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Eur J Cardiothorac Surg 2006;30:232-236
© 2006 Elsevier Science NL
a Department of Cardiothoracic Surgery, University Medical Center Groningen, The Netherlands
b Department of Internal Medicine, University Medical Center Groningen, The Netherlands
Received 6 March 2006; received in revised form 10 April 2006; accepted 11 April 2006.
* Corresponding author. Address: Thorax Centre, Room T4.234, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands. Tel.: +31 50 3613238; fax: +31 50 3611347. (Email: t.ebels{at}thorax.umcg.nl).
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Abstract |
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 Top Abstract 1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Key Words: Thoracic outlet syndrome • Surgery • Transaxillary approach
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1. Introduction |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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It is unknown whether the completeness of the first rib resection is related to residual or relapsing symptoms. The aim of the present report was to assess the relation between the remaining posterior first rib stump to residual symptoms in patients after transaxillary first rib resection for vascular TOS.
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2. Patients and methods |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Pre-, peri- and postoperative hospital records and PPG studies of the patients were reviewed retrospectively.
Follow-up information was obtained by a standardized telephone questionnaire. The symptomatic relief was classified as Excellent (relief of all symptoms); Good (relief of the major symptoms with some residue of symptoms); Fair (improvement in some symptoms, but persistence of major ones); and Poor (failure, no significant improvement). The procedure was considered a success if the patient reported an excellent, good or fair result [2,6].
Only those patients were included in the study in whom the piece of rib and the height of the 10th thoracic vertebra were clearly visible.
Measurements of the rib stump were made by one single person (L.I.G.) with a ruler in millimeter. Measurements of the height of the tenth thoracic vertebra were made by the same person on the same X-ray film to rule out magnifying problems. The line of the measurements was as close to the midline as possible, not to include the projection of the posterior spinous process.
2.2 Surgical technique
The technique used to perform the first rib resection is based on the transaxillary approach described by Roos [8]. The patient is positioned in a semi-lateral position with the arm in 90° abduction, held in position by a second (sturdy) assistant. The axillary space is opened through an incision in the lower axillary hairline from the pectoralis major to the latissimus dorsi muscles. The intercostobrachial nerve is spared if possible. The axillary vein, artery, and the plexus are identified. Unlike Roos’ original description, the periosteum is resected along with the first rib in order to avoid osteal regeneration. The anterior scalenus muscle is divided after passing a clamp behind it. The medial scalenus muscle's insertion is stripped off the first rib with a periostal elevator. Division of the medial scalenus muscle is not advisable for danger of damaging the long thoracic nerve. The intercostal muscles are divided between the first and second rib, by stripping them off the first rib with a forked periostal elevator. The costoclavicular ligament is divided. The rib is cut at its anterior aspect by a pair of straight bone scissors, then the rib is cut at its posterior aspect, posterior to the plexus, by a straight angled pair of bone scissors. Unlike Roos’ original description, the rib has not systematically been divided quite at the articulation with the transverse process, when this point was difficult to reach behind the brachial plexus, thus leaving a posterior rib stump of variable length. After removal of the rib, the cut surfaces of the rib stumps were carefully checked for sharp edges. Cervical ribs or other fibrous ligaments are resected when present. The pleura is checked for its integrity, when opened a drain is placed in the pleural cavity. Only the subcutaneous tissues and the skin are closed by absorbable sutures.
2.3 Patient demographics
Included in our group were 15 males and 17 females (N
= 32). One patient was lost to follow-up, three patients were excluded from this study because the rib stump could not be measured due to poor quality of the postoperative X-ray. Seven patients (18%) were operated on both sides; one patient was operated first on one side in another hospital, we did not include the result of that affected limb in our study. The right side was operated on 19 times (49%) and the left side 20 times (51%). Patients’ mean age was 43 ± 10 years (range 24–76 years). Mean follow-up time was 107 ± 40 months (range 8–153 months, almost 13 years). Mean body mass index was 24.2 ± 3.7. Mean time of onset of symptoms was 6.2 ± 7.2 years (range 0–32 years, median 3 years) prior to surgical removal of the first rib.
In our population, 8 patients (21%) had a previous trauma preceding symptoms of TOS. An old and healed clavicular fracture was diagnosed in two patients. Two patients with a previous trauma had complaints of both arms and were operated on both sides. Two patients had a previous thrombosis of the axillary vein (Paget–Schroetter syndrome), one patient had an occlusion of the ulnar artery.
Referring doctors were general practitioners, general surgeons and rehabilitation doctors. Patients visited generally a median of three other specialists before referral to our department, with a maximum of eight other specialists.
Preoperative EMG testing was negative for carpal tunnel syndrome in 23 affected upper limbs of the patient, 1 patient had a positive EMG test for carpal tunnel syndrome. For 15 affected upper limbs of the patient, EMG data are not known retrospectively. Six patients (15%) had a cervical rib visible on preoperative chest X-ray.
2.4 Statistical analysis
For statistical analysis of the data we used SPSS 11.0© (SPSS Inc., Chicago, IL, USA). Spearman's rho correlation test was used to evaluate the result with the relative rib stump length. One-way ANOVA testing was used for multi variance analysis. Independent sample t-test was used if necessary. Statistical significance was defined as P
< .05.
2.5 Complications
No patient died during follow-up. No other major complication occurred in our patient group. In 4 cases (10%), the intercostobrachial nerve was consciously sacrificed. In one patient a cervical rib was not resected, and a wound infect complicated the postoperative course of one other patient.
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3. Results |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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4. Discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Our series only included patients with clinically proven vascular compression in the thoracic outlet region. The vascular structures are positioned more anterior in the thoracic outlet region than in the brachial plexus. Possibly the symptoms of the patients in our study group with a poor outcome have shifted from vascular origin to a more neurological basis. The remaining posterior rib stump is said to be an anchoring point for attachment of scar tissue. The scar tissue may compromise the posterior structures more easily than the arterial structures positioned slightly more anterior in the thoracic outlet, but in the same space bordered by the scalenus muscles. This might explain why in patients who had obvious vascular compression but insufficient relief of the surgery, the vascular compression is no longer detectable by physical examination while symptoms remain: the symptoms have changed their origin from vascular compression to compromise of the brachial plexus. As patients with exclusive neurogenic TOS are not represented by our series, we cannot assess the role of the rib stump in patients with neurogenic TOS exclusively. The difference between these different groups of patients will be interesting for further investigation. Paradoxically, while patients were selected for vascular compression being located anterior to the plexus, the correlation with the length of the posterior rib stump suggests that the anatomic basis of the residual complaints is located posterior, and thus neurological in origin. We did not perform neurologic testing after the surgery to make the shifting of symptoms from a vascular origin to a more neurologic one more clear.
For the transaxillary first rib resection the surgical technique as described by Roos [8] was used. Traction on the arm was provided by an assistant. Urschel [12] describes his technique with continuous traction on the arm by a 1–2 lb weight. Continuous traction can cause ischemic damage to the nerves. If traction is provided by an assistant, the natural fatigue of the arms of the assistant are an indicator for lessening the traction, also on the nerves. Both nerves and assistant can recuperate shortly, before traction is continued and possible ischemic damage of the nerves is thus prevented. Obviously, this technique is dependent on the stamina of the assistant.
Axelrod et al. [13] reported a correlation between depression and reported pain and the outcome of the surgery for neurogenic TOS. By analyzing our data, we have excluded three patients with a poor outcome. We did not use psychological tests for preoperative screening of our patient group. Retrospectively we must conclude that although vascular compression was present in these patients, their symptoms were not caused (only) by TOS. In hindsight, these patients should not have been offered a first rib resection.
In our institute we used digital PPG to demonstrate and register arterial vascular compression. PPG is not often used in the clinical workup for a TOS patient. Leffert and Perlmutter [14] found in 82% of their patients a positive PPG. In their study, Lai et al. [15] found PPG as a significant predictor of outcome after surgery. Colon and Westdorp [16] studied the various maneuvers in healthy subjects of different age groups. Their conclusion was that zero flow during the Adson or ‘military’ maneuver in a patient with symptoms is a significant finding for thoracic outlet syndrome, but zero flow during 120° abduction is not. We did not analyze the PPG outcome as a predictive value for the surgery, but used it as a confirmation of our physical examination. We will perform a more detailed study evaluating the results of PPG in patients with TOS in the future. Although its role is still discussed, we find PPG a useful, non-invasive test to document arterial compression in provocative maneuvers.
The length of the follow-up time is an important parameter in interpreting the success rate of the surgery for TOS. Lepäntalo et al. [17] and Sanders et al. [9] reported that longer follow-up time worsens surgical outcome. Altobelli et al. [1] recommend a follow-up time of 
18 months. In our series of patients the mean follow-up time was 107 ± 40 months, well over the 18 months recommended. The mean follow-up time for the different result groups was 104 months for excellent, 108 months for good, 107 months for fair, and again 108 months for a poor result. There is no significant difference between the groups in follow-up time. Only one patient had a follow-up time (8 months) under the recommended 18 months; he reported a good result after the operation.
In this article we want to emphasize that our patient group was selected for arterial compression in the thoracic outlet. We only make the diagnosis ‘TOS’ if vascular compression is obvious on clinical examination and PPG. We have the impression that the diagnosis TOS is often offered to a wider patient population, especially if it concerns neurological symptoms. This is partly due to the lack of objective testing methods, but in our opinion it varies greatly with the doctor's own definition of TOS too. Some define TOS as the occurrence of paresthesias with brachial plexus nerve compression or muscle imbalance in the region of the back, neck, and shoulder [18], where others have serious reservations with the existence of this syndrome at all (or parts of it) [19]. This difference of opinion causes major problems in the interpretation of the investigated patient groups. Misdiagnosis of TOS is said to be the most common reason for poor outcome after first rib resection. Our strategy only to offer surgery to patients with proven vascular compression hopefully limits the number of misdiagnoses. In at least three patients in our group, the diagnosis was incomplete or not correct. Potentially this could be the case for a larger number of patients in our group.
We investigated the exact role of the posterior rib stump in the initial outcome after transaxillary first rib resection for TOS with proven vascular compression. The length of the posterior rib stump is correlated with the initial outcome of transaxillary first rib resection in our group of patients with TOS with vascular compression and probably not for the more diverse group with only neurological complaints. We advise to resect the first rib as close as possible to the articulation with the transverse process of the first thoracic vertebra.
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References |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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This article has been cited by other articles:
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  R. J. Sanders Vascular thoracic outlet syndrome Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 753 - 753. [Full Text] [PDF]
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L. I. Geven, A. J. Smit, and T. Ebels Reply to Sanders Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 753 - 754. [Full Text] [PDF]
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