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Trans-axillary decompression of thoracic outlet syndrome patients presenting with cervical ribs
Sinan O. Jabori, Hugh A. Gelabert, MD, Andrew Barleben, MD, Juan C. Jimenez, MD, Brian G. DeRubertis, MD, Jessica B. O'Connell, MD, Jill Klausner, David A. Rigberg, MD.
David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
OBJECTIVES: Presence of a cervical rib in conjunction with symptoms appropriate to thoracic outlet syndrome (TOS) presents a high probability of accuracy in establishing the diagnosis of TOS. Our objective is to report contemporary data regarding a series of patients with thoracic outlet syndrome and cervical ribs.
METHODS: A retrospective chart review of a prospectively maintained database for all consecutive patients who underwent surgery for Thoracic Outlet Syndrome (TOS) was undertaken. Presenting symptoms, preoperative evaluation, surgical course, and follow up data were collected and form the basis of this report.
RESULTS: Between 1997-2012, a total of 31 patients presenting with cervical ribs underwent 46 operations for management of TOS. Average age 35 (range 16 to 67), 25 female, 6 males. This represented 6% of all TOS related procedures (707) over this period.
Neurogenic TOS symptoms (nTOS) accounted for 27 patients, 5 of whom had true neurogenic TOS. Arterial thrombosis was the presentation of all 4 arterial TOS patients. For nTOS patients preoperative evaluation included anterior scalene muscle block (n=22), electrodiagnostic studies (n=28) and cervical X-rays (n=27).
Arterial TOS patients were initially managed by thrombectomy. Trans-axillary first and cervical rib resection (TAFRR) was performed in a delayed manner. Two patients had arterial aneurysms requiring post-decompression reconstruction.
37 TAFRRs were performed in 30 patients. Trans-axillary cervical rib resection alone was performed in 1 patient. Total anterior scalene muscle resections were required in 5, and 2 patients required arterial reconstruction.
There were no intra-operative or post-operative complications including need for transfusion, nerve injuries (brachial plexus, long thoracic, phrenic, or throacodorsal), post-operative hematomas, lymph leak, early re-hospitalizations. Average blood loss was 56cc. The mean follow up was 341 days.
Complete resolution or minimal symptoms were noted in 28 (90%) of patients post-operatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in 3 patients. The majority of patients (n=30, 97%) were able to return work and resume normal activities.
CONCLUSIONS: Cervical and first rib resection can be performed by means of a trans-axillary approach with high degree of success and minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, or abnormal electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS is a marker for excellent outcome.
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