OUR EXPERIENCE OF SURGICAL TREATMENT OF THORACIC OUTLET SYNDROME

Abstract

Thoracic outlet syndrome (TOS) is characterized by a series of symptoms, which arise from the compression of the neurovascular bundle between the supraclavicular space and its entry to the axilla. The type and intensity of symptoms is relative to the site of compression and the anatomic structures involved.

Between 1990 and 2001, 42 patients were operated for thoracic outlet syndrome utilizing a supra-clavicular incicion (8 bilateral). 12 were male and 30 female. Ages ranged from 21 to 55 years (mean 31). The time interval between the onset of first symptoms and operation was 7 to 12 months in 16 patients and 1 to 4 years in 26 patients. All patients had neurologic symptoms with pain, paresthesias and numbness in the lateral neck, shoulder or arm. The duration and intensity of symptoms was variable. 12 of them had symptoms arising from the arterial compression. Preoperative evaluation included a formal clinical and neurologic examination, radiographs of the chest and cervical spine, Electromyography was often performed if a carpal tunnel syndrome was suspected. Angiography was performed in patients with vascular symptoms. MRI scan of the cervical spine and supraclavicular spaces were routine practice. Most of the patients had undergone prolonged conservative treatment including medication (muscle relaxants and analgesics), physiotherapy, exercises and cervical brace immobilization. This approach produced only temporary improvement or even aggravation of their neurologic complaints.

Intraoperativelly we found: Hypertrophy of the scalene muscle with aberrant or broad insertion on the first rib (31 pts), perineural fibrosis (5 pts), long type cervical rib (2 pts), fibromuscular bands between the 7 transverse process and the first rib (4 pts), vascular bridge pinching the lower trunk (4 pts). In four cases no obvious anatomic finding within the thoracic outlet affecting the brachial plexus could be found. The follow up period ranged from 6 months to 10 years (mean 6 years). Results were classified as excellent in 16, who were free of symptoms. Good in 12, who complained of mild symptoms on daily activities but were significantly improved. Poor in 6 who had persistent or aggravation of their symptoms. 4 patients from the poor results group were treated by 1st rib excision, on a later stage and experienced significant improvement.

The operative complications include one case of pneumothorax and a temporary dysfunction of the phrenic and XI cranial (accessory) nerve. No postoperative complications were found and the average hospitalization period ranged between 24 – 48 hours.