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Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter


OBJECTIVE: neurogenic thoracic outlet syndrome (NTOS) is no longer either "controversial" or "disputed", but its optimal surgical management remains unclear. Many thoracic outlet decompression procedures are carried out by first rib resection, usually via a trans-axillary route.

METHODS: retrospective review of a prospectively-maintained NTOS database. Patients with NTOS associated with a cervical rib were excluded from analysis, as were patients with recurrent NTOS. All study patients satisfied a 5-point clinical diagnostic protocol and experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus and middle scalenectomy and brachial plexus neurolysis via a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All patients completed a preop and 3-or 6-month postop QuickDASH questionnaire.

RESULTS: Between 2011 and 2019 five hundred four thoracic outlet decompression procedures were carried out in 442 patients. Average operative time was 1.15 hours and average hospital length of stay was 1.05 days. Major complications (intra-operative arterial injury; post-operative wound hematoma requiring reoperation; chylothorax) occurred in 7 patients (1.4%). All but 2 (99.6%) patients improved symptomatically: Using a more rigorous definition of operative success of a >50% improvement in 3- or 6-month QuickDASH score, 458 (90.9%) rib-sparing neurogenic TOS operations were successful. In comparison to mean pre-operative QuickDASH scores of 62.6, post-operative QuickDASH scores averaged 25.2 (p = 0.001).

CONCLUSIONS: These results suggest that: 1) adherence to a rigorous preop diagnostic regimen, including scalene block, ensures, at the least, that operation for NTOS can successfully be restricted to patients actually suffering from the condition; 2) fibrotic, contracted scalene muscles are the cause of NTOS; 3) the first rib need not be removed for successful surgical treatment of NTOS; and 4) 90% of patients so treated can expect significant medium-term symptomatic and functional improvement.