|Year : 2012 | Volume
| Issue : 2 | Page : 101-105
Surgical treatment of thoracic outlet syndrome; by supraclavicular approach
Osman Abd Ellah Mohamed, Hedaya Mohamed Hassan, Hatem Mohamed El Samouly
Department of Orthopaedic, Neurosurgy, Al-Azhar University, Damietta, Egypt
|Date of Web Publication||10-Nov-2012|
Osman Abd Ellah Mohamed
Department of Orthopaedic, Neurosurgy, Al-Azhar University, Damietta
Source of Support: None, Conflict of Interest: None
Background: Thoracic outlet syndrome comprises a wide spectrum of disorders with different compressive pathologies attributed to the neurovascular bundle passing from the root of the neck to supply the upper extremity. New concepts and advances in diagnosis and treatment are emerging. This study evaluates effectiveness and safety of the supraclavicular approach in management of neurovascular compression at the thoracic outlet. Materials and Methods: Twenty patients (15 females and 5 males) with mean age of 20 years (ranging from 18 to 40 years) underwent anterior neurovascular decompression procedures because of symptoms of lower plexus compression (C8 - T1). Preoperative plain radiography, MRI and nerve conduction velocity studies confirmed the clinical diagnosis. Nine patients had neck pain, all had sensory deficit and eight had motor deficit. Results: After 35 months of follow-up, 17 patients showed excellent results, two cases had good results and one case had fair results according to the visual analog scale, and nerve conduction velocities. Conclusions: We recommend nerve conduction velocity studies beside clinical assessment for diagnosis and follow-up, and supraclavicular approach in neurogenic decompression which is relatively safe and effective.
Keywords: Cervical rib, supraclavicular approach, thoracic outlet syndrome
|How to cite this article:|
Mohamed OA, Hassan HM, El Samouly HM. Surgical treatment of thoracic outlet syndrome; by supraclavicular approach. Med J DY Patil Univ 2012;5:101-5
|How to cite this URL:|
Mohamed OA, Hassan HM, El Samouly HM. Surgical treatment of thoracic outlet syndrome; by supraclavicular approach. Med J DY Patil Univ [serial online] 2012 [cited 2020 Jul 12];5:101-5. Available from: http://www.mjdrdypu.org/text.asp?2012/5/2/101/103327
| Introduction|| |
Thoracic outlet syndrome (TOS) results from compression of the neural or vascular structures of the upper extremity at the thoracic outlet. Previously, the name was designated according to the etiologies of compression, such as scalenus anterior, costoclavicular, hyperabduction, cervical rib, or first rib syndromes. ,
The thoracic outlet is formed by first rib on both sides the vertebra posteriorly and manubrium sterni anteriorly. The scalene triangle is formed by the first thoracic rib below and the anterior and middle scalene muscles in front and behind, respectively. 
People who develop clinical manifestations of TOS have one or more congenital anomalies that predispose them to develop symptomsin the upper extremity such as pain, paresthesias, numbness, weakness, fatigability, swelling, discoloration, and Raynaud phenomenon. Four symptom patterns have been described: upper plexus, lower plexus, vascular (≤10% of all cases), and mixed. The lower brachial plexus pattern is the most common. 
Atypical pain involves the anterior chest wall and parascapular area, and is termed pseudo-angina because it simulates angina pectoris. ,,,,,
Ulnar neuropathy may be confused with TOS, because lower plexus lesions (C8 and T1 root lesions) and ulnar neuropathy give rise to sensory symptoms on the ulnar aspect of the hand. Positive nerve conduction studies, absence of involvement of the abductor pollicis brevis, Tinel's sign at the elbow, and clear sensory changes on the ulnar (as opposed to the radial) aspect of the ring finger, all serve to help distinguish the two disorders. ,
MRI scan has been cited to be both moderately sensitive and specific for TOS. Electromyogram studies are useful whenever muscle atrophy is suspected. Nerve conduction velocity (NCV) studies confirm the diagnosis when there are neurological signs with reduction in NCV to less than 60 m m/s; normal is 85 m/s, of either the ulnar or median nerves across the thoracic outlet. ,,,
In most cases the initial treatment is conservative. Surgery is indicated for acute vascular insufficiency, neurological dysfunction with a significantly reduced NCV, and refractory pain that fail conservative treatment. The surgical technique involves the release or removal of the structures that cause compression and can involve scalene muscle release, first rib resection, cervical rib excision, and resection of fibromuscular bands. ,,,,,,,,
| Materials and Methods|| |
The study is a case series, comprising of 20 patients operated upon for thoracic outlet syndrome from 2001 to 2011 in our University hospital to evaluate effectiveness and safety of the supraclavicular approach in management of neurovascular compression in the region of the thoracic outlet.
Lower plexus (C8-TI) compression at the root of the neck as evident by clinical examination and nerve NCV studies.
Pure vascular compression, vascular complication, double crush syndrome (peripheral nerve entrapment with proximal compressive pathology), cervical degenerative disc disease and malignant compressive pathology.
History and Clinical Examination
Pain in the supraclavicular fossa, radiating to upper arm, forearm and hand, particularly in the ulnar distribution. Pain worsened by arm abduction more than 30 minutes. Pain became worse 1-2 hrs after sleep. Three or more of the following present:
Imaging studies included preoperative anterior-posterior and lateral cervical spine plain radiography, MRI cervical spine to detect cervical ribs (bony, cartilaginous, or fibrous bands), or any compressive pathology as Pancost tumor.
- Distinct tenderness in the supraclavicular fossa.
- Tinel's sign in the supraclavicular fossa. Tapping this area with the head turned to the contralateral direction evokes tingling paresthesias in the hand C8/TI distribution.
- Tingling paresthesias in the hand C8/TI distribution with downward tugging on the arm or with abduction of the arm to a position above the head.
- Tingling paresthesias in the hand C8/TI distribution.
- Weakness and wasting in the hand C8/TI distribution especially the first dorsal interosseus muscle and abductor pollicis brevis muscle.
- Failure of medical treatment and physiotherapy more than 6 months.
Nerve conduction velocities (NCV) confirmed the clinical diagnosis with reduced NCV >60 m/s. (normal is 85 m/s).
Seventeen patients (80%) had neck pain, all (100%) had sensory deficit, and (30%) had motor deficit. Age group ranges from 18 to 40 years with average 20 years. Duration of symptoms ranges from 3 to 7 years with average 5 years.
All patients underwent neurovascular decompression through anterior scalenotomy utilizing the supraclavicular approach. The average operative time was 1 hour, and the average blood loss was 50 cc.
Supraclavicular Approach [Figure 1], [Figure 2], [Figure 3] and [Figure 4]
|Figure 1: The relationship of vascular and neural structures in the scalenic triangle|
Click here to view
|Figure 2: (a) Plain X-ray Anterior posterior view showing (lt) cervical rib. (b) Plain X-ray Lateral view showing (lt) cervical rib. (c) MRI fi nding in coronal view (lt) cervical rib|
Click here to view
|Figure 3: (a) The incision used for the supraclavicular to the brachial plexus. (b) Exposure. (c) Dissection of the anterior scalene muscle. (d) Anterior scalene muscle compressing trunks. (e) Cutting of anterior scalene muscle. (f) Neurolysis after anterior scalenectomy. (g) Excised rib|
Click here to view
|Figure 4: Postoperative antroposterior X-ray after of cervical rib with shadow of collar|
Click here to view
General anesthesia was used. An incision of about 5 cm was made parallel to the clavicle. The platysma was opened, and the lateral third of the sternocleidomastoid muscle was divided if needed. The omohyoid muscle was divided as the scalene fat pad was mobilized to reveal the upper trunk of the plexus. The anterior scalene muscle was encountered, along with the phrenic nerve, which courses along the axis of the muscle fibers in its position on top of the scalene muscle. A neurolysis of the phrenic nerve was performed and the nerve was mobilized in this manner away from the muscle. Tension in the anterior scalene muscle was examined as well as the space between the clavicle and the first rib. The anterior scalene muscle was then bisected retracted away. The middle trunk comes into view. The middle and lower trunks of the plexus lie in a position infero-posterior to the upper trunk. A neurolysis of the middle trunk was performed, followed by a neurolysis of the lower trunk. Vessel loops was placed around the middle trunk (the C7 root) and around the C8 and T1 roots. The T1 root emerges from the anterior side of the posterior aspect of the first rib.
Several different anomalies may be observed. Any fibrous bands that arise from the apex of the pleura or the first rib should be taken down. Dissection down to the first rib and apex of the lung can be done either between the lower and middle trunk, or alternatively between trunk, or alternatively between the middle and upper trunk. Resection of an anomalous cervical rib or band is quite easy with this approach.
| Results|| |
Patients were followed up immediate postoperatively, 1 month and then 12 months postoperatively; using the NCV studies and visual analog scale.
Preoperative NCV studies ranges from 54 to 49 m/s (Mean 50.82, SD 1.42), while the immediate postoperative values ranges from 63 to 75 m/s (Mean 69.29, SD 3.33) [Table 1].
|Table 1: Follow-up visual analog scale (VAS) and nerve conduction velocity (NCV)|
Click here to view
Preoperative visual analog scale ranges 7-9 (Mean 8, SD 0.79), while 12-month postoperative values range from 2 to 4 (Mean 3.20, SD 1.01) [Table 1].
The results were excellent with elimination of symptoms in 17 patients (85%), good with significant improvement of symptoms with no use of medications in two patients (10%), fair with moderate improvement of symptoms with occasionally use of medications in one patient (5%). None had persistence or aggravation of symptoms.
Three patients had increased shoulder and arm pain 1 month postoperatively which was controlled with simple analgesics. One patient had recurrent neck pain due to superficial wound infection which was resolved with antibiotics and analgesics.
Four patients had shoulder hypoesthesia because of severing of the supraclavicular nerves.
| Discussion|| |
The present study achieved good to excellent results in majority of the cases, with very few complications. Our results are consistent with the literature with the advantage of eliminating complications of first rib excision.
Adson  was the first to approach the thoracic outlet area from the front and to emphasize the contribution of the scalenus anticus tendon to the syndrome.
Samarasam,  reported a total of 60 patients underwent 63 operations for decompression of TOS. All the 63 first ribs, were excised by the transaxillary approach. In seven patients (16%), a combined transaxillary and supraclavicular approach was used. There was no operative mortality in the series. The operative complications included pneumothorax in four patients (6.3%), which was treated by insertion of chest drain, and lower brachial plexus neuropraxia in two patients (3%), which improved with conservative management. At 12 months following surgery, 56 patients (93%) had complete or partial relief of symptoms and only four patients (6.6%) had no relief of symptoms.
Nizard et al.,  operated upon 17 men (23%) and 59 women (78%) by musculotendinous release through a supraclavicular approach division of bands, scalenus anterior, scalenus medius, or accessory scalenus muscle as required and reported that severe pain present in 62 cases (82%) preoperatively was absent in 33 cases (43%), slight in 18 cases (24%), significant in 10 cases (13%) and severe in one case (1%) postoperatively. Weakness or a motor deficit was noted in 48 cases (63%) preoperatively and was found in 17 cases (22%) postoperatively. Sensory signs which were present in 61 cases (80%) preoperatively remained present in 22 cases (29%) postoperatively. The overall functional result as a function of the severity of the pain and the satisfaction of the patient showed 32% of excellent results, 44% of good results, 7% of fair results and 17% of poor results. Ten failures (13%) consisted of six (8%) recurrences after a period free of symptoms for between 6 months and 6 years and four (5%) immediate failures in which the operation was never effective.
Efstathopoulos et al.,  operated on 42 patients for thoracic outlet syndrome utilizing a supraclavicular incision reported that results were classified as excellent in 16, who were free of symptoms, good in 12, who complained of mild sympotoms on daily activities but were significantly improved, poor in 6 who had persistent or aggravation of their symptoms. Four patients from the poor results group were treated by 1 st rib excision, on a later stage and experienced significant improvement. The operative complications include one case of pneumothorax and a temporary dysfunction of the phrenic and XI cranial (accessory) nerve. No postoperative complications were found. Whilst the cause of recurrence remains controversial, many authors suggest that this is due to adhesions of scar tissue to the nerves and vessels at the axilla.
Altobeli et al.,  2005 operated upoin 185 patients with neurogenic TOS by the same operative protocol: (1) transaxillary first rib resection and the lower part of scalenectomy for the primary procedure with or without (2) the subsequent upper part of scalenectomy with supraclavicular approach for patients with persistent or recurrent symptoms. The complication rate was 4% and consisted of 7 pneumothoraxes, 3 subclavian vein injuries, 1 nerve injury, 1 internal mammary artery injury, and 1 suture granuloma.
Sanders and Hammond  reported 54 operations for neurogenic TOS with supraclavicular cervical rib resection and scalenotomy without first rib resection in 22 cases, supraclavicular cervical and first rib resection in 17 cases, supraclavicular excision of anomalous first ribs in five cases, and transaxillary anomalous first rib resections in two cases (total, 46 cases). Eight reoperations were performed for recurrent TOS in patients who previously had undergone cervical and first rib resections. The surgical failure rib rescetion in the work-related group was 75% compared with a failure rate of 38% in the non-work-related group. In contrast, when both cervical and first ribs were resected, the failure rate in the work-related group fell to 25% and in the non-work-related group to 20%. He concluded that surgery for neurogenic TOS in patients with cervical ribs should include both cervical and first rib resection.
Michael  in a heterogeneous group of 40 patients reported that in 23 patients, the cervical rib was removed together with fibrous band excision in 9 patients; 17 patients had no cervical rib. At follow-up (range, 3 months to 20 years). Arm pain significantly diminished or disappeared in 33 of 36 patients. Twenty-three patients reported improved hand function, and strength improved in 14 of 27 patients, although established muscle wasting never improved. Those with and without cervical ribs did equally well. Progressive wasting and weakness occurred despite surgery in 3 patients: two actually had spinal muscular atrophy and one had a Chiari malformation More Details.
The management of TOS is still challenging with many surgical approaches for decompression have been attempted, but only the transaxillary and supraclavicular routes carry the best outcomes. 
We recommend nerve conduction velocity studies beside clinical assessment for diagnosis and follow-up. We also recommend a selective and tailored approach via the supraclavicular route for anterior scalenotomy with resection of the first rib but with additional surgical procedures according to the underlying abnormalities. i.e. excision of cervical rib or band. This approach is relatively safe and effective with rewarding results in relieving neck and arm pain while allowing adequate neurovascular decompression in precisely selected patients with neurovascular compression in the region of the thoracic outlet.
| References|| |
|1.||Campbell JN. Thoracic outlet syndrome. In: The Adult Spine. Principles and Practice. Frymoyer JW, Frymoyer JW, editors. 2 nd ed. Lip-Pincott-Rave; 1997. p. 1349-55. |
|2.||Bisschop P. Nerve lesions and entrapment neuropathies of the upper limb in A System of Orthopedic medicine. Ombergt L, Bisschop P, Veer HJ, editors. 2 nd ed. Williams & 2003. p. 543- 80. |
|3.||Agur AM, Lee MJ. Grant Atlas of Anatomy. 9 th ed. The Neck: Williams & Wilkins; 1996. p. 549-606. |
|4.||Urschel HC Jr, Razzuk MA. Neurovascular Compression in the Thoracic Outlet: Changing Management Over 50 Years. Annals of surgery. Philadelphia: Lippincott Williams & Wilkins; 199. p. 609-17. |
|5.||Efstathopoulos D, Mihos P, Gakidis V, Seitaridis S, Kokkalis Z, Kaldis P. Thoracic outlet syndrome. Our experience from resection of the first rib through transaxillary approach. Orthopedic Preceedings: Hellenic Association of Orthopedic Surgery and Traumatology: Athens Greece. 2003. p. 15-9. |
|6.||Gerostathopoulos N, Georgiades G, Sotiropoulos C, Giannoulis F, Goudelis G. The results of the surgical treatment of the thoracic outlet syndtrome. Orthopaedic Proceedlings: Hellenic Association of Orthopaedic Surgery and Traumatology: Athens Greece. 2003. p. 15-9. |
|7.||Efstathopoulos D, Spridonos S, Aretaiou P, Seitaridis S, Dimitriadis A, Cavounelis A. Our experience of surgical treatment of thoracic outlet syndrome. Orthopedic Proceedings: Hellenic Assciation of Orthopedic Surgery and Traumatology (HAOST): Thessaloniki, Greece. 2002. p. 22-7. |
|8.||Naidu SH, Kothari MJ. Thoracic outlet syndrome: does fiction outweigh facts? Current Opinion in Orthopedics 2003;14:209- 14. |
|9.||Urschel HC Jr, Razzuk MA, Hyland JW, Matson JL, Solis RM, Wood RE, et al. Thoracic outlet syndrome masquerading as coronary artery disease. Ann Thorac Surg 1973;16:239-48. |
|10.||Caldwell JW, Crane CR, Krusen EM. Nerve conduction studies in the diagnosis of the thoracic outlet syndrome. South Med J 1971;64:210-2. |
|11.||Peet RM, Hendriksen JD, Anderson TP, Martin GM. Thoracic outlet syndrome: Evaluation of the therapeutic exercise program. Proc Staff Meet Mayo Clin 1956;31:281-7. |
|12.||Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery 2004;55:897-903. |
|13.||Nichols AW. The thoracic outlet syndrome in athletes. J Am Board Fam Pract 1996;9:346-55. |
|14.||Adson AW. The Classic surgical treatment for symtoms produced by cervical ribs and clinical orthopaedics and related research 1986;207:3-12. |
|15.||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. |
|16.||Nizard R, Castanedo A, Sedel L. Results of surgical treatment of neurological forms of the thoracic outlet syndrome. Orthopedic Proceedings: Societe Francaise Dechirurgie Orthopedique Et Traumatologique: Scientific Papers. Paris, France: 1995. p. 7-10. |
|17.||Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy BS, Ahn SS. Thoracic outlet syndrome: Pattern of clinical success after operative decompression. J Vasc Surg 2005;42:122-8. |
|18.||Sander RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg 2002;36:51-6. |
|19.||Michael R. Is surgery beneficial in thoracic outlet syndrome? Journal Watch Neurology 2000;2000:12. |
|20.||Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev 2010;1:CD007218. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]