First Rib Resection in Thoracic Outlet Syndrome

doi:10.1016/j.jhsa.2007.01.018

The Journal of Hand Surgery

Volume 32, Issue 4, April 2007, Pages 565-570

https://doi.org/10.1016/j.jhsa.2007.01.018 Get rights and content

Most patients with thoracic outlet syndrome (TOS) present with exercise-induced upper extremity paresthesia. Neurogenic TOS is the most common type where the brachial nerve plexus is compressed against a tight thoracic outlet. Vascular compromise although rare can result from thoracic outlet pressure against the subclavian artery or more commonly the subclavian vein. This article reviews the pathophysiology of TOS and describes several effective surgical interventions. Complete first rib resection with surgical decompression is an essential part of the treatment for TOS. First rib resection via supraclavicular or a preferred transaxillary route should be considered when conservative modalities provide no symptom improvement.

Section snippets

Pathophysiology of TOS

Thoracic outlet syndrome results from impending thoracic outlet pressure on the neurovascular bundle exiting the thoracic cavity and entering the upper extremity. The pressure is created by several factors. These include the first rib and accessory or cervical ribs. Associated surrounding hypertrophic muscles, namely the scalene and the subclavius with their corresponding tendons, will also contribute to this local pressure syndrome. Detailed understanding of the local anatomy is critical in

Diagnosis

A detailed history and examination is usually sufficient to suspect and even diagnose TOS. Arm claudication, exercise-induced paresthesia, color discoloration after exercise or after erect postures are highly suspicious of TOS. Absent radial pulse with contralateral head rotations (Adson maneuver) is helpful but not always present in patients with TOS. Some normal individuals also tend to have a positive Adson test. Additional investigations are helpful but not mandatory in the diagnostic

Treatment

Physical therapy with special dedicated postural exercises should be routinely used as the initial treatment for TOS. However, patients with severe symptomatic TOS will often not benefit from physical therapy.¹

The decompression of the neurovascular bundle in vascular TOS should include the first rib resection in each case.⁸ This is an essential step in therapy of all 3 types of TOS (neurogenic, venous, and arterial).

Cases of the venous form of TOS who present with Paget-Schroetter syndrome

Discussion

Some prefer a combination of approaches to treat TOS. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. Some prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.²²

One study followed 300 operations for TOS for at least 1 year. The first group was treated with either supraclavicular or transaxillary

Conclusions

Thoracic outlet syndrome should be suspected in individuals with upper extremity vascular compromise and paresthesia. First rib resection remains an important and essential step in management of the TOS. This procedure can be performed with minimal morbidity and with excellent outcomes. Both the supraclavicular route and the transaxillary route of the first rib resection remain effective surgical techniques and should be considered in patients with refractory symptoms.

References (26)

R.J. Sanders et al.
Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome
J Vasc Surg
(2002)
R.J. Sanders et al.
Subclavian vein obstruction without thrombosis
J Vasc Surg
(2005)
C.O. Brantigan et al.
Diagnosing thoracic outlet syndrome
Hand Clin
(2004)
C.O. Brantigan et al.
Etiology of neurogenic thoracic outlet syndrome
Hand Clin
(2004)
D.J. Caparrelli et al.
A unified approach to axillosubclavian venous thrombosis in a single hospital admission
Semin Vasc Surg
(2005)
D.B. Schneider et al.
Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty
J Vasc Surg
(2004)
H.C. Urschel et al.
Paget-Schroetter syndrome therapy: failure of intravenous stents
Ann Thorac Surg
(2003)
R.J. Sanders et al.
Supraclavicular first rib resection and total scalenectomy: technique and results
Hand Clin
(2004)
P.E. Fulford et al.
Outcome of transaxillary rib resection for thoracic outlet syndrome—a 10 year experience
Cardiovasc Surg
(2001)
G.G. Altobelli et al.
Thoracic outlet syndrome: pattern of clinical success after operative decompression
J Vasc Surg
(2005)

D.B. Roos

Experience with first rib resection for thoracic outlet syndrome

Ann Surg

(1971)

W.G. Jamieson et al.

Thoracic outlet syndrome: fact or fancy?A review of 409 consecutive patients who underwent operation

Can J Surg

(1996)

R.D. Leffert et al.

Thoracic outlet syndromeResults of 282 transaxillary first rib resections

Clin Orthop Relat Res

(1999)

Cited by (37)

Pectoralis minor syndrome – review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome
2022, JSES Reviews, Reports, and Techniques
Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.
PECS II Block Combined with Supraclavicular Brachial Plexus Block Allows Anesthesia for Transaxillary Thoracic Outlet Syndrome Decompression Surgery
2021, Journal of Cardiothoracic and Vascular Anesthesia
Measurement of Outlet Pressures Favors Rib Resection for Decompression of Thoracic Outlet Syndrome
2020, Annals of Thoracic Surgery
When conservative therapy for thoracic outlet syndrome fails, scalenectomy with or without first-rib resection (FRR) is the treatment of choice. We measured pressure in the costoclavicular space before and after FRR at time of neurogenic thoracic outlet syndrome release to evaluate whether FRR is required to completely decompress the costoclavicular space.
Using a supraclavicular exposure for anterior-middle scalenectomy with FRR, costoclavicular space pressures were measured using a balloon catheter with the patient’s arm in neutral anatomic position, secondarily, the arm abducted and externally rotated. Pressures were recorded in both arm positions before scalenectomy, after scalenectomy, and after FRR. Paired Student’s t test was used to compare differences in group means for paired samples. Patient-reported outcomes were reported using the Derkash classification and quick disabilities of the arm, shoulder, and hand (qDASH) questionnaire.
Fifteen patients (16 cases) surgically treated for neurogenic thoracic outlet syndrome were included in this retrospective study. There was no significant difference in pressure change between arm positions before scalenectomy (161.56 ± 71.65 mm Hg difference) or after scalenectomy (148.5 ± 80.24 mm Hg difference). There was a significant difference in pressure change between post-scalenectomy and post-FRR arm positions; mean pressure change between arm positions after FRR was 50.56 ± 40.28 mm Hg. Mean postoperative qDASH score was 20 ± 23.2. All patients reported improvement in symptoms and functional status.
Supraclavicular first rib resection for management of neurogenic thoracic outlet syndrome can be safely performed with favorable outcomes. The pressure increase in the costoclavicular space caused by arm abduction and external rotation was significantly reduced only after FRR, raising concerns about potential incomplete costoclavicular space decompression with scalenectomy alone for neurogenic thoracic outlet syndrome management.
Paget-Schroetter syndrome in pregnancy: A case report and discussion of management options
2020, Journal of Vascular Surgery Cases and Innovative Techniques
Paget-Schroetter syndrome is a form of primary venous thoracic outlet syndrome whereby thrombosis of the subclavian vein is instigated by repeated and vigorous overhead activity of the arm. We describe a 35-year-old pregnant white woman at 8 weeks' gestation, a competitive swimmer by profession, who was diagnosed with a left upper extremity thrombus. First rib resection through an infraclavicular approach was performed 1 week after percutaneous pharmacomechanical thrombectomy. Repeated venography demonstrated residual thrombus requiring percutaneous pharmacomechanical thrombectomy with balloon venoplasty. We present a challenging case with focus on the unique diagnostic evaluation and management of pregnant patients with this condition.
Pulse oximetry measurements in the evaluation of patients with possible thoracic outlet syndrome
2012, Journal of Hand Surgery
We present our experience in using pulse oximetry as an aid in the diagnosis of thoracic outlet syndrome (TOS). Our attention was given to those symptomatic patients without objective confirmatory data on imaging or electrodiagnostic evaluation.
Using a pulse oximeter, we measured the oxygen saturation and the pulse rate during a provocative extremity abduction stress test exercise maneuver in 18 patients with symptoms and signs consistent with a diagnosis of nonspecific neurogenic TOS. The oxygen saturation and pulse rates in 18 asymptomatic subjects were used as a control.
Resting oxygen saturation above 97% was present in both groups initially. After the provocative exercise maneuver, there was a significant reduction in the oxygen saturation levels, which dropped to 86% in the symptomatic TOS group compared with 94% in the control group. There was a significant increase in pulse rate in those subjects suspected of having TOS compared with a minimal increase in pulse rate in control subjects.
Pulse oximetry produced objective confirmatory measurements, which support a hypothesis that hypoperfusion in the upper limb during provocative activities or exercise may cause disabling symptoms associated with nonspecific neurogenic TOS. This method may be a useful, noninvasive, rapid, and inexpensive clinical tool in the diagnosis of TOS, a condition frequently lacking in objective, confirmatory diagnostic data.
Diagnostic III.
An investigation of the relationship between thoracic outlet syndrome and the dimensions of the first rib and clavicle
2011, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Following the system change in 2003, the first rib and clavicular measurements could be more accurately and easily determined. Anomalous first ribs are well-documented causes of TOS.10,11 Anatomically, they form the inferior border of the interscalene space and the posterior border of the costoclavicular space.
Abnormalities of the first rib including rib width, rib shape and rib angulation were noted intra-operatively in our thoracic outlet syndrome (TOS) operative patients. The purpose of this study is to investigate the relationship between TOS and the first rib in TOS operative patients and normal population.
Between 1993 and 2003, 32 patients with TOS undergoing surgical decompression and 30 normal subjects as the control group were included in this investigation. The investigation was from posteroanterior chest and antero-posterior C-spine radiographs. Sternal head width and vertebral head width of the first rib were measured. In addition, sternal head width, the acromion head width and the length of the clavicle were measured for comparison. Comparison between affected side and unaffected side first ribs was also performed in the unilateral TOS patients.
In TOS patients, the widths of the vertebral end and sternal end of the first rib were significantly wider than the control group (both, P = 0.0001).
Patients with wider vertebral end width of the first rib (>15 mm) or wider sternal end width of the first rib (>20 mm) may develop TOS.

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Review articleFirst Rib Resection in Thoracic Outlet Syndrome

Section snippets

Pathophysiology of TOS

Diagnosis

Treatment

Discussion

Conclusions

J Vasc Surg

J Vasc Surg

Hand Clin

Hand Clin

Semin Vasc Surg

J Vasc Surg

Ann Thorac Surg

Hand Clin

Cardiovasc Surg

J Vasc Surg

Experience with first rib resection for thoracic outlet syndrome

Ann Surg

Thoracic outlet syndrome: fact or fancy?A review of 409 consecutive patients who underwent operation

Can J Surg

Thoracic outlet syndromeResults of 282 transaxillary first rib resections

Clin Orthop Relat Res

Review article
First Rib Resection in Thoracic Outlet Syndrome