What is the role of surgery in the treatment of acute thoracic outlet syndrome?

Updated: Jan 10, 2019
  • Author: Daryl A Rosenbaum, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Answer

Little argument exists against the surgical treatment of a patient with severe compression or compromise of the subclavian vein or artery. [10, 14, 15, 32, 42] Likewise, patients with atrophy of the intrinsic muscles of the hand secondary to thoracic outlet syndrome with no distal sites of compression need surgical intervention. [16]  However, less severe cases are more controversial.

Because of the high prevalence of surgical complications and variable reports of success, many surgeons offer surgery to patients with disputed or nonspecific-type thoracic outlet syndrome only as a last resort after prolonged conservative management and a detailed discussion regarding the risks and complications of surgery. Potential complications from surgery can include pneumothorax, injury to the subclavian artery or vein, injury to the brachial plexus and long thoracic nerve, apical hematoma, intercostobrachial nerve injury, and injury to the thoracic duct. [43]

The surgical approach used varies and may be specialty dependent, with the transaxillary approach preferred by many thoracic and vascular surgeons and the anterior supraclavicular approach favored by most neurosurgeons. [11, 44] Both approaches allow for supraclavicular decompression, which consists of first rib (and cervical rib if present) removal and part or total scalene muscle removal. In a study of 33 patients with venous thoracic outlet syndrome, Siracuse et al reported good results with an infraclavicular surgical approach. [45]

For neurogenic thoracic outlet syndrome with examination findings of tenderness or reproduction of symptoms on palpation of the coracoid space only, isolated pectoralis minor tenotomy may be sufficient. [46]

Success rates for surgery vary dramatically in the literature. One review of 47 patients with thoracic outlet syndrome revealed 75% lower plexus and 50% upper plexus compressions remained asymptomatic at 4.6 years. [47] Morbidity in this study involved 17% of patients and was most frequently the result of incisional pain.

A literature review by Peek et al found evidence that most patients who undergo surgery for thoracic outlet syndrome benefit from the treatment. The investigators reported that postoperatively, 90% of the study's patients with arterial or venous thoracic outlet syndrome improved under Derkash’s classification to an excellent/good rating, while patients with neurogenic thoracic outlet syndrome showed a 28.3-point improvement in their Disabilities of the Arm, Shoulder and Hand scores. [48]

However, not all studies have been so impressive. One retrospective analysis of patients with nonspecific neurogenic thoracic outlet syndrome demonstrated work disability at 1 year after surgery in 60% of patients. At 4.8 years of follow-up, 72.5% patients were limited in activities. [49]

This has led many surgeons to agree with Wood et al, who empathically stated in 1988 that some errors always occur in diagnosis, and, therefore, surgery should be advised "on a basis of exclusion and with great reservation." [25] This is especially true for disputed or nonspecific-type thoracic outlet syndrome. [11]

A study that evaluated the outcomes of patients who underwent first rib resection (FRR) for all 3 forms of thoracic outlet syndrome (TOS) during a period of 10 years reported that excellent results were seen in this surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, use of a standard protocol for venous patients, and expedient intervention in arterial patients. [50]


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