Controversies in NTOS: Transaxillary or Supraclavicular First Rib Resection in NTOS?
Most believe that proper treatment of neurogenic thoracic outlet syndrome (NTOS) requires excision of the first rib and adequate scalenectomy. The supraclavicular approach allows most thorough scalene muscle excision and brachial plexus neurolysis, while
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Richard M. Green
Abstract
Most believe that proper treatment of neurogenic thoracic outlet syndrome (NTOS) requires excision of the first rib and adequate scalenectomy. The supraclavicular approach allows most thorough scalene muscle excision and brachial plexus neurolysis, while the transaxillary approach is most cosmetic and seems to decompress the thoracic outlet very nicely. Large series utilizing either approach show excellent and equivalent results. I believe that the patient with upper plexus symptoms, cervical tenderness, a broad bony cervical rib and/or a history of trauma is best treated by supraclavicular first rib excision. By contrast, those patients with clear-cut lower plexus (ulnar nerve) symptoms in the absence of trauma should be offered transaxillary resection.
There are large series of patients from reputable centers demonstrating that neurologic thoracic outlet syndrome (NTOS) can be safely and successfully treated by both transaxillary and supraclavicular [1–3]. I believe that both procedures are complimentary and that anyone treating patients with NTOS should be facile in each. The choice for me largely depends on the patient’s presenting symptoms, the body habitus, and the presence of bony anomalies. Whether or not NTOS exists remains a matter of debate [4]. As my own practice has evolved I am recommending operative decompression in fewer patients while utilizing therapy and R.M. Green, MD Department of Surgery, Lenox Hill Hospital, 130 East 77th St, New York, NY 10075, USA e-mail: [email protected]
conditioning as my first and best option unless an accompanying anatomic abnormality is identified or the patient presents with a significant neurologic impairment [5]. Nonoperative therapy consists of correcting any muscular imbalance in the cervicoscapular region by increasing mobility, strength (endurance) and range of motion all with the goal of decreasing compression on the brachial plexus. In addition to traditional physical therapy, postural training to correct drooping or sagging shoulders is essential. When aggressive nonoperative management fails in a compliant patient there is usually a fixed anatomic abnormality such as a fibromuscular band that requires decompression. A review of our experience with NTOS at the University of Rochester in 136 patients was conducted to determine what factors affected outcome after transaxillary first rib resection [6].
K.A. Illig et al. (eds.), Thoracic Outlet Syndrome, DOI 10.1007/978-1-4471-4366-6_44, © Springer-Verlag London 2013
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The mean follow-up was 60 ± 7 months. Secondary supraclavicular operations were required in 20 patients. This rather high recurrence rate has been noticed by others [7]. The quality of the operative result was determined by whether the patient was able to return to pre-illness activities and whether the patient would undergo operation again if the same result would be obtained. The most important determinant of result was a history of trauma precipitating the neurologic symptoms, particularly in women. On
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