颈椎横突过长2例。均行手术治疗。术中发现31例均有纤维束带压迫臂丛神经，作前、中、小前斜角肌切断术；3例骨异常者同时切除增长的骨组织和颈肋。术后随访4年8个月-8年3个月．平均为5年4个月。以症状、体征有无复发以及是否恢复原工作为随访主要观察项目。疗效按胸廓出口综合征评定标准评定。结果 术后症状明显改善15例16侧，部分改善6例，无效10例。优良率为68．7％。结论 该组病例远期疗效的优良率为68．7％，因此，胸廓出口综合征的治疗方法仍是个有待于进一步研究的临床课题。     

Pathology of the shoulder as it relates to the differential diagnosis of thoracic outlet compression.

Shoulder pathology and its diagnosis must be considered in evaluation of the patient suspected of having thoracic outlet syndrome (TOS). Overlooking usually treatable conditions in the shoulder may lead to unfavorable results, if treatment is directed, instead, to neurolysis of the brachial plexus or first rib resection.     

Thoracic outlet syndrome: influence of personal history and surgical technique on long-term results.

OBJECTIVE: Long-term results after surgery for thoracic outlet syndrome (TOS) are reviewed in terms of personal histories and surgical techniques. METHODS: Forty-eight operations were performed in 37 patients. In 21 instances, the picture was one of ordinary TOS, in eight TOS was traumatic and in nine the picture was sub-acute. Cervical ribs were excised through a supraclavicular approach (in seven cases), and first ribs through transthoracic, transaxillary or supraclavicular approaches (in 25, 15 or one, respectively). Long-term follow-up was obtained in 41 cases and averaged 11.7 years. RESULTS: Surgical decompression was successful in 28 cases (68%), including all patients with traumatic TOS (8/8) and seven with sub-acute symptoms (7/9). Outcome was good in five of seven supraclavicular cervical rib resections, and in 23 of 34 first rib excisions. First rib resections performed transaxillary had shorter post-operative stays, fewer complications. CONCLUSION: Surgical decompression is more successful when TOS is traumatic or sub-acute. When involved, a cervical rib can be resected through a supraclavicular approach, since the procedure is easy and has little morbidity. The transaxillary approach should be preferred for first rib resections because of shorter post-operative stays and fewer complications than after the transthoracic approach.     

Two year follow-up of patients operated on for thoracic outlet syndrome. Effects on sick-leave incidence

This report is based on 175 cases of Thoracic Outlet Syndrome (TOS) which were followed for two years after resection of the first rib. Good or fair results were achieved in 59%. An anomaly restricting the thoracic outlet was significantly more often found in patients with a good outcome after surgery. The results of surgery correlated well to the time for sick-leave. A conservative attitude to surgical treatment of TOS is recommended, due to the difficulty in establishing the diagnosis.     

Vascular thoracic outlet syndrome: successful outcomes with multimodal therapy

PURPOSE: Vascular thoracic outlet syndrome (TOS) can present with signs of arterial impingement or, more commonly, as venous obstruction. In an effort to decrease morbidity associated with vascular thoracic outlet syndrome, we have used an aggressive multimodal treatment approach. METHODS: Since November 1992, we have evaluated 29 patients with vascular thoracic outlet syndrome. Nine of ten patients with arterial thoracic outlet syndrome had first rib resections. Eighteen of 19 patients with venous occlusion underwent anticoagulation, thrombolysis, and first rib resection. Eight patients required additional endovascular therapy for persistent stenoses, either venous angioplasty alone (2) or angioplasty plus stent placement (6). RESULTS: Follow up extends to 75months with a mean of 24months. Patients with stents have been followed for a mean of 38months. Twenty-five of 28 patients managed with multimodal therapy were essentially asymptomatic at last follow up. CONCLUSION: Thrombolysis, anticoagulation, surgical decompression, and endovascular procedures act synergistically to improve results of therapy in patients with vascular thoracic outlet syndrome.     

Cerebral embolic stroke and arm ischemia in a teenager with arterial thoracic outlet syndrome: a case report

A rare presentation of arterial thoracic outlet syndrome (TOS) is described in a young woman. Arterial TOS caused by a cervical rib produced acute upper extremity ischemia due to subclavian artery aneurysm formation. Clinical presentation also included left hemiparesis caused by right subclavian artery thrombosis and retrograde embolization of thrombus via the common carotid artery to the right middle cerebral artery distribution. Surgical repair of the subclavian artery was performed, but permanent neurologic deficit remained. Acute thrombosis of the right subclavian artery can produce cerebrovascular complication. The assessment of such risk in patients with arterial TOS is warranted and the arterial lesion corrected surgically.     

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.     

Thoracic outlet syndrome with arterial complication treated by the subclavicular transsternal approach: report of a case

A 42-year-old female was referred to our vascular service because of her right arm fatigue and cold sensitivity. On elevation of right arm, her radial pulse was absent with pallor of the hand. Angiography demonstrated a significant stenosis of the right subclavian artery, which was considered to be complication of thoracic outlet syndrome. We performed resection of the first rib using the standard subclavicular approach and the subclavian-subclavian artery bypass using a new transsternal extension approach to the subclavian artery. After follow-up 18 months, she was working and asymptomatic. This transsternal extension is effective to treat the arterial complication after decompression of the thoracic outlet.     

Association of Disturbances in the Thoracic Outlet in Subjects with Carpal Tunnel Syndrome: A Case-Control Study

Introduction

A limited amount of research has investigated the potential relationship between carpal tunnel syndrome (CTS) and thoracic outlet dysfunction.

Purpose of the Study

To compare the prevalence of positive clinical tests suggestive of disputed neurogenic thoracic outlet syndrome (TOS) in subjects with CTS (CTS+) with that of subjects without CTS (control).

Study Design

Case-control study.

Methods

Subjects with electrodiagnostically confirmed CTS (CTS+) were recruited consecutively and matched by age (±2 years) and gender with asymptomatic (control) subjects. Subjects underwent clinical testing for neurogenic TOS using two provocative tests: modified Cyriax release test and elevated arm stress test (EAST). Subjects were tested for the presence of an elevated first rib using cervical rotation lateral flexion (CRLF) test.

Results

A total of 32 investigational subjects and 32 matched control subjects was included in each group (mean age: 43.5 + 5.9 years). A significantly greater number of CTS+ subjects presented with positive provocative testing for TOS (modified Cyriax release test p = 0.005; EAST approached significance p = 0.027) and for the presence of an elevated first rib (CRLF test p = 0.003) as compared with controls. The likelihood of neck pain, shoulder pain, or an elevated first rib was 16 times greater in the CTS+ group as compared with that in the control group.

Conclusions

A greater number of subjects with CTS presented with proximal dysfunctions suggestive of TOS and history of neck and shoulder pain. Evaluation of proximal structures involved with thoracic outlet dysfunction in persons with CTS has clinical merit.

Level of Evidence

Level III-b.     

Combined surgical treatment of thoracic outlet syndrome: transaxillary first rib resection and transcervical scalenectomy

Transaxillary first rib resection and transcervical scalenectomy are common procedures used for treatment of thoracic outlet syndrome (TOS). In the early 1980s, some surgeons started to perform both procedures, starting with the scalenectomy and following with a transaxillary first rib resection. The author has found that performing these procedures in the reverse order, starting with the first rib resection and following immediately with a transcervical scalenectomy is an easier approach, providing total decompression, better relief of symptoms, and a lower recurrence rate.