Objective: Long-term results after surgery for thoracic outlet syndrome (TOS) are reviewed in terms of personal histories and surgical techniques. Methods: Forty-eight operations were performed in 37 patients. In 21 instances, the picture was one of ordinary TOS, in eight TOS was traumatic and in nine the picture was sub-acute. Cervical ribs were excised through a supraclavicular approach (in seven cases), and first ribs through transthoracic, transaxillary or supraclavicular approaches (in 25, 15 or one, respectively). Long-term follow-up was obtained in 41 cases and averaged 11.7 years. Results: Surgical decompression was successful in 28 cases (68%), including all patients with traumatic TOS (8/8) and seven with sub-acute symptoms (7/9). Outcome was good in five of seven supraclavicular cervical rib resections, and in 23 of 34 first rib excisions. First rib resections performed transaxillary had shorter post-operative stays, fewer complications. Conclusion: Surgical decompression is more successful when TOS is traumatic or sub-acute. When involved, a cervical rib can be resected through a supraclavicular approach, since the procedure is easy and has little morbidity. The transaxillary approach should be preferred for first rib resections because of shorter post-operative stays and fewer complications than after the transthoracic approac

Berney, Thierry

Pugin, François

Robert, John

Spiliopoulos, Anastase

Toso, Christian

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Thoracic outlet syndrome: in¯uence of personal history and surgicaltechnique on long-term resultsChristian Toso, John Robert*, Thierry Berney, FrancËois Pugin, Anastase SpiliopoulosUnit of Thoracic Surgery, Geneva University Hospital, CH-1211 Geneva 14, SwitzerlandReceived 2 November 1998; received in revised form 23 February 1999; accepted 23 March 1999AbstractObjective: Long-term results after surgery for thoracic outlet syndrome (TOS) are reviewed in terms of personal histories and surgicaltechniques. Methods: Forty-eight operations were performed in 37 patients. In 21 instances, the picture was one of ordinary TOS, in eightTOS was traumatic and in nine the picture was sub-acute. Cervical ribs were excised through a supraclavicular approach (in seven cases), and®rst ribs through transthoracic, transaxillary or supraclavicular approaches (in 25, 15 or one, respectively). Long-term follow-up wasobtained in 41 cases and averaged 11.7 years. Results: Surgical decompression was successful in 28 cases (68%), including all patientswith traumatic TOS (8/8) and seven with sub-acute symptoms (7/9). Outcome was good in ®ve of seven supraclavicular cervical ribresections, and in 23 of 34 ®rst rib excisions. First rib resections performed transaxillary had shorter post-operative stays, fewer complica-tions. Conclusion: Surgical decompression is more successful when TOS is traumatic or sub-acute. When involved, a cervical rib can beresected through a supraclavicular approach, since the procedure is easy and has little morbidity. The transaxillary approach should bepreferred for ®rst rib resections because of shorter post-operative stays and fewer complications than after the transthoracic approach. q 1999Elsevier Science B.V. All rights reserved.Keywords: Syndrome; Thoracic outlet; Surgery; Study; Follow-up1. IntroductionThoracic outlet syndrome (TOS) refers to a variety ofdisorders in the upper limb, such as pain, paresthesia anddysesthesia. It is caused by the compression of neural orvascular structures between the scalene muscles, betweenthe ®rst rib and the clavicle, or under the pectoralis minormuscle [1]. Symptoms can be reproduced by compressiveand positional maneuvers (Adson's test, hyperabduction andcostoclavicular maneuvers). Diagnosis of TOS is dif®cult,however, because such maneuvers [2] and other diagnostictests (nerve conduction studies, electromyographs, X-ray®lms, sensory tests) are not speci®c [3]. Furthermore otherpathologic conditions in the neck and the thoracic outletmay mimic TOS (herniated cervical disk, rotator cuffrupture, tumors or peripheral nerve entrapment) [1,4]. Dif®-culties in diagnosis and variability in patient selectionaccount for the wide range of results achieved in the surgicalmanagement of TOS (from 24 to 100% of symptom relief)[4].Conservative management is the initial treatment ofchoice, since patients with TOS may be cured with posturalcorrection, stretching and strengthening exercises [6±8].Surgery may be successful when TOS fails to improvewith conservative treatment or when patients have symp-toms too severe to tolerate conservative management [1].Selection of patients likely to bene®t from surgery on onehand, and timing of surgery on the other hand, are howeverstill debated. Numerous surgical procedures have beendescribed for decompression [1]. Although ®rst rib resectionvia Roos' transaxillary approach is the most frequently used[9], no clear advantage has been demonstrated for any tech-nique [10], and the choice of a procedure still largelydepends on the surgeon's preference.The purpose of this study is to review the long-termoutcome of patients after surgical management of TOS,with special reference to their pre-operative histories andto the surgical technique used.2. Patients and methodsFrom 1978 to 1997, 37 patients (eight men and 29women) aged from 16 to 51 years (median 33) were oper-ated for TOS in the Unit of Thoracic Surgery at GenevaEuropean Journal of Cardio-thoracic Surgery 16 (1999) 44±471010-7940/99/$ - see front matter q 1999 Elsevier Science B.V. All rights reserved.PII: S10-1079(40)99001-268* Corresponding author. Tel.: 1 41-22-3727875; fax: 1 41-22-3727880.University Hospital. Eleven patients were operated on bothsides, amounting to a total of 48 surgical procedures. Allpatients underwent extensive history taking and physicalexamination and had chest or cervical X-rays. The follow-ing studies were performed prior to admission: upper limbangiography (35/48), electroneuromyography (17/48),Doppler ultrasonography (10/48) and/or phlebography (5/48). None of these studies suggested another diagnosis.A conservative treatment was always attempted prior tosurgery, but proved unsuccessful in all patients. Most (21/37) took painkillers (non-steroidal antiin¯ammatory drugs,paracetamol), for more than 4 months, and physiotherapywas given for an median period of 7 months (range 1±16).Such conservative management was occasionally felt unef-fective from the start, leading to early surgery (in the so-called subacute cases of TOS).Patients were classi®ed in four groups: neurological (28/48, 59%), arterial (3/48, 6%), arterial and neurological (15/48, 31%), or venous (2/48, 4%) TOS. Symptoms of patientswith neurologic TOS were pain (18/28) and paresthesia (14/28) in the neck, shoulder or arm. Adson test was positive in15 cases (15/28). Hypoesthesia was noted in ®ve patients,paresia in ®ve, brachial plexus tenderness in two, and atro-phia of the involved limb in one.The three patients with arterial TOS had a history ofischemia of the arm, at rest or in abduction. Two had aRaynaud history with a positive Adson test. Angiographyshowed extrinsic compression of the subclavian artery atrest or in abduction in all three.Patients with a combination of arterial and neurologicsymptoms had pain (10/15), paresthesia (9/15), edema (2/15), or cyanosis (1/15) of the upper limb. The followingsigns were noted at examination: a positive Adson test(11/15), loss of sensitivity (5/15), loss of strength (4/15),or diminished re¯exes (1/15).Both patients with venous TOS had pain, swelling andcyanosis of the arm. Adson test was positive in both. Onehad a thrombosis of the axillary vein (Paget-Schroettersyndrome) and had a 3-month anticoagulation therapyprior to surgery.Median duration of the symptoms before surgery was 21months (range 1-72). Nine patients (eight women and oneman), aged 22±51 (median 41) suffered from subacute TOS.Their symptoms were severe, they could not tolerate conser-vative management, and surgery took place within 6 monthsof onset. TOS was of the neurological type in six, neurolo-gical and arterial in 2, and arterial in one.Their were eight cases of trauma-related TOS in sevenpatients (three men and four women, aged 19±45, median29), ®ve of the neurological type and three neurological andarterial. Trauma took place 7 to 36 months (median 14) priorto decompressive surgery. Three cases involved seat-beltinjuries in car accidents and one suffered a direct anteriorconcussion of the shoulder in a ski accident. The other threeoccurred in somewhat more chronic fashion (Table 1). Noneinvolved a clavicle fracture. Eleven patients had bilateralcervical ribs, ®ve of them presenting with a supraclavicularmass.Techniques and approaches used for decompression arereviewed in Table 2. In the case of a cervical rib, a resectionof this rib through a supraclavicular approach was the tech-nique most often performed. For ®rst rib resections, Roos'transaxillary approach [9] was used in the late period and atransthoracic approach in the early period. The latter proce-dure was conducted through a classic anterolateral thoracot-omy with extraperiotal resection of the ®rst rib [11].A median follow-up of 11.7 years (range 1.1±19.2) wasobtained in 41 of 48 operated cases (85%). Follow-up wasobtained during a clinical visit performed for the purpose ofthe study in 14 cases, or by phone in 27. Outcome aftersurgery was graded as `good' when symptoms improvedand when patients were able to return to their pre-illnessactivities. Outcome after surgery was graded as `poor'when symptoms did not improve or worsen, or whenpatients could not return to their usual activities. Surgicaloutcome was also correlated with pre-operative histories,with the type of TOS, and with the presence of cervicalrib. The three surgical approaches used were evaluated interms of outcome, duration of hospital stay, and morbidity.Student's t-test was used for comparison of continuous vari-C. Toso et al. / European Journal of Cardio-thoracic Surgery 16 (1999) 44±47 45Table 1Clinical pictures of trauma related TOSNo. of patientsCar crash injuries (seat-belt injuries) 3Two repeated trauma of the shoulder in high-levelathletes (tennis, gymnastics)2Overuse of the shoulder in a paraplegic patient inwheelchair1 (both sides)Ski trauma (direct anterior trauma of the shoulder) 1Table 2Approach and technique used for decompression according to the presence or absence of a cervical ribApproach Cervical rib present No cervical rib TotalCervical rib resection First rib resection First rib resectionSupraclavicular 7 ± 1 8Transaxillary ± 1 14 15Transthoracic ± 3 22 25Total 7 4 37 48ables, and Fisher's exact test for categorical variables.Values of P , 0:05 were considered signi®cant.3. ResultsAt follow-up, surgery was graded as good in 28 cases(68%): patients were satis®ed and would chose surgeryagain, should TOS symptoms reappear. Pre-illness activitywas resumed within 3 months in 27 cases (66%). Sixpatients did not return to their pre-illness activity or hadto change profession. Results for the different groups ofTOS are listed in Table 3. Among the 12 cases with a cervi-cal rib, seven had the cervical rib resected through a supra-clavicular approach, with good results in ®ve of them,whereas the remaining ®ve who had their ®rst rib resected(and their cervical rib left in place) by a transthoracic or anaxillary route did poorly in four instances.First rib resections (n  34) were successful in 23 cases,but did not bring any relief in 11. Of the seven cervical ribresections, ®ve were successful. Outcome, duration of post-operative hospital stay and long-term complications foreach surgical approach are reviewed in Table 4. Transitoryloss of strength of the involved arm was attributed to abrachial plexus lesion (BPL) and resolved within 18 monthswith physiotherapy in all cases. When noted, the loss ofsensitivity of the inner aspect of the arm or of the breast(LS) persisted years after surgery. Pleural effractions occur-ring after Roos' approach (pneumothorax in one and effu-sion in two) were treated by aspiration, whereas pleuraldrainage was used in all 20 patients who had had a trans-thoracic decompression. A second operation was neededafter a transthoracic decompression because of the painfulluxation of a fractured second rib. Two cases of Homer'ssyndrome occurred, one after a transthoracic decompressionwhich required surgical suspension of the upper eyelid 3years later, and the other after an axillary procedure.4. DiscussionDiagnosis and management of TOS are still controversial,more than forty years after the initial description by Peet etal. [12]. One explanation is the lack of a reliable paraclinicaltest, accounting for the absence of clear criteria for surgery.Extensive history taking and clinical examinations shouldbe performed by experienced clinicians, possibly withinmultidisciplinary groups, in order to achieve a better selec-tion of patients.Clearly, conservative management should be tried ®rst,since many patients suffer primarily from muscle imbalanceand misalignment of their shoulders that cause the compres-sion. Symptoms are frequently relieved by postural correc-tion, stretching and strengthening exercises for the shoulder-girdle muscles [6±8]. Exercises and posture programsshould be continued at home to assure long-term success.An operation can be proposed when symptoms are toosevere to bear physiotherapy, or after 6±12 months of unsuc-cessful conservative management.Good results after surgery are obtained in up to 80% ofcases, whatever technique is used [10]. In the present study,C. Toso et al. / European Journal of Cardio-thoracic Surgery 16 (1999) 44±4746Table 3Long-term outcome after TOS decompression according to pre-operativehistoryPost-operative evolution Good outcome Poor outcomeTotal 28 13Type of TOSNeurologic 11 5Neurologic and arterial 8 5Arterial 1 2Venous 8 1Particular pre-operative historyTraumatic TOSa 8 0Acute symptomsb 7 2Presence of a cervical rib 6 6a History of trauma or overuse of the shoulder.b Duration of symptoms ,6 months prior to decompression.Table 4Long-term outcome after TOS decompression according to the surgical approach usedPost-operative evaluation Supra-clavicular approach Transaxillary approach (Roos) Transthoracic approachTotal 8 13 20Good outcome 5 (63%) 9 (69%) 14 (70%)Post-operative stay (days) 5 7 8ComplicationsBPL 1 1 1LS 0 1 6Pleural lesion 0 3 ±aFractured rib 0 0 1Horner's syndrome 0 1 1a Transthoracic approach involved pleural drainage in all cases.two-thirds of operated cases had improvement of theirsymptoms. These average results may be explained by thelong follow-up period (11.7 years), since symptoms of TOSmay recur after initially successful surgery [10]. In a studyreporting more than 90% of initially successful thoracicoutlet decompressions, good outcome decreased to 73±76% and to 69±71% 1±2 years and 3±4 years after surgery,respectively [10]. In the present study, success was de®nedby the subjective feeling of symptom relief, by the ability toreturn to work, and by the willingness of patients to undergothe same operation, should TOS symptoms reappear. Thesecriteria of evaluation seem appropriate, since the feeling ofwell-being is the goal of TOS treatment. However, this typeof assessment may result in lower success rates compared toclinical examination alone, since a high proportion ofpatients with TOS suffer psychological problems or experi-ence dif®culties with their insurances, and thus may notfairly appreciate improvement of their symptoms.History taking and physical examination are the mostimportant criteria for surgical treatment. Various traumaticlesions may lead to TOS: clavicle fractures, acromioclavi-cular joint dislocations, blows against the anterior aspect ofthe shoulder and the anterior chest wall [13] and repeatedstress of the shoulder in high level-athletes [14]. In thepresent study, all patients with traumatic TOS had a success-ful outcome. All these patients had non-work related trauma(results are reported to be 13% better than in a work-relatedtrauma group [15,16]). Patients with sub-acute symptoms(duration of symptoms before surgery , 6 months) alsohave better results after treatment. The absence of a signi®-cant difference may be explained by the small size of thisgroup. As already noted [17], surgery is more gratifyingwhen the clinical picture is that of rapid involvement ofthe whole brachial plexus. Although the presence of a cervi-cal rib is helpful in making the diagnosis of TOS, surgicaloutcome is not better in patients with such a morphologicabnormality. These poor results are mainly due to the pooroutcome of ®rst rib resections when a cervical rib is presentand left in place (1/5). Results of cervical rib resections aresimilar to overall results (Table 4).Many surgical procedures have been described for themanagement of TOS: scalenotomy, scalenectomy, clavicu-lectomy, pectoralis minor release, ®rst rib resection andcervical rib resection [5]. In the present study, as observedby others [10], rates of successful outcome after decompres-sion with ®rst rib or cervical rib resections are similar.Patients with a cervical rib should thus undergo excisionof this rib through a supraclavicular approach, since theprocedure is easier and has less morbidity than ®rst ribresection. First rib resection, with or without scalenectomy,is the procedure most frequently performed [18]. This tech-nique opens the space under the clavicle and loosens theanterior and middle scalene muscles no longer attached tothe ®rst rib [1]. It should be performed in the absence of acervical rib, when clear symptoms of TOS are present.These decompression procedures can be achieved bydifferent approaches: transaxillary, supraclavicular, trans-thoracic, posterior, subclavicular, or transclavicular [5,15].In a previous paper, our group proposed a transthoracicapproach for ®rst rib resections [11], because it appearedless hazardous for the brachial plexus. With longer follow-up periods, transthoracic and Roos' axillary approacheshave similar outcome, but since the latter has shorter post-operative stay and fewer long-term complications, it shouldbe recommended for ®rst rib resections.Surgical decompression for TOS is a controversial andchallenging problem. Emphasis should be put on a betterselection of patients eligible for early surgery (traumaticTOS, acute symptoms). The supraclavicular approachshould be preferred for cervical rib resections, and Roos'axillary approach for that of the ®rst rib.References[1] Oates SD, Daley RA. Thoracic outlet syndrome. Hand Clin.1996;12:705±718.[2] Rayan GM, Jensen C. Thoracic outlet syndrome: provocative exam-ination maneuvers in a typical population. J Shoulder Elbow Surg.1995;4:113±117.[3] Novack CB, Mackinnon SE, Patterson GA. Evaluation of patientswith thoracic outlet syndrome. Hand Surg. 1993;18A:199±292.[4] Lindgren KA. Conservative treatment of thoracic outlet syndrome: a2-year follow-up. 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Thoracic outlet syndrome: influence of personal history and surgical technique on long-term results

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