Remaining or Residual First Ribs are the Cause of Recurrent Thoracic Outlet Syndrome

Surgical intervention for Neurogenic Thoracic Outlet Syndrome (NTOS) is not always successful. Treatment plans can be difficult in patients presenting with recurrent symptoms. The purpose of this study was to evaluate outcomes of this patient subset, who underwent operative intervention to remove a remaining or residual first rib due to recurrent TOS-related symptoms.

METHODS:

Data on 15 patients who presented with previous scalenectomy, brachial plexus lysis, or first rib resection and scalenectomy (FRRS) with residual rib present on chest radiograph from 2004-2012 were retrospectively reviewed from a prospectively maintained database, with approval from the Institutional Review Board (IRB). Patients were classified as having a remaining first rib if they presented with recurrent NTOS symptoms, had previously undergone scalenectomy and/or brachial plexus lysis alone to decompress the thoracicoutlet, and exhibited an intact first rib on chest x-ray, whereas patients were classified as having a remnant rib if they presented with recurrent symptoms of NTOS, had previously undergone a first rib resection at another institution, and exhibited an anterior or posterior first rib on chest x-ray. Demographic and clinical characteristics along with postoperative outcomes were evaluated.

RESULTS:

Different precipitating events re-aggravated symptoms in 12 patients. Events included car accidents(n=4), work related repetitive movements(n=5), lifting heavy objects(n=2) and repetitive injury(n=1). Group 1: Previous scalenectomy(n=2), brachial plexus lysis alone(n=2), or both(n=3) Seven patients(2M/5F; mean age 34(25-53)) presented with neurogenic TOS symptoms due to a remaining first rib at an average of 24 months(range 2-68) following their initial operation at another institution. All underwent transaxillary first rib resection, residual scalene resection, and lysis of scar tissue. Perioperative complications included 3 pneumothoraces without any artery, vein or brachial plexus injury. Average follow-up was 17 months(range 1-79) and all patients improved in the postoperative period. Group 2: Residual rib(n=8) Eight patients(2M/6F; mean age 39(24-58)) presented with a residual first rib at an average of 44 months(range 12-107) following their initial operation at another institution. Six patients had undergone prior supraclavicular FRRS, 1 had undergone previous transaxillary FRRS, and 1 had undergone FRRS via an anterior chest approach. Seven of the 8 patients presented with neurogenic symptoms alone, and 1 presented with recurrent venous thrombosis in addition. A residual rib was present in all 8 patients, as seen by chest radiograph. A transaxillary approach was used to resect the residual first rib, anterior scalene muscle remnant, and scar tissue in 7 patients and a supraclavicular approach was used in 1 patient. Perioperative complications included 4 pneumothoraces without any artery, vein, or brachial plexus injury. Average follow-up was 13 months(range 1-64) and all patients improved in the postoperative period.

CONCLUSIONS:

Patients who present with recurrent symptoms of thoracic outlet syndromeneed to be evaluated for remaining or residual first ribs. Operative intervention to remove the remaining or residual first rib in this patient subset is beneficial and can be performed without significant morbidity. Patients undergoing procedures for thoracic outlet syndrome supports our procedure of complete first rib removal at the time of the initial operation to prevent recurrence of symptoms.

Copyright © 2014 Elsevier Inc. All rights reserved.

PMID:

 

24462539

 

[PubMed - as supplied by publisher]