Controversies in NTOS: To Remove the First Rib or Not?
The first rib may not always require excision in NTOS. It has been shown that the pathology is in the scalene muscles (fibrosis), not in the rib. Scalenectomy alone has as good a long-term improvement rate as first rib resection, and rib resection results
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Richard J. Sanders
Abstract
The first rib may not always require excision in NTOS. It has been shown that the pathology is in the scalene muscles (fibrosis), not in the rib. Scalenectomy alone has as good a long-term improvement rate as first rib resection, and rib resection results in more complications and morbidity. However, if when performing scalenectomy, the lower trunk of the brachial plexus is found to lie touching the first rib, it should be excised.
Introduction Most clinicians today believe that the first rib should be excised in essentially all patients with NTOS, but there are both theoretical and empirical data to suggest that this does not always need to be performed.
The Pathology is in the Scalene Muscles It has been well documented that in most patients with neurogenic thoracic outlet syndrome (nTOS) the pathology lies mainly in the scalene muscles,
R.J. Sanders, MD Department of Surgery, HealthONE Presbyterian-St. Lukes Hospital, 4545 E. 9th Ave #240, Denver, CO 80220, USA e-mail: [email protected]
primarily anterior but also middle. Supporting this point of view are the following: 1. Histologic demonstration of a threefold increase in the amount of scar tissue in the scalene muscles of nTOS patients [1] (See Fig. 6.2). 2. Histologic demonstration of an increase in slow twitch muscle fibers (Type 1) and decrease, atrophy, and anisocytosis of fast twitch fibers (Type 2) [1, 2] (See Fig. 6.2). 3. The observation that scalene muscle block with lidocaine relaxes the anterior scalene muscle and relieves most symptoms within 120 seconds [3, 4]. 4. And, most importantly, the observation that scalenectomy without first rib resection has as good a success rate as scalenectomy with first rib resection [5, 6]. Although first rib resection is the most common operation for relief of symptoms of nTOS, we suggest that it is successful not because the
K.A. Illig et al. (eds.), Thoracic Outlet Syndrome, DOI 10.1007/978-1-4471-4366-6_45, © Springer-Verlag London 2013
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R.J. Sanders
320 Fig. 45.1 (a) Almost vertical first rib which rests against the lower trunk of the brachial plexus and is excised. (b) Curved first rib which usually lies free of the lower trunk and is not removed (Reprinted from Sanders [9]. With permission from Elsevier)
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first rib has been removed but rather because to remove the rib anterior and middle scalenotomy must be performed. It should be noted that some nTOS patients who undergo scalenectomy without first rib resection do not improve and a second operation to remove the rib is required. While identifying these patients is difficult, we have found that at the time of performing supraclavicular anterior and middle scalenectomy the relationship of the lower trunk of the brachial plexus and first rib can easily be observed. If the nerve is in contact with the rib, the rib is removed; otherwise the rib remains. In following this protocol we found that only about 30 % of patients require first rib resection while 70 % require scalenectomy alone, with the overall suc
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