|Year : 2019 | Volume
| Issue : 3 | Page : 118-122
Transaxillary decompression of thoracic outlet syndrome: A single-center study
Ambrish Kumar1, Vikas Singh1, Monika Bhandari2, Sarvesh Kumar1
1 Department of Cardiovascular and Thoracic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||30-Sep-2019|
Dr. Vikas Singh
Department of Cardiovascular and Thoracic Surgery, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: Transaxillary approach for the surgical management of thoracic outlet syndrome (TOS) has the advantage of minimal manipulation of brachial plexus and lesser perioperative and postoperative complications. We studied the clinical presentation and transaxillary surgical excision of the first rib in TOS at our center.
Materials and Methods: All patients with TOS were reviewed for their clinical presentation and outcomes of transaxillary approach for thoracic outlet decompression over a period of 10 years. We evaluated the clinical presentation, surgical details, and postoperative course of all patients who underwent surgery.
Results: Sixty-three patients of TOS were studied who underwent decompression through transaxillary approach over a period of 10 years. Nearly 79.4% of the patients had neurological symptoms, whereas 20.6% had arterial symptoms. Almost all patients (98.4%) had a cervical rib. One-fourth of the study population had bilateral cervical ribs. Around 17.46% of the patients presented with acute thromboembolism of the brachial artery and were managed with emergency thromboembolectomy. Postoperative complications encountered were pleural breach (11.11%), wound infection (7.94%), and re-thrombosis (1.59%).
Conclusions: Transaxillary resection of the cervical/ first rib has excellent results, with less morbidity. It is efficient in relieving symptoms and gives cosmetically acceptable scar. It is proposed that whenever any patient presents with acute upper-limb ischemia, he/she must be evaluated for cervical rib as a cause of TOS.
Keywords: Cervical rib, thoracic outlet syndrome, thromboembolectomy
|How to cite this article:|
Kumar A, Singh V, Bhandari M, Kumar S. Transaxillary decompression of thoracic outlet syndrome: A single-center study. Heart India 2019;7:118-22
|How to cite this URL:|
Kumar A, Singh V, Bhandari M, Kumar S. Transaxillary decompression of thoracic outlet syndrome: A single-center study. Heart India [serial online] 2019 [cited 2020 Jan 28];7:118-22. Available from: http://www.heartindia.net/text.asp?2019/7/3/118/268166
| Introduction|| |
Thoracic outlet syndrome (TOS) or costoclavicular syndrome is present in about 0.05%–3% of population, and is more common in females.,, Cervical rib is mostly associated with TOS. It is divided on the basis of presentation as neurogenic (NTOS), arterial (ATOS), and venous TOS [Figure 1]a. Diagnosis is based on the characteristic history and positive provocative tests, supported by nerve conduction velocities, plain X-rays of cervical region, color Doppler, and angiography. Early decompression is considered to prevent muscular weakness, chronic ischemia, and limb loss. Excision of the first rib with or without cervical rib can be approached by several methods, namely supraclavicular, infraclavicular, transaxillary, and video-assisted approaches., Posterolateral thoracotomy is generally used for reoperation. We used transaxillary approach at our center for the resection of the first rib and the cervical rib.
|Figure 1: Schematic diagram showing the contents of cervicoaxillary canal with cervical rib (a), the minimal postoperative scar in transaxillary approach (b)|
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| Materials and Methods|| |
The study involved 63 patients with TOS who underwent resection of the first rib and cervical rib at the Department of Cardiovascular and Thoracic Surgery, King George's Medical University, over a period of 10 years. The study was approved by the Ethical Committee of the university. After proper clinical evaluation, all patients underwent provocative tests, nerve conduction velocities (when clinically indicated), X-ray chest and cervical spine, and Doppler study for vascular abnormalities. Somatic Pain Scale was used for assessing the symptom severity. Once the diagnosis was established with reasonable certainty, patients with neurogenic symptoms who had ulnar nerve conduction velocities of >60 m/s were managed using physical therapy and muscle exercises of the trapezoid region. If the conduction velocity was less than that level, most patients despite physiotherapy remained symptomatic, and definitive surgery was performed. For patients who presented with arterial thromboembolism, thromboembolectomy was done.
Surgical decompression of TOS was performed through a transaxillary extraperiosteal approach, and the first rib and associated anomalies (fibrous band and cervical rib) were resected in lateral position, arm was retracted and then holded with an arm holder. A 4-cm-sized transaxillary incision was given just below the hair line and in between the pectoralis major and latissimus dorsi muscle [Figure 1]b.
Patients' perioperative data were recorded such as X-ray findings, vascular complications, duration of surgery, total blood loss, preoperative complications (such as hemothorax, pneumothorax, and need for further reoperation), and length of hospital stay. All patients who underwent TOS surgery were followed up at 2 weeks, 3 months, 6 months, and 1 year for clinical assessment. Patients who had arterial thromboembolectomy were followed up with duplex ultrasound scan.
In this observational study, sample size (n) was calculated with the following formula: n = z2 × p̂ (1 − p̂)/ε2, where confidence level = 95%, margin of error = 5%, population proportion = 3%, z is the z score (1.96 for confidence level 95%), ε is the margin of error, and p̂ is the population proportion, z = 1.96, p̂ =0.03, and ε = 0.05. The data were entered in MS Excel spreadsheet, and analysis was done using Statistical Package for the Social Sciences software version 16.0 (UNICOM Global, California, US).
| Results|| |
A total of 63 patients were operated for TOS over a period of 10 years. Most of the patients were young with approximately 2/3rd of the study population under the age of 30 years, with a mean age of 37 years. There was a female preponderance (63.5%) in our study population. Almost all the patients presented with a cervical rib (98.4%), and ¼th of them had a bilateral cervical rib. The majority (96%) of the patients were right handed, and in 59% of the patients, the presenting symptoms were right sided. There were 50 (79.37%) patients with NTOS and 13 (20.63%) with ATOS [Table 1].
|Table 1: Demographic profile, clinical features, and operative findings in patients of thoracic outlet syndrome|
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Neurological symptoms such as hypoesthesia along the course of the ulnar nerve or in the whole hand, fatigue and weakness of the small muscles of the hand, and pain in the neck and medial aspect of the upper limb were most predominant (79.4%). Rest of the patients presented with arterial symptoms such as claudication of the upper limb and coldness. Eleven out of the 13 patients who presented with ATOS required emergency thromboembolectomy [Table 1].
Plain chest X-ray view showed a cervical rib in all patients except in one patient who had a bifid first rib. Bilateral cervical rib was present in 16 (25.4%) patients [Figure 2]. Nerve conduction velocity (NCV) testing was done in 54 patients, and stress test was done in all patients. NCV was reduced in 48 (76.2%) patients, and in 50 (79.4%) patients, stress test was positive. Arterial color Doppler was abnormal in all patients, and 11 patients who required emergency thromboembolectomy had loss of waveforms [Table 1].
|Figure 2: X-ray chest depicting bilateral cervical rib (a) and complete right-sided cervical rib (b)|
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Operative findings correlated with radiological findings. Anomalous fibrous band was present in 13 (20.63%) patients. Cervical rib along with the first rib was resected in all the patients, and thromboembolectomy was done along with rib resection in 11 patients (17.46%) [Table 1].
The mean hospital stay was 3.09 days, and most of the patients were discharged within 3 days. There was no major blood loss in any patient requiring blood transfusion. All patients had symptomatic improvement, especially in pain and numbness. Postoperative complications occurred in 13 (20.6%) patients. Of these 13 patients, pleural breach occurred in 7 patients, which was managed per-perative by intercostal drainage tube placement. Minor wound infection was seen in five patients, which was managed conservatively using antibiotics and daily dressing. One patient had re-thrombosis which required repeat thromboembolectomy [Table 1].
| Discussion|| |
We studied 63 patients with TOS over a period of 10 years. Sixty-two (98.4%) cases had a cervical rib, which is similar to the 139 patients in a study by Lattoo et al., in which the prevalence of cervical rib was 100%. In another Indian study carried out by Samarasam et al., the prevalence of cervical rib was 95% in patients with TOS., In contrast, in a meta-analysis carried out by Henry et al., the overall prevalence of cervical rib in patients with TOS was only 29.5%, which was 39.9% in Asian subgroup population. The symptoms of TOS may be neurological, arterial, venous, or a combination of these, with or without autonomic disturbances. Neurological symptoms may result from compression of the lower divisions and trunks of the brachial plexus and result in brachial neuralgia, usually in the ulnar or median nerve distribution, or pain in the suprascapular region., Physical signs may be absent, but can include wasting and weakness, principally of the intrinsic muscle of the hand. when entrapment of upper portion of nerve plexus occurs, deltoid, scapular and occipital pain predominates. The autonomic symptoms of TOS include excessive sweating, pallor, or a blotchy appearance of the hands.,, ATOS may present as aching, fatigue, or upper-limb claudication, or with signs following prolonged arterial constriction including poststenotic aneurysm and distal emboli.,,, Venous constriction may present as acute venous thrombosis. Perhaps, the most common, but nonspecific, complaint is heaviness of the affected limb. There is no single definitive investigation that will confirm a diagnosis of TOS. However, arteriography and venography or duplex ultrasonography may show a vascular abnormality or its sequelae. Nerve conduction studies may suggest brachial plexopathy, or may confirm a more peripheral nerve entrapment. Plain radiography has little to offer, whereas computed tomography and magnetic resonance scans may demonstrate bony or soft-tissue elements which may be implicated in the syndrome.,, In the absence of any definitive investigation, the diagnosis of TOS is based on clinical findings in the majority of cases the stress tests (Adson, Halstead, and Wright tests) were most vauable investigation and tests became negative in those who had symptom resolution after surgery. Both medical and surgical management of the TOS have been described; strengthening of the shoulder girdle muscle, stretching of the pectoral minor muscle, and postural adjustments are parts of physiotherapy. Physiotherapy never corrects the pathophysiology of TOS, especially in the structural abnormality or bony anomaly, but it can delay surgical requirement. If symptoms do not improve on physiotherapy, an early surgical treatment should be considered. Different surgical approaches have been described for the decompression of TOS. Supraclavicular, infraclavicular, transaxillary, and video-assisted approaches are common in practice. Transaxillary approach of decompression of TOS is associated with the highest success rate, and similar results were seen in our study with 100% symptomatic relief., Per-operative, anomalous fibrous bands were discovered in 13 (20.6%) patients in addition to the cervical rib which was also excised. We did excision of the first rib and cervical rib in all the 63 patients for decompression of TOS through transaxillary subperiosteal approach. Eleven of the 13 patients who presented as an ATOS required thromboembolectomy along with first-rib excision. Bilateral disease was present in 16 (25.4%) patients, but only one side was operated at a time. Resolution of symptoms was seen in most of the patients in the early postoperative period. It is important that the minimum follow-up time exceeds 6 months for these patients, as in the majority of the cases, recurrence of symptoms occurs within 4 months of surgery.
All the patients in our series complained of significant physical impairment, and some were unable to continue their work. Majority of them were young within 18 and 56 years of age. Thoracic outlet decompression allowed a return to normal or near-normal levels of activity in the vast majority of those treated.
The morbidity in our series was low. Seven patients needed tube thoracostomy and five developed superficial wound infections. Only one patient developed re-thrombosis which was due to improper anticoagulation postoperatively. Patients achieved their preoperative level of mobility within a week of surgery, with most claiming improvement in activity following resolution of their symptoms. The morbidity encountered in our series was not sufficient to deter us from continuing to offer transaxillary rib resection.
Proper history and clinical examination are essential to diagnose and assess the functional disability. Radiographs, duplex scan, and angiogram are important in planning the treatment. In our opinion, whenever there is cervical rib as a cause of TOS, it is worthwhile to excise the first rib with cervical rib via transaxillary route. A heightened clinical awareness of TOS, coupled with a willingness to offer a low morbidity procedure to patients, may result in significant symptomatic improvement in a group of unfortunate patients who are physically impaired.
| Conclusions|| |
Transaxillary resection of the cervical/ first rib for TOS shows excellent results, with less morbidity. It is efficient in relieving symptoms and gives cosmetically acceptable scar. It is proposed that whenever any patient presents with acute upper-limb ischemia, he/she must be evaluated for cervical rib as a cause of TOS.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Davies AH, Walton J, Stuart E, Morris PJ. Surgical management of the thoracic outlet compression syndrome. Br J Surg 1991;78:1193-5.
Krishnan KG, Pinzer T, Schackert G. The transaxillary approach in the treatment of thoracic outlet syndrome: A neurosurgical appraisal. Zentralbl Neurochir 2005;66:180-9.
Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery 2004;55:897-902.
Criado E, Berguer R, Greenfield L. The spectrum of arterial compression at the thoracic outlet. J Vasc Surg 2010;52:406-11.
Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med 2009;11:176-83.
Glynn RW, Tawfick W, Elsafty Z, Hynes N, Sultan S. Supraclavicular scalenectomy for thoracic outlet syndrome – Functional outcomes assessed using the DASH scoring system. Vasc Endovascular Surg 2012;46:157-62.
Lattoo MR, Dar AM, Wani ML, Bhat MA, Ahangar AG, Lone GN, et al.
Outcome of trans-axillary approach for surgical decompression of thoracic outlet: A retrospective study in a tertiary care hospital. Oman Med J 2014;29:214-6.
Samarasam I, Sadhu D, Agarwal S, Nayak S. Surgical management of thoracic outlet syndrome: A 10-year experience. ANZ J Surg 2004;74:450-4.
Henry BM, Vikse J, Sanna B, Taterra D, Gomulska M, Pękala PA, et al.
Cervical rib prevalence and its association with thoracic outlet syndrome: A meta-analysis of 141 studies with surgical considerations. World Neurosurg 2018;110:e965-e978.
Thompson JF, Winterborn RJ, Bays S, White H, Kinsella DC, Watkinson AF, et al.
Venous thoracic outlet compression and the Paget–Schroetter syndrome: A review and recommendations for management. Cardiovasc Intervent Radiol 2011;34:903-10.
Likes KC, Orlando MS, Salditch Q, Mirza S, Cohen A, Reifsnyder T. Lessons learned in the surgical treatment of neurogenic thoracic outlet syndrome over 10 years. Vasc Endovascular Surg 2015;49:8-11.
Weaver ML, Lum YW. New diagnostic and treatment modalities for neurogenic thoracic outlet syndrome. Diagnostics (Basel) 2017;7. pii: E28.
Al-Hashel JY, El Shorbgy AA, Ahmed SF, Elshereef RR. Early versus late surgical treatment for neurogenic thoracic outlet syndrome. ISRN Neurol 2013;2013:673020.
Lum YW, Brooke BS, Likes K, Modi M, Grunebach H, Christo PJ, et al.
Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome. J Vasc Surg 2012;55:1370-5.
Chandra V, Olcott C 4th
, Lee JT. Early results of a highly selective algorithm for surgery on patients with neurogenic thoracic outlet syndrome. J Vasc Surg 2011;54:1698-705.
Marine L, Valdes F, Mertens R, Kramer A, Bergoeing M, Urbina J. Arterial thoracic outlet syndrome: A 32-year experience. Ann Vasc Surg 2013;27:1007-13.
Nehler MR, Taylor LM Jr., Moneta GL, Porter JM. Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg 1997;132:527-32.
Molina JE, D'Cunha J. The vascular component in neurogenic-arterial thoracic outlet syndrome. Int J Angiol 2008;17:83-7.
Moore R, Wei Lum Y. Venous thoracic outlet syndrome. Vasc Med 2015;20:182-9.
Arányi Z, Csillik A, Böhm J, Schelle T. Ultrasonographic identification of fibromuscular bands associated with neurogenic thoracic outlet syndrome: The “Wedge-sickle” sign. Ultrasound Med Biol 2016;42:2357-66.
Magill ST, Brus-Ramer M, Weinstein PR, Chin CT, Jacques L. Neurogenic thoracic outlet syndrome: Current diagnostic criteria and advances in MRI diagnostics. Neurosurg Focus 2015;39:E7.
Gillet R, Teixeira P, Meyer JB, Rauch A, Raymond A, Dap F, et al.
Dynamic CT angiography for the diagnosis of patients with thoracic outlet syndrome: Correlation with patient symptoms. J Cardiovasc Comput Tomogr 2018;12:158-65.
Roos DB. The place for scalenectomy and first-rib resection in thoracic outlet syndrome. Surgery 1982;92:1077-85.
[Figure 1], [Figure 2]